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Neuromuscular Blockers (5.2) Flashcards

1
Q

Which subunits must be occupied to open the nicotinic receptor at the motor endplate?
a. alpha and alpha
b. alpha and gamma
c. alpha and delta
d. alpha and epsilon

NMBs

A

a. alpha and alpha

two alpha units; both must be occupied by an agonist (Ach or succ)

pre-lesson Q1

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2
Q

All of the following statements regarding extrajunctional nicotinic receptors are true except:
a. it’s opened by choline
b. an epsilon subunit replaces a gamma subunit
c. it opens for a longer period of time
d. denervation allows for its proliferation

NMBs

A

b. an epsilon subunit replaces a gamma subunit

other way around

pre-lesson Q2

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3
Q

Fade during train-of-four stimulation is caused by:
a. agonism of presynaptic nicotinic receptors
b. antagonism of presynaptic nicotinic receptors
c. impaired presynaptic acetylcholine reuptake
d. decreased acetylcholine synthesis

NMBs

A

b. antagonism of presynaptic nicotinic receptors

pre-lesson Q3

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4
Q

Identify the statement that best characterizes a phase 2 block following succinylcholine. (Select 2)
a. fade with tetany
b. post-tetanic potentiation is absent
c. constant but diminished response to double burst stimulation
d. prolonged duration

NMBs

A

a. fade with tetany
d. prolonged duration

occurs with excessive dose

pre-lesson Q4

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5
Q

Identify the most sensitive indicator of recovery from neuromuscular blockade.
a. nerve stimulator shows 4/4 twitches with no fade
b. tidal volume 6 mL/kg
c. vital capacity >20 mL/kg
d. inspiratory force better than -40 cm H2O

NMBs

A

d. inspiratory force better than -40 cm H2O

poss. when 50% or less receptors blocked; others are 70% or more blocked

pre-lesson Q5

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6
Q

Identify the statement that demonstrates the most accurate understanding of succinylcholine. (Select 2)
a. hypertension is a normal side effect
b. it’s an absolute contraindication with an open globe injury
c. severe sepsis increases the risk of hyperkalemia
d. masseter spasm warrants cancellation of the planned procedure

NMBs

A

a. hypertension is a normal side effect
c. severe sepsis increases the risk of hyperkalemia

pre-lesson Q6

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7
Q

Which enzymes hydrolyze succinylcholine? (Select 3)
a. butyrylcholinesterase
b. type 1 cholinesterase
c. true cholinesterase
d. pseudocholinesterase
e. plasma cholinesterase
f. acetylcholinesterase

NMBs

A

a. butyrlycholinesterase
d. pseudochoineserase
e. plasma cholinesterase

all the same thing

pre-lesson Q7

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8
Q

Which factors prolong the duration of succinylcholine? (Select 3)
a. metoclopramide
b. edrophonium
c. obesity
d. late-stage pregnancy
e. myasthenia gravis
f. esmolol

NMBs

A

a. metoclopramide
d. late-stage pregnancy
f. esmolol

reduce pseudocholinesterase activity; myasthenia gravis is resistant

pre-lesson Q8

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9
Q

A patient with a dibucaine number of 20 received succinylcholine. This patient:
a. is heterozygous for pseudocholinesterase
b. fails to produce pseudocholinesterase in sufficient quantity
c. should receive FFP
d. will be paralyzed for eight hours

NMBs

A

d. will be paralyzed for eight hours

qualitative defect, homozygous patient

pre-lesson Q9

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10
Q

The routine administration of succinylcholine is contraindicated in young children because of the possibility of:
a. malignant hyperthermia
b. hyperkalemic rhabdomyolysis
c. trismus
d. bradycardia

NMBs

A

b. hyperkalemic rhabdomyolysis

pre-lesson Q10

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11
Q

Identify the patient at the highest risk for developing postoperative myalgia following succinylcholine.
a. 6-year-old boy for strabismus correction
b. 24-year-old female for umbilical hernia repair
c. 35-year-old pregnant patient for appendectomy
d. 86-year-old male for total hip arthroplasty

