Exam 4: 31 Mar Reversal Agents and Patient Safety Flashcards
What is the purpose of neuromuscular monitoring in anesthesia?
To assess the level of neuromuscular blockade and ensure patient safety during anesthesia.
What is the most commonly used technique for neuromuscular monitoring?
Train of four.
What are the key parameters to evaluate before extubating a patient?
- Head lift of at least 5 seconds
- Peak inspiratory force of more than -25 to -30 cm H2O
True or False: Residual neuromuscular blockade occurs in 33% of postoperative patients.
True.
What is sugamadex?
A reversal agent used for neuromuscular blockade.
What are the adverse effects associated with volatile anesthetics?
- Cardiovascular side effects
- Muscarinic effects
Fill in the blank: The goal of anesthesia providers is _______.
[patient safety]
What are the three classifications of neuromuscular blocking agents based on duration of action?
- Short acting
- Intermediate acting
- Long acting
What is the importance of knowing the duration of action of paralytic agents?
To ensure safe extubation and avoid residual neuromuscular blockade.
What are the common reversal agents for neuromuscular blockers?
- Neostigmine
- Edrophonium
- Sugammadex
What is the role of anticholinergic agents when administering reversal agents?
To counteract muscarinic effects from acetylcholinesterase inhibitors.
What is the significance of the study by Bailart and colleagues in 1995?
It highlighted the necessity of neuromuscular monitoring in reducing postoperative residual neuromuscular blockade.
What is the other name for neuromuscular monitoring?
Accelero biography.
What is the most common nerve and muscle being monitored for neuromuscular blockade?
Ulnar nerve and adductor pollicis muscle.
What type of neuromuscular blocking agent is usually metabolized by plasma esterases?
Benzyl isoquinolones.
What is the clinical significance of re-curarization?
It refers to the reappearance of neuromuscular blockade after reversal.
What is the peak onset of neuromuscular blocking drugs important for?
Determining the timing of administering reversal agents.
Fill in the blank: The study from 2000 to 2004 showed a reduction in postoperative residual neuromuscular blockade to _______.
[4%]
What role does situational awareness play in anesthesia practice?
It enhances patient safety and improves crisis management.
What is the recommended approach when neuromuscular monitoring devices are not available?
Know the duration of action and peak onset of the drugs used.
What can contribute to postoperative nausea and vomiting (PONV)?
- Hypoxemia
- Pain
What is the role of educational opportunities in anesthesia?
To improve crisis management and patient safety.
What is the significance of dynamic kinetic pharmacology in selecting reversal agents?
It helps in determining the appropriate reversal agent based on the patient’s response.
True or False: Muscarinic effects can occur from the use of cholinergic agents.
True.
What is the function of the fiber optic bronchoscope in patient management?
To assist in reintubation when necessary.
What are neostigmine and edrophonium classified as?
Polynastase inhibitors
These agents inhibit the enzyme acetylcholinesterase, increasing acetylcholine availability at neuromuscular junctions.
What is the mechanism of action of reversal agents like neostigmine?
Inhibit the hydrolysis of acetylcholine by acetylcholinesterase
This results in increased acetylcholine binding to receptors, promoting action potentials.
What is a key effect of neostigmine and edrophonium at the neuromuscular junction?
They act as competitive antagonists
They compete for binding sites with acetylcholine, thereby enhancing neuromuscular transmission.
What is the ceiling effect in the context of reversal agents?
A limit on the effectiveness of the drug when overdosed
For example, administering more than five milligrams of neostigmine can lead to Phase One block.
What is the recommended dose of neostigmine for reversal?
0.4 to 0.7 mg/kg
A common practice is to memorize a middle value, such as 50 mcg/kg.
True or False: Post-tetanic stimulation is a reliable method for assessing neuromuscular blockade.
False
Train of four technique is preferred for assessing twitches in neuromuscular blockade.
What should be assessed before administering reversal agents?
The depth of neuromuscular blockade
This includes checking for twitches and their strength.
What is the duration of action for neostigmine?
