NMBD Reversal Agents (4) Flashcards
What is another name fore neuromuscular monitoring?
Acceleromyography
What is the most common location nerve and muscles are monitored?
- Hand
- Adductor pollicis
- Ulnar nerve
List NMBD reversal agents:
- Edrophonium
- Neostigmine
- Suhhammadex
What anticholinergic drugs can be used for NMBD reversal?
- Atropine sulfate
- Glycopyrrolate
Why isnt physostigmine used for NMBD reversal?
Crosses BBB
What is the MOA of NMBD reversal agents? What type of antagonism do they create?
Acetylcholinesterase inhibitor (cholinergic agents)
Competitive antagonism
What does it mean that NMBD reversal agents have a ceiling effect?
They will not work with deep blockade
What is the dose for neostigmine for reversal?
40-70mcg/kg
MAX 5mg
What 5 things does reversal of NMBD depend on?
- Depth of the NM Block
- AchE Inhibitor choice
- Dose administered
- Rate of plasma clearance of NMBD
- Anesthesia agent choice and depth (Postoperative Residual NM Blockade)
What is the dose, onset, and duration of suggamadex?
2-16 mg/kg
onset: 1-4 min
duration: 1.5-3 hours
What is the drug classification of Sugammadex?
Gamma cyclodextrin
What is the dose, onset, duration and anticholinergic dose for neostigmine?
Dose: 40-70mcg/kg (0.04-0.07mg/kg)
Onset: 5-10 min
Duration: 60min
Anticholinergic: Glycopyrrolate 0.2mg/mg of neostigmine
What med do we give first before edrophonium?
Atropine (anticholinergic) so the HR increases first then give edrophonium to counter act the anticholinergic
What is the dose, onset, and duration of edrophonium?
Dose: 0.5-1 mg/kg
onset: 1-2 min
duration: 5-15 min
What dose of glyco is given with neostigmine?
0.2mg glyco/ mg of neostigmine
5mL
5mL
How is neostigmine excreted?
Renal excretion 50%
How is pyridostigmine and edrophonium excreted?
75% Renal excretion
How does chronic renal failure affect pharmacokinetics of NMBS reversal agents?
Decreases plasma clearance and prolongs action
What is the hepatic clearance of NMBD reversal agents if no renal function?
30-50%
What are some NMBD reversal side CV effects?
CV: Bradycardia, dysrhythmias, asystole, ↓SVR
What are NMBD reversal pulmonary side effects?
Pulmonary: Bronchoconstriction, increased airway resistance, increased salivation
What are GI side effects of NMB reversal drugs?
GI: Hyperperistalsis, enhanced gastric fluid secretion, PONV
What side effects with the eyes from NMB reversal drugs?
Miosis
What is the dose of atropine?
7-10 mcg/kg
*matches profile of edrophonium
What is the dose for glycopyrrolate?
7-15 mcg/kg (1mg max)
*matches profile of neostigmine
Why do we give anticholinergic/antimuscarinic drugs with NMB reversal drugs?
Prevention of side effects:
* Atropine (mydriasis and initial tachycardia)
What patient population would glycopyrrolate be preferred?
Cardiac disease→ administer slowly over 2-5 minutes
What is happening if there is a persistent NM bloackade?
MOA:
* Acetylcolinesterase is maximally inhibited
* No further anticholinesterase is effective
What is the primary intervention for persistent NM block?
Sedation and postop ventilation
What is the max for edrophonium?
1mg/kg
What drug was used to reverse Gantancurium?
Cystiene
What drug was used to reverse Mivacurium?
purified human plasma cholinesterases
What drug works by selective relaxant binding agents with aminosteroid (roc)?
Sugammadex
What are pharmacokinetics of sugammadex?
- Dextrose units from starch
- Highly water soluble
What NMBs does sugammadex work the best on?
Rocuronium > Vecuronium >Pancuronium
What is the MOA of sugammadex?
Tight reversal by encapsulation
Intermolecular forces (van der Waals) and thermodynamic bonds (H bonds) and hydrophobic interactions
Where does sugammadex work?
It reversed via encapsulations by binding the free drug in the plasma
How is sugammadex eliminated? What is the elimination 1/2 time?
Urine
* 70% in 6hrs
* 90% in 24hrs
E1/2T= 2 hours
When is sugammadex contraindicated?
Renal impairment on dialysis
What dose of sugammadex is given for moderate block? What constitutes a moderate block?
- Reappearance of 2nd twitch on TOF
- 2mg/kg
What dose of sugammadex is given for deep block? What constitutes a deep block?
- No twitch response to TOF, but has 1-2 post tetanic counts
- 4mg/kg
What dose of sugammadex is used with extreme blockade?
8-16 mg/kg
How does the rate of recovery compare when using sugammadex vs neostigmine to reverse rocuronium?
How does the rate of recovery compare when using sugammadex vs neostigmine to reverse vecuronium?
What are side effects of sugammadex?
Dose related:
* N/V
* Pruritus
* Urticaria
* anaphylaxis
* Marked bradycardia
* No effect (wont work to reverse)
What is the minimum wait time to re-administer Rocuronium after reversal has been given?
5 min→ then give 1.2mg/kg roc
What is the minimum wait time to re-administer Vecuronium after reversal has been given?
4 hours→ 0.1mg/kg vec (or 0.6mg/kg roc)
What if you have reversed a NMBD but then need to redose before the time constraints have passed?
Use non-steroidal neuromuscular blocking agent
What are cautions with sugammadex?
- Birth control: Binds with progesterone (7 days)
- Toremifene (anti estrogen): displaces NMBD from sugammadex
- Coagulopathy/bleeding
- Recurarization: lower than recommended doses
What is recurarization?
When neuromuscular blockade returns after it had been reversed (happens with lower than recommended doses)
“re-paralyzed patient”
What signs in PACU indicate recurarization?
- Decreasing SaO2
- Decreasing respiratory effort d/t pharyngeal collapse (worst case)
- Unresponsiveness
- floppy/uncoordinated
- unable to lift head/grasp
- ineffective abd/intercostal activity
Time to maximum block of each NMBD:
What are treatment goals for a patient with recurarization?
- urgent and aggressive treatment
- re-sedate
- Give more reversal agents in divided doses (neostigmine 0.5mg/kg= longer DOA)