NMBs

A

b. 24-year-old female for umbilical hernia repair

children, elderly, pregnant patients have lowest incidence

pre-lesson Q11

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12
Q

Which diseases are associated with hyperkalemia following succinylcholine administration? (Select 3)
a. hyperkalemic periodic paralysis
b. multiple sclerosis
c. hypokalemic periodic paralysis
d. myotonic dystrophy
e. Huntington chorea
f. Guillain-Barre

NMBs

A

a. hyperkalemic periodic paralysis
b. multiple sclerosis
f. Guillain-Barre

pre-lesson Q12

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13
Q

Rank the nondepolarizing neuromuscular blockers in terms of potency. (1 most potent, 4 least potent)
a. pancuronium
b. rocuronium
c. cisatracurium
d. atracurium

NMBs

A
  1. cisatracurium
  2. pancuronium
  3. atracurium
  4. rocuronium

pre-lesson Q13

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14
Q

Match each drug with the primary event that terminates its effect.
1. rocuronium
2. pancuronium
3. atracurium
4. cisatracurium
a. biliary excretion
b. renal excretion
c. non-specific ester hydrolysis
d. Hofmann elimination

NMBs

A

1a (rocuronium biliary excretion)
2b (pancuronium renal excretion)
3c (atracurium non-specific ester hydrolysis)
4d (cisatracurium Hofmann elmination)

pre-lesson Q14

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15
Q

Which drugs potentiate neuromuscular blockade? (Select 3)
a. desflurane
b. gentamycin
c. phenytoin
d. mannitol
e. dantrolene
f. hydrocortisone

NMBs

A

a. desflurane
b. gentamycin
e. dantrolene

pre-lesson Q15

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16
Q

Which condition precludes the use of pancuronium?
a. aortic regurgitation
b. hypertrophic cardiomyopathy
c. first degree AV block
d. bradycardia

NMBs

A

b. hypertrophic cardiomyopathy

increases HR, bad for HCM

pre-lesson Q16

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17
Q

Which neuromuscular blocker is most likely to cause anaphylaxis?
a. atracurium
b. cisatracurium
c. succinylcholine
d. rocuronium

NMBs

A

c. succinylcholine

pre-lesson Q17

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18
Q

Select the most sensitive clinical endpoint of recovery from a neuromuscular blocker.
a. tidal volume
b. vital capacity
c. inspiratory force
d. double burst stimulation

NMBs

A

c. inspiratory force

post lesson quiz

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19
Q

What muscles are the slowest to undergo spontaneous recovery after rocuronium administration? (Select 2)
a. adductor pollicis
b. corrugator supercilii
c. diaphragm
d. flexor hallucis

NMBs

A

a. adductor pollicis
d. flexor hallucis

post lesson quiz

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20
Q

Which enzymes are present in the synaptic cleft? (Select 2)
a. butyrylcholinesterase
b. specific cholinesterase
c. false cholinesterase
d. type 1 cholinesterase

NMBs

A

b. specific cholinesterase
d. type 1 cholinesterase

post lesson quiz

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21
Q

Which neuromuscular blocker should be avoided in the patient with a spinal cord transection that occurred 3 months ago?
a. atracurium
b. mivacurium
c. succinylcholine
d. rocuronium

NMBs

A

c. succinylcholine

avoid within 24-48 hours then after 1 year following injury

post lesson quiz

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22
Q

Which neuromuscular blocker is capable of producing a phase 1 block?
a. succinylcholine
b. pancuronium
c. cisatracurium
d. vecuronium

NMBs

A

a. succinylcholine

post lesson quiz

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23
Q

Succinylcholine carries a black box warning in children due to the risk of undiagnosed:
a. anaphylaxis
b. skeletal muscle myopathy
c. malignant hyperthermia
d. rhabdomyolysis

NMBs

A

b. skeletal muscle myopathy

post lesson quiz

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24
Q

A 6-year-old male experiences cardiovascular collapse following succinylcholine. What treatment is the first priority?
a. defibrillation
b. epinephrine
c. fluid administration
d. calcium chloride