60 minutes
This duration is important for planning extubation and recovery.
Which anticholinergic agent is commonly paired with neostigmine?
Glycopyrrolate
The typical dose is 0.2 mg per mg of neostigmine.
What is the onset of action for edrophonium?
1 to 2 minutes
This rapid onset makes it useful in acute situations.
What dosage adjustment is recommended for patients with 50% neuromuscular blockade?
50% of the calculated reversal agent dose
It is important to titrate the dose based on clinical assessment.
What is the recommended dosing for sugammadex?
2 to 16 mg/kg
This depends on the depth of the neuromuscular blockade.
What is the clinical duration of response for rocuronium?
36 minutes
Knowing this helps in planning the timing of reversal.
What is the effect of volatile anesthetic agents on neuromuscular blockade?
They have muscle relaxant properties
This can contribute to postoperative residual neuromuscular blockade.
What should be monitored after administering reversal agents?
The patient’s respiratory function
This is crucial as deep neuromuscular blockade can affect respiratory muscles.
What is the typical administration approach for edrophonium and atropine?
Atropine is given first, followed by edrophonium
This sequence helps manage potential bradycardia.
Fill in the blank: The onset of action for glycopyrrolate is _______.
[specific duration not provided]
Typically, glycopyrrolate is administered alongside neostigmine.
What is the typical order of administration for atropine and adrophone?
Atropine is usually given first, followed by adrophone
This sequence is based on clinical practice to avoid complications.
What is the onset of action for neostigmine?
5 to 10 minutes
This timing is crucial for reversing neuromuscular blockade during surgery.
When should neostigmine be administered during surgery?
When the surgical team is closing the fascia
This timing allows for effective reversal before the patient is extubated.
What is the duration of action for neostigmine?
60 minutes
This duration is favorable compared to intermediate-acting paralytic agents.
What is the clinical duration of action for pancuronium?
86 minutes
This longer duration requires careful monitoring when reversing.
What is the recommended dose of neostigmine?
50 mcg per kg
This is the middle range for effective reversal.
How do renal function issues affect the clearance of neostigmine?
Decreased renal function prolongs action of the drug
Renal excretion accounts for 50% of neostigmine clearance.
What are the side effects of neostigmine?
Increased nicotinic and muscarinic activities
This includes bradycardia, dysrhythmias, and bronchoconstriction.
What is a major concern when reversing neuromuscular blockers in patients with asthma or COPD?
Bronchoconstriction
This can exacerbate respiratory issues.
What is the dose range for atropine?
7 to 10 mcg per kg
This is often simplified to 10 mcg per kg for ease of calculation.
What is the dose of glycopyrrolate?
10 mcg per kg
This dose matches the profile with neostigmine.
What is the importance of baseline neuromuscular function checks?
To ensure accurate monitoring and reversal during induction
Consistent checks prevent misinterpretation of neuromuscular block status.
What should be monitored before administering succinylcholine?
Train of four twitches
This helps assess the neuromuscular block level.
What is a potential intervention for persistent neuromuscular blockade?
Sedation and post-operative ventilation
This may involve using BiPAP or reintubation if necessary.
What is the role of anticholinergic agents like atropine and glycopyrrolate?
To counteract muscarinic side effects of reversal agents
These agents help mitigate bradycardia and increased salivation.
True or False: The clearance of neostigmine is not affected by hepatic function.
False
Hepatic clearance can impact the drug’s action duration.
What is the matching formula for neostigmine and glycopyrrolate?
1 mg of neostigmine is paired with 0.2 mg of glycopyrrolate
This formula is essential for proper dosing.
What is the primary factor influencing neuromuscular blocking drug reversal?
The intensity of the block and the reversal drug used
Patient conditions such as pH levels and temperature can also affect reversal.
What is the recommended dosage of neostigmine for reversal when there are two out of four twitches?
2.5 mg
This is a practice suggestion, not a strict test answer.
True or False: It is common practice to give a 100% reversal dose of neuromuscular blocking agents.
