Exam 4 - NMB Reversals Flashcards

1
Q

What is another name for neuromuscular monitoring?

A

Acceleromyography

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2
Q

What does it mean for NMB reversal drugs to have a ceiling effect?
How does this effect reversal?

A

“Once the inhibition of acetylcholinesterase is complete, administering additional doses of neostigmine will serve no useful purpose because the concentration of acetylcholine that can be produced at the neuromuscular junction is finite.” - Stoelting p. 1052

This means that NMB drugs will not be able to reverse deep blockade (no twitches)

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3
Q

Max dose for neostigmine and edrophonium?

A

Neostigmine: 50 mcg/kg or 5 mg
Edrophonium: 1 mg/kg

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4
Q

Reversal of NMJ blockade is dependent on these 5 factors:

A
  1. Depth of block
  2. Drug choice (neo vs edro)
  3. Dose
  4. Rate of plasma clearance
  5. Anesthetic agent and depth
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5
Q

What is the onset and duration of neostigmine?

A

Onset: 5 - 10 min
Duration: 60 min

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6
Q

What is the dosage of edrophonium?

A

1 mg/kg

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7
Q

What is the onset and duration of edrophonium?

A

Onset: 1-2 min
Duration: 5-15 min

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8
Q

What is the formula for glycopyrrolate to be used with a NMB reversal drug?

A

0.2 mg of glycopyrrolate / mg of neostigmine

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9
Q

What is the max dose for glycopyrrolate?

A

1 mg

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10
Q

A 100 kg patient has 2/4 twitches. Neostigmine is available in 1 mg/mL vials. How much neostigmine will you give in mL?

A

5 mL (max dose of 5 mg)

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11
Q

What percentage of neostigmine is renally excreted?

A

50%

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12
Q

What percentage of both pyridostigmine and edrophonium are renally excreted?

A

75%

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13
Q

How are NMB reversal agents cleared if the patient has no innate renal function?

A

30 - 50% cleared hepatically

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14
Q

What is the major side effect of NMBD reversal agents?

A

↑PSNS activity (from increased nACh and mACh activity)

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15
Q

What drugs would be coupled with NMBD reversal agents to prevent adverse side effects from these drugs?

A

Anti-cholinergic / Anti-muscarinics

  • Atropine for edrophonium
  • Glycopyrrolate for neostigmine and pyridostigmine
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16
Q

If you’re concerned about someone’s cardiac status due to existing disease, which Anticholinergic drug would you use?

A

Glycopyrrolate

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17
Q

What is the dose of atropine for use with edrophonium?

A

10 mcg/kg

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18
Q

What common side effects are seen right after atropine administration?

A
  • Mydriasis
  • Tachycardia
19
Q

How long does glycopyrrolate need to be administered over?

20
Q

Mechanism of persistant NM blockade?
Treatment?

A
  • Maximum AChesterase inhibition
  • Sedation and post op ventilation
21
Q

What patient conditions may effect NMBD reversal?

A
  • Metabolic acidosis
  • Respiratory acidosis
  • Hypothermia
22
Q

What reversal drug is specific to mivacurium?

A

Purified human plasma cholinesterase

23
Q

What reversal drug is specific to gantacurium?

24
Q

What reversal drug is very specific to aminosteroids?

A

Sugammadex

25
Q

What type of drug is sugammadex?

A

Selective relaxant-binding agent

26
Q

What should be known about sugammadex’s organic structure and physical properties?

A
  • γ-cyclodextrin
  • Dextrose units from starch
  • Very H₂O-soluble
27
Q

What is the MOA of Sugammadex?

A

Encapsulates rocuronium via:

  • Van der Waals forces
  • H-bonds
  • Hydrophobic interactions
28
Q

What drugs does sugammadex work with best?

A

Roc > Vec > Pancuronium

29
Q

Where does suggamadex work?

A

It binds to NMB drug in the plasma

30
Q

What is the E ½ time of sugammadex?

31
Q

How is sugammedex eliminated?

A

Urine:

  • 70% gone in 6 hours
  • 90% gone in 24 hours
32
Q

When is sugammadex contraindicated?

A

Renal impairment on dialysis

33
Q

Differentiate a moderate block vs a deep block.

A
  • Moderate: 2/4 twitches on TOF
  • Deep: No twitches to TOF, but will have a twitch w/ post tetanic stimulation
34
Q

What is the Sugammadex dose for a moderate block?

35
Q

What is the Sugammadex dose for a deep block?

36
Q

What is the sugammadex dose for an extreme (overdose) block?

A

8 - 16 mg/kg

37
Q

What are the side effects of Sugammadex?

A
  • dose-related N/V
  • dose-related Pruritis
  • dose-related Urticaria
  • Anaphylaxis
  • Bradycardia
38
Q

If 1.2 mg/kg of rocuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

39
Q

If 0.6 mg/kg of rocuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

40
Q

If 0.1 mg/kg of vecuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

41
Q

What drugs/conditions are relative contraindications to sugammadex?

A
  • Contraceptives (7 days)
  • Toremifene (displaces roc from sugammadex)
  • Coagulopathy (↑ bleeding)
42
Q

What is recurarization?

A

Resumption of NMJ blockade after period of reversal

43
Q

What s/s would indicated recurarization?

Say you just brought the patient to PACU.

A
  • ↓ SpO₂
  • ↓ respiratory effort
  • Floppy/uncoordinated
  • Unresponsive
44
Q

What drugs and dose would be a good choice for a recurarizing patient in the PACU?
Why might this be a good choice?

A
  • Neostigmine 0.05 mg/kg IV
  • Longer duration of action
  • Re-sedate the patient so they don’t remeber being paralyzed while awake