NMBs

A

d. calcium chloride

immediately need to treat hyperkalemia

post lesson quiz

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25
Which conditions are most likely to cause residual neuromuscular blockade following cisatracurium administration? (Select 2) a. alkalosis b. hyperthermia c. acidosis d. hypothermia ## Footnote NMBs
c. acidosis d. hypothermia ## Footnote post lesson quiz
26
Which conditions necessitate a dose reduction for rocuronium? (Select 2) a. hyperkalemic periodic paralysis b. Duchenne muscular dystrophy c. Charcot-Marie-Tooth d. Multiple sclerosis ## Footnote NMBs
b. Duchenne muscular dystrophy d. Multiple sclerosis | more sensitive ## Footnote post lesson quiz
27
Which neuromuscular blocker does not produce an active metabolite? a. rocuronium b. vecuronium c. succinylcholine d. atracurium ## Footnote NMBs
a. rocuronium ## Footnote post lesson quiz
28
All of the following ions pass through the nicotinic receptor at the neuromuscular junction except: a. calcium b. potassium c. chloride d. sodium ## Footnote NMBs
c. chloride ## Footnote review exam
29
Succinylcholine is metabolized by: (Select 2) a. type 1 cholinesterase b. butyrylcholinesterase c. acetylcholinesterase d. plasma cholinesterase ## Footnote NMBs
b. butyrylcholinesterase d. plasma cholinesterase ## Footnote review exam
30
Which antiemetic can prolong succinylcholine's duration of action? a. scopolamine b. ondansetron c. metoclopramide d. droperidol ## Footnote NMBs
c. metoclopramide | impairs the ability of pseudocholinesterase ## Footnote review exam
31
Interpret each dibucaine number. 1. 20 2. 50 3. 80 a. homozygous atypical plasma cholinesterase b. homozygous typical plasma cholinesterase c. heterozygous atypical plasma cholinesterase ## Footnote NMBs
1a 2c 3b | DOA homo-typical 5-10" hetero-atypical 20-30" homo-atypical 4-8' ## Footnote review exam
32
All of the following have been shown to reduce the incidence of postoperative myalgia following the administration of succinylcholine except: a. lidocaine b. ketorolac c. fentanyl d. use of a higher dose rather than a lower dose of succinylcholine ## Footnote NMBs
c. fentanyl | NSAIDs, lido 1.5 mg/kg, and a higher dose may reduce the risk of myalgia ## Footnote review exam
33
Which neuromuscular blocking agents are aminosteroid compounds? (Select 2) a. mivacurium b. vecuronium c. atracurium d. pancuronium ## Footnote NMBs
b. vecuronium d. pancuronium | also rocuronium ## Footnote review exam
34
Match each neuromuscular blocker with its ED95. 1. vecuronium 2. succinylcholine 3. atracurium a. 0.30 mg/kg b. 0.21 mg/kg c. 0.04 mg/kg ## Footnote NMBs
1c 2a 3b | higher dose = lower potency = higher ED95 ## Footnote review exam
35
The duration of action of cisatracurium is prolonged by: a. hypothermia b. metabolic alkalosis c. hepatic failure d. homozygous atypical pseudocholinesterase ## Footnote NMBs
a. hypothermia | also metabolic acidosis ## Footnote review exam
36
Choose the best neuromuscular blockers to administer to a patient with hypertrophic cardiomyopathy. (Select 2) a. pancuronium b. atracurium c. cisatracurium d. vecuronium ## Footnote NMBs
c. cisatracurium d. vecuronium | pancuronium=inc. HR atracurium release histamine =inc. HR,dec. afterload ## Footnote review exam
37
Which inhaled anesthetic potentiates the neuromuscular blocking effect of nondepolarizing neuromuscular blockers the most? a. isoflurane b. desflurane c. nitrous oxide d. sevoflurane ## Footnote NMBs
b. desflurane | des>sevo>iso>N2O>prop ## Footnote review exam
38
Which antibiotics prolong the duration of action of vecuronium? (Select 2) ## Footnote NMBs
Gentamycin Clindamycin ## Footnote review exam
39
Which of the following neuromuscular blockers is most likely to increase airway resistance? a. cisatracurium b. mivacurium c. rocuronium d. pancuronium ## Footnote NMBs
