NMBD Reversals - test 4 Flashcards
In a study performed, what percent of patients had post-op residual blockade when there was no NM monitoring or reversal given?
33%
In a study performed, what percent of patients had post-op residual blockade when NM monitoring ad reversal was used?
4%
Do AChE inhibitors work with deep NM blockade?
No
Max neostigmine range:
40-70 mcg/kg
Max edrophonium dose:
1 mg/kg
Reversal of NM blockade depends on 5 factors:
- 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
Onset and duration of neostigmine:
Onset: 5-10 minutes
Duration: 60 minutes
Onset and duration of Edrophonium:
Onset: 1-2 minutes
Duration: 5-15 minutes
Dose for edrophonium:
0.5-1 mg/kg
What percentage of neostigmine is renally excreted?
50%
What percentage of pyridostigmine and edrophonium is renally excreted?
75%
How are reversal agents cleared if the patient has no renal function?
Hepatic clearance - 30-50%
What is the major side effects of NMBD reversal agents?
*Increased Nicotinic/muscarinic activity
CV side effects from NMBD reversal agents:
- Bradycardia
- Dysrhythmias
- Asystole
-↓SVR
Pulmonary side effects from NMBD reversal agents:
- Bronchoconstriction
- increased airway resistance
- Increased salivation
GI side effects of NMBD reversal agents:
- Hyperperistalsis
- Enhanced gastric fluid secretion
- PONV
What is a side effect that happens in the eyes after NMBD reversal agents?
Miosis
What drugs would be given with NMBD reversal agents to prevent side-effects?
Anti-cholinergic/Anti-muscarinic
- Atropine (7-10 mcg/kg)
- Glycopyrrolate (7-15 mcg/kg)
Atropine matches profile of ___:
Edrophonium
Glycopyrrolate matches profile of ____ and ____:
Neostigmine and Pyridostigmine
Which anti-cholinergic would you use if you were concerned about someone with a pre-existing cardiac disease?
Glycopyrrolate - give slowly, over 2-5 minutes
What happens in persistent NM blockade?
- Acetylcholinesterase is maximally inhibited
- No further anticholinesterase if effective
Intervention for persistent NM blockade:
Sedation and post-op ventilation
What side effects can be seen right after atropine administration?
Mydriasis and initial tachycardia
What 5 factors influence NMBD reversal?
- Intensity of block
- Which NMBD you use
- Continues volatile anesthetic
- Which reversal drug are you using
- Patient conditions (met. acidosis, resp. acidosis, hypothermia)
What reversal agent is used for mivacurium?
Purified human plasma cholinesterase
What reversal agent is used for gantacurium?
Cystiene
What reversal agent is used for roc (aminosteroid)?
sugammadex
What type of drug is sugammadex?
Selective relaxant-binding agent
Sugammadex organic and physical properties:
-γ-cyclodextrin
- dextrose units from starch
- highly water soluble
MOA of sugammadex:
Very tight reversal by encapsulation of
- intermolecular forces
- thermodynamic bonds
- hydrophobic interactions
*binds to free drug in plasma
What drugs do sugammadex work on?
Rocuronium > vec»_space; pancuronium
Sugammadex major route of elimination:
__ in 6 hours
__ in 24 hours
Urine; 70%; 90%
*renal impairment: C/I with dialysis
What is the E 1/2 time of sugammadex?
2 hours
Moderate vs. Deep block:
- Moderate: 2/4 twitches on TOF
- Deep: No twitches to TOF, but will have a twitch w/ post tetanic stimulation
Sugammadex dose for a moderate block:
2 mg/kg
Sugammadex dose for a deep block:
4 mg/kg
Sugammadex dose for an extreme block:
8-16 mg/kg
Side effects of sugammadex:
- Dose related N/V
- Dose related pruritus
- Dose related urticaria
- Anaphylaxis
- Marked bradycardia
- Doesn’t work
Re-administration of Roc or Vec after reversal:re
How does sugammadex interact with oral contraceptives?
Binds with progesterone (7 days)
How does sugammadex interact with toremifene?
Displaces NMBD from sugammadex
Sugammadex cautions for coagulopathy/bleeding:
Heparin/LMWH; elevated PTT, PT, INR
Sugammadex cautions for recurarization:
Lower than recommended doses
What is recurarization?
Re-paralyzing the patient after a period of reversal
Signs and symptoms of recurarization:
- 02 sats
- unresponsive patient
- appears “floppy” or uncoordinated
- ineffective abdominal and intercostal activity
- sometimes can verbalize suffocating feeling
- unable to sustain lift or hand grasp
- worst case = pharyngeal collapse and respiratory obstruction
Treatment goal for recurarization:
*treat urgently and aggresively
- Re-sedate the patient
- Give additional reversal agents in divided
