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COPY Anesthesia Pharm (Spring 2023) > NMBD Reversal Agents (Exam IV) > Flashcards

NMBD Reversal Agents (Exam IV) Flashcards

1
Q

How long, generally, until NMJ blockade is fully reversed with neostigmine?

A

20-30 min

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2
Q

What is the clinical duration of response for ND-NMBD?
- Pancuronium
- Rocuronium
- Vecuronium
- Atracurium
- Cisatracurium
- Mivacurium

A

Pancuronium - 86 mins
Rocuronium - 36 mins
Vecuronium - 44 mins
Atracurium - 46 mins
Cisatracurium - 45 mins
Mivacurium - 16.8 mins

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3
Q

Do AChE inhibitors work with DEEP neuromuscular blockade? what is this called?

A

No
Ceiling effect

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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

Which paralytic has to be reconstituted with 10mL of H₂O ?

A

Vecuronium

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6
Q

What is the max dosage of neostigmine?

A

40 - 70 mcg/kg

0.04 - 0.07 mg/kg
5mg

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7
Q

What is the onset and duration of neostigmine?

A

Onset: 5 - 10 min
Duration: 60 min

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8
Q

What is the dosage of edrophonium?

A

0.5 - 1 mg/kg

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9
Q

What is the max dosage of edrophonium?

A

1- 1.5 mg/kg

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10
Q

What is the onset and duration of edrophonium?

A

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

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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?
CV, pulmonary, GI, eyes?

A

↑PSNS activity (from increased nACh and mACh activity)
CV: bradycardia, dysrhythmias, asystole, decreased SVR
Pulm: bronchoCONSTRICTION, increased airway resistance, increased salivation
GI: hyperperistalsis, enhanced gastric fluid secretion, PONV
Eyes: Miosis

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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
  • Glycopyrrolate
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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 NMBD(s) is glycopyrrolate used with?

A
  • Neostigmine
  • Pyridostigmine
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18
Q

What NMBD(s) is atropine used with?

A

Edrophonium

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19
Q

What is the dose of Atropine?

A

7 - 10 mcg/kg

20
Q

What common side effects are seen right after atropine administration?

A
  • Mydriasis
  • Tachycardia
21
Q

What is the maximum dose of glycopyrrolate?

A

1mg max dose

22
Q

How long does glycopyrrolate need to be administered over?

A

2 - 5 min

23
Q

What reversal drug is specific to mivacurium?

A

Purified human plasma cholinesterase

24
Q

What reversal drug is specific to gantacurium?

A

Cystiene

25
Q

What reversal drug is very specific to rocuronium?

A

Sugammadex

26
Q

What type of drug is sugammadex?

A

Selective relaxant-binding agent w/ aminosteroids

27
Q

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

A
  • γ-cyclodextrin
  • Dextrose units from starch
  • Very H₂O-soluble
28
Q

What is the MOA of Sugammadex?

A

Encapsulates rocuronium via:

  • Intramolecular (Van der Walls) forces
  • Thermodynamic (Hydrogen) bonds
  • Hydrophobic interactions
29
Q

True/False: Sugammadex binds to “free drug” in plasma

A

TRUE

30
Q

What drugs does sugammadex work with?

A

Roc > Vec > Pancuronium

31
Q

What is the E ½ time of sugammadex?

A

2 hours

32
Q

How is sugammedex eliminated?

A

Urine:

  • 70% gone in 6 hours
  • 90% gone in 24 hours
33
Q

Differentiate a moderate block vs a deep block.

A
  • Moderate: 2/4 twitches on TOF
  • Deep: No twitches to TOF
34
Q

What is the Sugammadex dose for a moderate block?

A

2 mg/kg

35
Q

What is the Sugammadex dose for a deep block?

A

4 mg/kg

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
  • Bradycardia (get glycopyrrolate and atropine ready)
  • dose-related N/V
  • dose-related Pruritis
  • dose-related Urticaria
  • anaphylaxis
38
Q

What is the dose of Roc and Vec after reversal for a minimum waiting time of 5 minutes and 4 hours?
what NMBD can you give right after reversal w/ sugammadex instead and why?

A

5 mins: 1.2 mg/kg roc
4 hours: 0.6 mg/kg roc or 0.1 mg/kg vec

can give benzylisoquinolone (atracurium, Cisatracurium, mivacurium) right after sugammadex bc not a aminosteroid?

39
Q

What drugs/conditions are relative contraindications to sugammadex?

A
  • Contraceptives
  • Toremifene (displaces roc from sugammadex)
  • Coagulopathy
  • ESRD (excreted renally)
40
Q

How long should does sugammadex bind w/ progesterone? and what should you educate the patient about?

A

7 days
they are fertile for 7 days - so need an alternative form of Birth control

41
Q

What is recurarization?

A

Resumption of NMJ blockade after period of reversal

42
Q

What s/s would indicate recurarization?

Say you just brought the patient to PACU.

A
  • ↓ SpO₂
  • ↓ respiratory effort
  • Floppy/uncoordinated
  • Unresponsive
  • sometimes can verbalize: suffocating feeling
  • unable to sustain head lift or hand grasp
  • WORST case: pharyngeal collapse and respiratory obstruction
43
Q

What drug and dose would be a good choice for a recurarizing patient in the PACU?
Why might this be a good choice?
What is the treatment goal?

A
  • Neostigmine 0.05 mg/kg IV
  • Longer duration of action

Treatment goal: treat urgently and aggressively
- resedate the pt
- give additional reversal agent in divided doses

44
Q
A
45
Q
A

COPY Anesthesia Pharm (Spring 2023) (20 decks)

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