NMBD Reversal Agents (Exam IV) Flashcards
How long, generally, until NMJ blockade is fully reversed with neostigmine?
20-30 min
What is the clinical duration of response for ND-NMBD?
- Pancuronium
- Rocuronium
- Vecuronium
- Atracurium
- Cisatracurium
- Mivacurium
Pancuronium - 86 mins
Rocuronium - 36 mins
Vecuronium - 44 mins
Atracurium - 46 mins
Cisatracurium - 45 mins
Mivacurium - 16.8 mins
Do AChE inhibitors work with DEEP neuromuscular blockade? what is this called?
No
Ceiling effect
Reversal of NMJ blockade is dependent on these 5 factors:
- Depth of block
- Drug choice (neo vs edro)
- Dose
- Rate of plasma clearance
- Anesthetic agent and depth
Which paralytic has to be reconstituted with 10mL of H₂O ?
Vecuronium
What is the max dosage of neostigmine?
40 - 70 mcg/kg
0.04 - 0.07 mg/kg
5mg
What is the onset and duration of neostigmine?
Onset: 5 - 10 min
Duration: 60 min
What is the dosage of edrophonium?
0.5 - 1 mg/kg
What is the max dosage of edrophonium?
1- 1.5 mg/kg
What is the onset and duration of edrophonium?
Onset: 1-2 min
Duration: 5-15 min
What percentage of neostigmine is renally excreted?
50%
What percentage of both pyridostigmine and edrophonium are renally excreted?
75%
How are NMB reversal agents cleared if the patient has no innate renal function?
30 - 50% cleared hepatically
What is the major side effect of NMBD reversal agents?
CV, pulmonary, GI, eyes?
↑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
What drugs would be coupled with NMBD reversal agents to prevent adverse side effects from these drugs?
Anti-cholinergic / Anti-muscarinics
- Atropine
- Glycopyrrolate
If you’re concerned about someone’s cardiac status due to existing disease, which Anticholinergic drug would you use?
Glycopyrrolate
What NMBD(s) is glycopyrrolate used with?
- Neostigmine
- Pyridostigmine
What NMBD(s) is atropine used with?
Edrophonium
What is the dose of Atropine?
7 - 10 mcg/kg
What common side effects are seen right after atropine administration?
- Mydriasis
- Tachycardia
What is the maximum dose of glycopyrrolate?
1mg max dose
How long does glycopyrrolate need to be administered over?
2 - 5 min
What reversal drug is specific to mivacurium?
Purified human plasma cholinesterase
What reversal drug is specific to gantacurium?
Cystiene
What reversal drug is very specific to rocuronium?
Sugammadex
What type of drug is sugammadex?
Selective relaxant-binding agent w/ aminosteroids
What should be known about sugammadex’s organic structure and physical properties?
- γ-cyclodextrin
- Dextrose units from starch
- Very H₂O-soluble
What is the MOA of Sugammadex?
Encapsulates rocuronium via:
- Intramolecular (Van der Walls) forces
- Thermodynamic (Hydrogen) bonds
- Hydrophobic interactions
True/False: Sugammadex binds to “free drug” in plasma
TRUE
What drugs does sugammadex work with?
Roc > Vec > Pancuronium
What is the E ½ time of sugammadex?
2 hours
How is sugammedex eliminated?
Urine:
- 70% gone in 6 hours
- 90% gone in 24 hours
Differentiate a moderate block vs a deep block.
- Moderate: 2/4 twitches on TOF
- Deep: No twitches to TOF
What is the Sugammadex dose for a moderate block?
2 mg/kg
What is the Sugammadex dose for a deep block?
4 mg/kg
What is the sugammadex dose for an extreme (overdose) block?
8 - 16 mg/kg
What are the side effects of Sugammadex?
- Bradycardia (get glycopyrrolate and atropine ready)
- dose-related N/V
- dose-related Pruritis
- dose-related Urticaria
- anaphylaxis
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?
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?
What drugs/conditions are relative contraindications to sugammadex?
- Contraceptives
- Toremifene (displaces roc from sugammadex)
- Coagulopathy
- ESRD (excreted renally)
How long should does sugammadex bind w/ progesterone? and what should you educate the patient about?
7 days
they are fertile for 7 days - so need an alternative form of Birth control
What is recurarization?
Resumption of NMJ blockade after period of reversal
What s/s would indicate recurarization?
Say you just brought the patient to PACU.
- ↓ 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
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?
- 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
