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KM (Spring 2024) Anesthesia Pharm ** > *NMBD Reversal Agents (Exam IV) > Flashcards

*NMBD Reversal Agents (Exam IV) Flashcards

1
Q

What are the 3 classifications of NMBD Reversal Agents?

A
  1. AcetylcholineEsterase (AchE) Inhibitors
  2. Cholinergic Agents
  3. COMPETITIVE ANTAGONISTS

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2
Q

What is the MOA if AChE

A
  • Rapid hydrolysis (catalyze) of Ach

Inhibition of Esterase enzyme = more Acetylcholine available → Ach binds to alpha subunits

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3
Q

Where is AChE available at?

A
  • Preganglionic (SNS & PNS)
  • NMJ: neuromuscular junction

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4
Q

Do AChE inhibitors work with deep neuromuscular blockade?

A

No

S10

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5
Q

What do we do when patient has deep NM blocked according to Dr. Castillo?

A

WAIT
until we get a TOF and Tetany

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6
Q

What is the max dosage of neostigmine?

A

40 - 70 mcg/kg

0.04 - 0.07 mg/kg

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7
Q

What is the max dosage of edrophonium?

A

1 mg/kg

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8
Q

Reversal of NMJ blockade is dependent on these 5 factors:

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

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9
Q

What is the ED50 and ED90 of Pancuronium?

A

ED50 = 0.036

ED90 = 0.067

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10
Q

What is the ED50 and ED90 of Rocuronium?

A

ED50 = 0.147

ED90 = 0.305

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11
Q

What is the ED50 and ED90 of Vecuronium?

A

ED50 = 0.027

ED90 = 0.043

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12
Q

What is the ED50 and ED90 of Atracurium?

A

ED50 = 0.12

ED90 = 0.21

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13
Q

What is the ED50 and ED90 of Cisatracurium?

A

ED50 = 0.026

ED90 = 0.040

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14
Q

What is the ED50 and ED90 of Mivacurium?

A

ED50 = 0.039

ED90 = 0.067

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15
Q

What is the onset and duration of neostigmine?

A

Onset: 5 - 10 mins
Duration: 60 mins

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16
Q

What is the dosage of edrophonium?

A

0.5 to 1 mg/kg

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17
Q

What is the onset and duration of edrophonium?

A

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

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18
Q

What percentage of neostigmine is renally excreted?

A

50%

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19
Q

What percentage of both pyridostigmine and edrophonium are renally excreted?

A

75%

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20
Q

How does Chronic Renal Failure affect NMBD reversal agents?

A

decreases plasma clearance
→ prolonged action

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21
Q

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

A

30 - 50% cleared hepatically

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22
Q

What is the major side effect of NMBD reversal agents?

A

Increased Nicotinic/Muscarinic Activity

S17

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23
Q

What CV side effects of NMBD Reversal Agents?

A
  • Bradycardia
  • dysrhythmias
  • asystole
  • ↓SVR

S17

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24
Q

What pulmonary side effects of NMBD Reversal Agents?

A
  • Bronchoconstriction
  • increased airway resistance
  • increased salivation

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25
Q

What GI side effects of NMBD Reversal Agents?

A
  • Hyperperistalsis
  • enhanced gastric fluid secretion
  • PONV

S17

26
Q

What opthalmic side effects of NMBD Reversal Agents?

A

Miosis

S17

27
Q

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

A

Anti-cholinergic / Anti-muscarinics

  • Atropine
  • Glycopyrrolate

S18

28
Q

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

A

Glycopyrrolate

S18

29
Q

What NMBD Reversal(s) is glycopyrrolate used with?

A
  • Neostigmine
  • Pyridostigmine

S18

30
Q

What NMBD Reversal(s) is atropine used with?

A

Edrophonium

S18

31
Q

What is the dose of Atropine?

A

7 - 10 mcg/kg

S18

32
Q

What common side effects are seen right after atropine administration?

A
  • Mydriasis
  • Tachycardia

S18

33
Q

What is the maximum dose of glycopyrrolate?