b. mivacurium | stimulate histamine release ## Footnote review exam
40
Select the best intraoperative test to confirm the diagnosis of an anaphylactic response caused by a neuromuscular blocker? a. intradermal skin test b. homocysteine c. tryptase d. white blood cell count with differential ## Footnote NMBs
tryptase | elevated level consistent with mast cell degranulation; peaks 15-120 min ## Footnote review exam
41
Select the best location to monitor the onset of neuromuscular blockade. a. oculomotor nerve b. trigeminal nerve c. facial nerve d. ulnar nerve ## Footnote NMBs
c. facial nerve | muscle: orbicularis oculi/corrugator supercilii ## Footnote review exam
42
Match each muscle with its mechanical action. 1. corrugator supercilii 2. medial rectus 3. orbicularis oculi 4. adductor pollicis a. closes the eyelid b. adducts the eyeball c. moves the eyebrow d. adducts the thumb ## Footnote NMBs
1c (CN VII) 2b (CN VII) 3a (ulnar nerve) 4d (CN III) ## Footnote review exam
43
The adductor pollicis muscle can be stimulated by placing the negative electrode at: a. posterior aspect of thumb web b. base of thumb c. distal aspect of ulnar side of wrist d. 4 cm from c ## Footnote NMBs
b. base of thumb c. distal aspect of ulnar side of wrist | a & b = direct muscle stimulation red is Positive & Proximal ## Footnote review exam
44
The risk of pulmonary aspiration increased when the train-of-four ratio measured at the adductor pollicis is less than: a. 0.9 b. 0.8 c. 0.7 d. 0.6 ## Footnote NMBs
a. 0.9 | assoc. w/impaired pharyngeal fcn & swallowing & dec. up esoph. sphincter ## Footnote review exam
45
Which finding is most consistent with recovery from neuromuscular blockade in a 70 kg patient? a. tidal volume = 350 mL b. train-of-four monitor reveals 4 equal twitches c. vital capacity = 1400 mL d. patient holds tongue blade in mouth against force ## Footnote NMBs
d. patient holds tongue blade in mouth against force ## Footnote review exam
46
Where does Ach bind to the post-junctional nicotinic receptor at the NMJ? ## Footnote NMBs
Alpha subunits; 2 Ach molecules must simultaneously occupy the two alpha subunits of the postsynaptic nicotinic receptor ## Footnote lesson 1 flashcard
47
Why don't anions pass through the postsynaptic nicotinic receptor channel? ## Footnote NMBs
They're repelled by the negative charge in the channel ## Footnote lesson 1 flashcard
48
How is the action of Ach terminated at the postjunctional nicotinic receptor? ## Footnote NMBs
1. Ach is metabolized by acetylcholinesterase to choline & acetate 2. It diffuses away from the receptor ## Footnote lesson 1 flashcard
49
Why is upregulation of extrajunctional receptors dangerous? ## Footnote NMBs
The presence of extrajunctional receptors predisposes the patient to hyperkalemia, especially after the administration of succinylcholine ## Footnote lesson 2 flashcard
50
What pathologic states promote the proliferation of extrajunctional receptors? ## Footnote NMBs
-upper and lower motor neuron injury -spinal cord injury -burns -CVA -muscular dystrophy -sepsis -skeletal muscle trauma ## Footnote lesson 2 flashcard
51
How soon should succinylcholine be avoided after an injury that causes extrajunctional receptors to proliferate? ## Footnote NMBs
24-48 hours ## Footnote lesson 2 flashcard
52
What role does Ca++ play in the presynaptic nerve terminal at the NMJ? ## Footnote NMBs
Ca++ influx (due to depolarization of the nerve terminal), destabilizes the proteins that hold the Ach vesicles in place; this step is required for the Ach vesicles to be released via exocytosis ## Footnote lesson 3 flashcard
53
What is the role of the presynaptic Nn receptors in the synaptic cleft? ## Footnote NMBs
Ach binds to these receptors, which stimulates the mobilization of Ach vesicles inside the presynaptic nerve ## Footnote lesson 3 flashcard
54
What causes fade during train-of-four stimulation? ## Footnote NMBs