True
However, variations exist based on clinical judgment.
What is sugammadex used for?
It is a selective relaxant binding agent for reversing neuromuscular blockade caused by amino steroids
Primarily effective for rocuronium.
What is the mechanism of action of sugammadex?
It encapsulates the free drug in plasma through hydrophobic interactions and Van der Waals forces
This creates a tight binding around the neuromuscular blocking agent.
What percentage of sugammadex is eliminated through urine within 24 hours?
90%
Renal impairment can contraindicate its use.
What is the elimination half-life of sugammadex?
2 hours
What defines a deep neuromuscular block?
No twitches with train of four response
Response to post-tetanic count may still be present.
Fill in the blank: The recommended dosage of sugammadex for a deep block is _______.
4 mg/kg
What is the recovery time for rocuronium reversal using sugammadex compared to neostigmine?
1.4 minutes for sugammadex vs. 9.8 minutes for neostigmine
This indicates a significant advantage in recovery speed.
How does sugammadex affect recovery time when reversing vecuronium?
2.1 minutes for sugammadex vs. 29 minutes for vecuronium without it
This shows a dramatic difference in recovery times.
What are the major routes of elimination for sugammadex?
Urine
It is highly water soluble, leading to renal clearance.
True or False: Sugammadex binds with plasma proteins significantly.
False
It does not bind significantly, leading to more active form availability.
What is the significance of the practice regarding reversal doses based on twitches?
Doses may vary based on clinician preference and patient response
For testing, 100% reversal is often expected unless specified otherwise.
What was the focus of the research conducted by classmates regarding sugammadex?
Comparative efficacy and safety outcomes in patients with end-stage renal disease
The study concluded that sugammadex is safe and effective in these patients.
What is the role of Van der Waals forces in the action of sugammadex?
They facilitate the binding of sugammadex to the neuromuscular blocking agent
This occurs at a thermodynamic level, aiding in drug encapsulation.
What type of steroids are pancuronium?
Amino steroids
What is the recovery time for sugamidex versus vacuronium?
Sugamidex: 2.1 minutes, Vacuronium: 29 minutes
What are some adverse effects associated with sugamidex?
- Nausea
- Vomiting
- Pruritus
- Urticaria
- Anaphylactic reaction
What should be done if a patient has multiple allergies before administering sugamidex?
Give a test dose
What is the recommended dose of rocuronium after reversal with sugamidex?
1.2 mg/kg after waiting four minutes
What should be avoided if a patient has limited renal function?
Amino steroids
What can be administered if rocuronium is not available?
Benzyl isoquinolones
What is the effect of sugamidex on oral contraceptives?
It can encapsulate and negate their effectiveness for up to seven days
What can sugamidex displace in patients using non-steroidal anti-estrogens?
Neuromuscular blocking drugs
What are the potential effects of sugamidex on bleeding or coagulopathy?
It can affect PT, PTT, or INR
What is a critical assessment to perform post-surgery in the case of respiratory distress?
Assess for respiratory effort and signs of re-paralysis
What signs indicate a patient may be experiencing re-paralysis?
- Inability to sustain head lift
- Weak hand grasp
- Hypoxemia
What is the first step in treating a patient suspected of respiratory obstruction?
Ensure airway, breathing, and circulation
What additional reverse agents can be given if neostigmine has reached its ceiling effect?
Physostigmine
What factors contributed to communication failures in the reported case study?
- Failed communication
- Loss of situational awareness
What should CRNAs advocate for when positive end-tidal CO2 is present?
Do not extubate the patient
What situation led to the patient in the case study ultimately dying?
Anoxic brain injury due to failed intubation
What does the term ‘recolorization’ refer to in anesthesia?
The return of neuromuscular block after reversal
What is a significant risk when administering sugamidex to patients on oral contraceptives?
Potential failure of contraceptive effectiveness
What is the importance of team communication during emergency situations in anesthesia?
To ensure patient safety and effective management
What should be done if a patient’s breath sounds are absent after reintubation?
Confirm the position of the endotracheal tube