A

1mg max dose

S18

34
Q

How long does glycopyrrolate need to be administered over?

A

2 - 5 min

administer SLOWLY

S18

35
Q

What is the mechanism when there is persistent NM blockade?

A
  • Acetylcholinesterase is maximally inhibited
  • No further anticholinesterase is effective

S20

36
Q

What is the intervention for persistent NM blockade?

A

Sedation and postop ventilation

S20

37
Q

What do you need to do before giving paralytics during Induction according to Dr. Castillo?

A

CHECK YOUR BASELINE TOF!!

(make sure to test the TOF and it has adequate batteries also)

38
Q

What factors influencing NMBD Reversal?

A
  • Intensity of block
  • Which NMBD did you use (renal vs liver)?
  • Continued volatile anesthetic?
  • Which reversal drug are you using?
  • Patient conditions
    -Metabolic acidosis
    -Respiratory acidosis
    -Hypothermia

S21

39
Q

What to do when titrating down Glycopyrrolate according to Dr. Castillo?

A

Be careful with titrating down and DO NOT go below 50%

NMBD Reversal Agents

40
Q

What reversal drug is specific to mivacurium?

A

Purified human plasma cholinesterase

S22

41
Q

What reversal drug is specific to Gantacurium?

A

Cystiene

S22

42
Q

What reversal drug is very specific to rocuronium?

A

Sugammadex

S22

43
Q

What type of drug is sugammadex?

A

Selective relaxant-binding agent

S22

44
Q

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

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

S24

45
Q

What is the MOA of Sugammadex?

A

Encapsulates rocuronium via:

  • Intermolecular (Van der Waals forces)
  • Thermodynamic (H-bonds)
  • Hydrophobic interactions

S25

46
Q

What drugs does sugammadex work with?

A

Roc > Vec > Pancuronium

S25

47
Q

Where does Sugammadex binds to?

A

The “free drug” in plasma

S25

48
Q

What is the E ½ time of sugammadex?

A

2 hours

S26

49
Q

How is sugammedex eliminated?

A

Urine:

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

Renal impairment: cleared with dialysis

S26

50
Q

What is the Sugammadex dose for a moderate block?

A

2 mg/kg

S27

51
Q

What is the Sugammadex dose for a deep block?

A

4 mg/kg

S27

52
Q

Differentiate a moderate block vs a deep block.

A
  • Moderate: 2/4 twitches on TOF
  • Deep: No twitches to TOF

S27

53
Q

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

A

8 - 16 mg/kg

S28

54
Q

What are the side effects of Sugammadex?

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

S31

55
Q

What is the NMBD and dose to administer after waiting 5 minutes after Reversal?

A

1.2 mg/kg ROCuronium

S32

56
Q

What is the NMBD and dose to administer after waiting 4 hours after Reversal?

A

0.6 mg/kg ROCuronium

or

0.1 mg/kg VECuronium

S32

57
Q

What drugs/conditions are relative contraindications to sugammadex?

A
  • Contraceptives
  • Toremifene (displaces NMBD from sugammadex)
  • Coagulopathy
  • ESRD (excreted renally)
  • Recurarization (lower than recommended dose)

S33

58
Q

What is
Recurarization?

A

aka REPARALYZED the patient

Resumption of NMJ blockade after period of reversal

S36

59
Q

What s/s would indicate recurarization?

Say you just brought the patient to PACU.

A
  • ↓ SpO₂
  • Unresponsive
  • Floppy/uncoordinated
  • ineffective abdominal and intercostal activity

S36

60
Q

What drug 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

S38

61
Q

What specific s/s of Recurarization?

A
  • sometimes can verbalize: suffocating feeling
  • unable to sustain head lift or hand grasp
  • worst case: pharyngeal collapse and respiratory obstruction

S40

62
Q

What are treatments goals of Recurarization?

A

Treat urgently and aggressively
* Re-sedate the patient
* Give additional reversal agents in divided doses (Neostigmine 0.05 mg/kg IV = longer duration of action).

S40

KM (Spring 2024) Anesthesia Pharm ** (101 decks)

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