antagonism of presynaptic Nn receptors by nondepolarizing neuromuscular blockers ## Footnote lesson 3 flashcard
55
Describe phase 1 blockade ## Footnote NMBs
-no fade -no post-tetanic potentiation -normally seen with succinylcholine ## Footnote lesson 4 flashcard
56
Describe phase 2 blockade ## Footnote NMBs
-fade -post-tetanic potentiation present -normally seen with non-depolarizers ## Footnote lesson 4 flashcard
57
Name 2 situations that increase the risk of a phase 2 block from succinylcholine ## Footnote NMBs
-dose >7-10 mg/kg -greater than 30-60 minutes of continuous exposure (IV infusion) ## Footnote lesson 4 flashcard
58
What is the best place to measure the onset of neuromuscular blockade? ## Footnote NMBs
orbicularis oculi (closed eyelid) or corrugator supercilii (eyebrow twitch) ## Footnote lesson 5 flashcard
59
What is the best nerve to monitor the onset of neuromuscular blockade? ## Footnote NMBs
facial nerve (CN 7) ## Footnote lesson 5 flashcard
60
Where are the best 2 places to measure the recovery of neuromuscular blockade? ## Footnote NMBs
1. adductor pollicis 2. flexor hallucis ## Footnote lesson 5 flashcard
61
What are the 2 best nerves to monitor the recovery of neuromuscular blockade? ## Footnote NMBs
1. unlar nerve 2. posterior tibial nerve ## Footnote lesson 5 flashcard
62
Name 7 side effects of succinylcholine. ## Footnote NMBs
1. bradycardia 2. tachycardia 3. potassium release 4. inc. ocular pressure 5. inc. ICP 6. inc. intragastric pressure 7. malignant hyperthermia ## Footnote lesson 6 flashcard
63
Why does succinylcholine produce bradycardia and tachycardia? ## Footnote NMBs
1. bradycardia: stimulation of the M2 receptor in the SA node 2. tachycardia: mimics the action of Ach at the sympathetic ganglia ## Footnote lesson 6 flashcard
64
How much does an induction dose of succinylcholine raise serum potassium? ## Footnote NMBs
Serum K+ increases by 0.5-1.0 mEq/L ## Footnote lesson 6 flashcard
65
Metabolizes acetylcholine: ## Footnote NMBs
-acetylcholinesterase -genuine cholinesterase -type 1 cholinesterase -true cholinesterase -specific cholinesterase | primary location: NMJ ## Footnote lesson 7 flashcard
66
Metabolizes succinylcholine, mivacurium, and ester LAs ## Footnote NMBs
-butyrylcholinesterase -pseudocholinesterase -type 2 cholinesterase -false cholinesterase -plasma cholinesterase | primary location: plasma ## Footnote lesson 7 flashcard
67
List 7 drugs that reduce pseudocholinesterase activity. ## Footnote NMBs
1. metoclopramide 2. esmolol 3. neostigmine 4. echothiopate 5. oral contraceptives 6. cyclophosphamide 7. MAO inhibitors ## Footnote lesson 8 flashcard
68
List 8 conditions that reduce pseudocholinesterase activity. ## Footnote NMBs
1. atypical PChE 2. severe liver disease 3. chronic renal failure 4. burns 5. neoplasm 6. advanced age 7. malnutrition 8. late-stage pregnancy ## Footnote lesson 8 flashcard
69
How long is succinylcholine expected to last in the patient with the following plasma cholinesterase variants? 1. typical homozygous 2. heterozygous 3. atypical homozygous ## Footnote NMBs
1. 5-10 minutes 2. 20-30 minutes 3. 4-8 hours ## Footnote lesson 9 flashcard
70
List 5 types of skeletal muscle dystrophy. ## Footnote NMBs
1. Duchenne 2. Becker 3. Emery-Dreifuss 4. Facioscapulohumeral 5. Limb-girdle ## Footnote lesson 10 flashcard
71
Why does succinylcholine have a black box warning from the FDA? ## Footnote NMBs
It can cause cardiac arrest and sudden death secondary to hyperkalemia in children with undiagnosed skeletal muscle myopathy. ## Footnote lesson 10 flashcard
72
What is the dose of calcium chloride that should be administed to a child with succinylcholine-induced hyperkalemia? ## Footnote NMBs
20 mg/kg ## Footnote lesson 10 flashcard
73
Who is at greatest risk for succinylcholine-induced myalgia? ## Footnote NMBs
