NMB Reversals Flashcards
1995 Prospective Study on Vecuronium:
* No NM monitoring
* No Reversal
What was the Post-Op Residual NM Blockade?
33% ( n=435)
2002, 2003, 2004 Studies on NMB
* Used NM monitoring
* Reversal Used
What was the Post-Op Residual NM blockade?
4%
What is another name for neuromuscular monitoring?
Acceleromyography
The most common location, nerve, and muscle monitor are?
- Hand
- Abductor Pollicis
- Ulnar Nerve
Clinical Duration Response of Pancuronium
86 minutes
Clinical Duration Response of Rocuronium
36 minutes
Clinical Duration Response of Vecuronium
44 minutes
Clinical Duration Response of Atracurium
46 minutes
Clincial Duration Response of Cistracurium
45 minutes
Clinical Duration Response of Mivacurium
8 minutes
Edrophonium is most commonly paired with _______.
Atropine Sulfate
Neostigmine is most commonly paired with ________.
Glycopyrrolate
Name the (3) NMB Reversal Agents
- edrophonium
- Neostigmine
- Sugammadex
Name the (2) Anti-Cholinergic Agents that are paired with NMBD Reversals
- Atropine
- Glycopyrrolate
Name the (3) Classifications for NMBD Reversal Agents
- Acetylcholine (AchE) Inhibitors
- Cholinergic Agents
- Competive Antagoinst
Time to Max Block: Panuronium
2.9 mins
Time to Max Block: Rocuronium
- 1.7 mins
Time to Max Block: Vecuronium
2.4 Mins
Time to Max Block: Atracurium
3.2 mins
Time to Max Block: Cistracurium
5.2 mins
Time to Max Block: Mivacurium
3.3 mins
Acetylcholinesterase (AchE) Inhibitors MOA:
* rapid ________ of ACH.
* AchE Inhibition = ______ Acetylcholine available.
* ACH binds to _______ subunits.
- Hydrolysis
- more
- alpha
Acetylcholinesterase is available at:
* _________ (SNS & PNS)
* _________ junction
- Preganglionic
- Neuromuscular Junction (NMJ)
Ceiling Effect of NMBD: Reversal Agents will not _______ with _____ NM Blockade
- work
- deep
Max dose of Neostigmine
Ceiling Dose
40 to 70 mcg/kg
Max dose of Edrophonium
ceiling dose
1mg/kg
Reversal of NM Blockade depends on (5) factors:
1. __________ of NM block
2. ________ inhibitor dose
3. ________ administed
4. Rate of Plasma __________ of NMBD
5. Anesthesia _________ of choice and depth (Post-Op Residual)
- Depth
- AchE
- Dose
- Clearance
- agent
Succinycholine (Anectine)
Dose/Onset/Duration
- 1-1.5 mg/kg
- 30-60 sec
- 5-10 mins
Cisatricurium (Nimbex)
Dose/onset/duration
- 0.1 mg/kg
- 2-3 mins
- 40-75 mins
Vecuronium (Norcuron)
dose/onset/duration
- 0.1 mg/kg
- 2-3 mins
- 45-90 mins
Rocuronium (Zemuron)
RSI dose
dose/onset/duration
- 1.2 mg/kg
- 1.5 mins
- 35-75 mins
Pancuronium (Pavulon)
dose/onset/duration
- 0.1 mg/kg
- 2-3 mins
- 60-120 mins
Rocuronium (Zemuron)
dose/onset/duration
- 0.6 mg/kg
- 2-3 mins
- 35-75 mins
Edrophonium
dose/onset/duration
- 0.5-1 mg/kg
- 1-2 mins
- 5-15 mins
Neostigmine
dose/onset/duration
- 40-70 mcg/kg
- 5-10 mins
- 60 mins
NMBD Reversal agents are excretely by the ________ and _________.
- Renal
- Hepatic
Renal Excretion of NMBD:
* Neostigmine ____%
* Edrophonium ____%
- 50%
- 75%
Chronic Renal failure _______ plasma clearance and causes a ________ action.
- decreases
- prolonged
If there is no Renal Function, _____% to ____% of NMBD will be excreted Hepatically.
- 30-50%
Name the (5) systems that will have side effects associated with NMBD.
- Nicotinic/Muscarinic
- CV
- Pulmonary
- GI
- Eyes
NMBD _______ Nicotinic/Muscarinic Activity
Increase
NMBD causes _________, dysrhythmias, _________, and ________ SVR
- Bradycardia
- asystole
- decreased
NMBD cause ______________, ____ airway resistance and _____ salivation in the Pulmonary system.
- bronchoconstriction
- increased
- increased
NMBD causes _________, _____ gastric fluid secretion and ________ in the GI system.
- hyperperistalsis
- enhanced
- PONV
NMBD causes ____ in the eyes.
Miosis
To prevent side-effects _____ and _____ is given with NMBD reversals.
- Atropine
- Glycopyrolate
Name the drug classifications for Atropine and Glycopyrrolate.
- Anti-Cholinergic
- Anti-Muscarinic
With Cardiac disease, what Anti-Cholinergic/Anti-Muscarinic is prefered?
- Glycopyrrolate
Glycopyrolate should be given slowly over ___ - ___ minutes
- 2-5 mins
Atropine Dose
- 7 -10 mcg/kg
Name (2) side effects of Atropine
- mydriasis
- initial tachycardia
Dose and Max Dose of Glycopyrolate
- 7-15 mcg/kg
- Max 1 mg
A Persistent NM blockade is created when ______ is maximally inhibited and no further ______________ is effective.
- Acetylcholinesterase
- anticholinesterase
With a peristent NM blockade, you need to ensure proper _______ and ______ _______.
- sedation
- postop ventilation
Name (5) Factors Influencing NMBD Reversal:
* __________ of block
* __________ used
* Continued __________ Anesthetic
* _________ Drug used
* Patient condition
- Intensity
- NMBD
- Volatile
- Reversal
- Patient condition
Metabolic _______ , Respiratory _______ and Hypothermia can all affect NMB.
- acidosis
- acidosis
Name (3) other Reversal Drugs for NMBD
- Purified human plasma cholinesterase
- Cystiene
- Sugammadex
Sugammadex is a selectively binding agent with _______.
- aminosteroids
- Rocuronium
Castillo kept relating Sugammadex to Roc in lcass. Notes say aminosteroi
Name the NMBD that Cystience works well with.
Gantacurium
AchE work by rapidly _______ of Acetylcholine.
- hydrolysis (catalyze)
Acetylcholine is available in the __________ and ________.
- Preganglionic (SNS & PNS)
- NMJ
Sugammadex is a γ- ________, containes ______ units from starch and is _______ water soluble.
- Cyclodextrin
- dextrose
- highly
Sugammadex MOA is due to its intermolecular (___ ____ ____) forces, thermodynamic (__________) bonds and hydrophobic interactions that causes a very tight reversal by __________.
- Van der Walls
- Hydrogen
- encapsulation
Name the (3) NMBD that Sugammadex reverses
- Rocuronium
- Vecuronium
- Pancuronium
Sugammadex bind to _____ drug in the plasma.
- Free
Sugammadex major route of elimination is the _______.
Urine
Sugammadex Moderate block Dose – reappearance of second twitch.
- 2mg/kg
Sugammadex dose for Deep Block — No twitch to TOF & 1-2 post-tentanic
- 4 mg/kg
The Elimination 1/2 time for Sugammadex is ___ hours.
- 2 hours
Sugammadex Dose with an extreme block
- 8 -16 mg/kg
Does Recurarization occur with Sugammadex?
- Not observed at appropriate dose.
Sugammade Side effects include N/V, ______, Urticaria, Anaphylaxis, _________, or it doesn’t work.
- Pruritus
- Bradycardia
Suggamedex can cause issues when given to patient taking ______ contraceptives and ____________.
- Oral Contraceptives
- Toremifene
Tomemifene (non-steroidal anti estrogen) _______ NMBD from Sugammadex.
- displaces
Sugammadex when given to a pt taking oral contraceptives can ________ with Progesterone for ___ day. Making the oral contraceptive __________.
- Bind
- 7
- inactive
Suggamadex can cause an increasing in __________/ __________ when given with Heparin/LMWH and can __________ PTT, PT and INR.
- Coagulopathy/Bleeding
- Elevated
Recurarization (re-paralyzation) can only occur with Suggamedex when given a _________ than recommended dose.
Lower
Recurarization is immediately apparent in PACU d/t declining _____ and _________ effort.
- SaO2
- Respiratory
Signs and Symptoms of Recurarization include decrease O2 sats, ________ patient, appears _________ or uncoordinated and ineffective _____ and intercostal activity.
*unresponsive
* floppy
* abdominal
Does Edrophonium or Neostigmine have a longer duration of action?
Neostigmine
Treatment of Recurarixation is to treat urgently and _______, ________ the patient, and give additional ______ agents in divided doses.
- aggressively
- re-sedate
- reversal
When a patient experiences recurarization, the can sometime verbalize a _________ feeling, are unable to sustain a _____ lift or hand ______. In worst case senario, _________ collapse and respiratory obstruction.
- suffocating
- head
- grasp
- pharnygeal
Which non-depolarizing NMBD has the longest time to maximum block?
Cistracurium (5.2 mins)