young adults undergoing ambulatory surgery (women>men) and those that don't routinely engage in stenuous activity ## Footnote lesson 11 flashcard
74
Who is at the lowest risk for succinylcholine-induced myalgia? ## Footnote NMBs
children, the elderly, pregnant patients ## Footnote lesson 11 flashcard
75
Can a nondepolarizing agent be used to prevent the risk of succinylcholine-induced myalgia? ## Footnote NMBs
yes ## Footnote lesson 11 flashcard
76
Besides nondepolarizing NMBs, what other drugs help to reduce the risk of succinylcholine-induced myalgia? ## Footnote NMBs
-NSAIDs -lidocaine 1.5 mg/kg -using a higher dose instead of a lower dose of succinylcholine ## Footnote lesson 11 flashcard
77
Diseases susceptible to succinylcholine-induced hyperkalemia ## Footnote NMBs
-Guillain-Barre -ALS -Charcot-Marie-Tooth -multiple sclerosis | no effect: myasthenia gravis, huntingtons, myotonic dystrophy ## Footnote lesson 12 flashcard
78
Which co-existing diseases increase sensitivity to nondepolarizing NMBs? ## Footnote NMBs
-Multiple Sclerosis -Duchenne Muscular Dystrophy -Amyotrophic Lateral Sclerosis -Huntington Chorea -Guillain Barre -Myasthenia Gravis | no change: MH, Charcot-Marie-Tooth, Hyperkalemic periodic paralysis ## Footnote lesson 12 flashcard
79
Short-acting NMB ## Footnote NMBs
mivacurium ## Footnote lesson 13 flashcard
80
Intermediate-acting NMB ## Footnote NMBs
Cisatracurium Atracurium Rocuronium Vecuronium ## Footnote lesson 13 flashcard
81
Long-acting NMB ## Footnote NMBs
pancuronium ## Footnote lesson 13 flashcard
82
Name 2 NMBAs that don't produce an active metabolite. ## Footnote NMBs
1. rocuronium 2. mivacurium ## Footnote lesson 14 flashcard
83
Which NMBs produce laudanosine? ## Footnote NMBs
cisatracurium atracurium ## Footnote lesson 14 flashcard
84
List 4 neuromuscular blockers that undergo organ-independent elimination? ## Footnote NMBs
1. atracurium 2. cisatracurium 3. mivacurium 4. succinylcholine ## Footnote lesson 14 flashcard
85
Where is each drug metabolized? 1. atracurium 2. cisatracurium 3. mivacurium 4. rocuronium 5. vecuronium 6. pancuronium ## Footnote NMBs
1. Plasma: ester hydrolysis + Hofmann elimination 2. Plasma: Hofmann elimination 3. Plasma: Pseudocholinesterase 4. None-biliary excretion 5. Liver 6. Liver ## Footnote lesson 14 flashcard
86
Which inhaled anesthetic potentiates NMBs the most? ## Footnote NMBs
desflurane ## Footnote lesson 15 flashcard
87
Which inhaled anesthetic potentiates NMBs the least? ## Footnote NMBs
nitrous oxide ## Footnote lesson 15 flashcard
88
List 4 electrolyte disorders that potentiate neuromuscular blockade. ## Footnote NMBs
1. Decreased Ca++ 2. Decreased K+ 3. Increased Mg++ 4. Increased Li++ ## Footnote lesson 15 flashcard
89
Why does hypothermia potentiate neuromuscular blockade? ## Footnote NMBs
hypothermia reduces the metabolism and clearance of neuromuscular blockers ## Footnote lesson 15 flashcard
90
List 3 neuromuscular blockers that can alter the heart rate independent of histamine release. ## Footnote NMBs
1. succinylcholine 2. pancuronium 3. rocuronium (maybe) ## Footnote lesson 16 flashcard
91
Which neuromuscular blocker can cause tachycardia by stimulating the autonomic ganglia? ## Footnote NMBs
succinylcholine ## Footnote lesson 16 flashcard
92
NMBs that cause histamine release ## Footnote NMBs
mivacurium atracurium succinylcholine ## Footnote lesson 16 flashcard
93
What 2 neuromuscular blockers are most likely to cause anaphylaxis? ## Footnote NMBs
1. succinylcholine (most likely) 2. rocuronium ## Footnote lesson 17 flashcard
94
What enzyme is measured to diagnose an anaphylactic reaction? ## Footnote NMBs
tryptase; an elevated tryptase level reflects mast cell and basophil degranulation and peaks between 15-120 minutes after exposure ## Footnote lesson 17 flashcard

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