Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

KM (Spring 2024) Anesthesia Pharm ** > NMBDs: Physiology/Succinylcholine Exam III > Flashcards

NMBDs: Physiology/Succinylcholine Exam III Flashcards

1
Q

Which of the following is the newest NMBD?
A. Atracurium
B. Vecuronium
C. Pancuronium
D. Cistracurium

A

A. Atracurium (1980)
B. Vecuronium (1980)
C. Pancuronium (1960)
D. Cistracurium (1995)

S2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Why was Rapacurium (Raplon) discontinued in 2001?

A

Massive laryngospasm and bronchospasm leading to death.

S2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

The effect of NMBD is to interrupt the transmission of nerve impulses at the _____.

A

Neuromuscular Junction (NMJ)

S3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

The MOA of NMBD is either depolarizing or non-depolarizing.

Deploarizing NMBD will _________ the action of ACh.
Non-depolarizing NMBD will ______ the action of ACh.

A

Depolarizing NMBD will mimic the action of ACh.
Non-depolarizing NMBD will interfere with the action of ACh.

S4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Purpose of NMBD for anesthesia.

A
  1. Decrease airway trauma
  2. Facilitate surgical exposure
  3. Minimize injury from patient movement

S5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What classification of NMBD is Succinylcholine (Anectine)?

A

Depolarizing NMBD

Only depolarizing agent used in anesthesia.

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Name a long-acting non-depolarizing NMBD.

A

Pancuronium (Pavulon)

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Name a short-acting non-depolarizing NMBD.

A

Mivacurium (Mivacron)

Move a lot, short-acting

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the chemical classification of Pancuronium?

A

Aminosteroid

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the chemical classification of Mivacurium?

A

Benzylisoquinoline

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the chemical classification of Pancuronium (Pavulon)?

A

Aminosteroid

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which intermediate-acting NMBDs are Benzylisoquinolines?

A

Atracurium (Tracrium)
Cisatracurium (Nimbex)

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which intermediate-acting NMBD are Aminosteroids?

A

Vecuronium (Nocuron)
Rocuronium (Zemuron)

S6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is ED95 in regards to NMBDs?

A

The potency of NMBD. The dose that is necessary to produce a 95% suppression of a single twitch in the presence of nitrous/ barbiturate/ opioid anesthesia.

S7

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What nerve is stimulated so that the adductor pollicis muscle will produce a single twitch at 1 Hz (thumb adduction)?

A

Ulnar nerve

S7

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

The order of block for NMBD is dependent on:

A
  • Number of presynaptic ACh-containing vesicles released.
  • Number of ACh receptors.
  • Blood Flow to the area.
  • Drug potency

S8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Low potency NMBD will onset _________ than higher potency NMBD.

A

Faster

Lower potency NMBD will have more molecules than higher potency NMBD. This will create a higher concentration gradient and result in a faster onset.

S8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Small, rapidly moving muscles will be blocked ________ than large muscles.

A

Faster

Eyes will be paralyzed first before diaphragm.

S8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What does this graph show?

A
  1. Both Larynx and Adductor Pollicis muscle received 0.5 mg/kg of Rocuronium.
  2. Both muscles experience a dramatic decrease in twitch percent height, but the adductor pollicis is completley blocked while the larynx got down to a twitch height of 20%.
  3. Both muscles recovered at the same rate. Almost 100% twitch response returned by minute 40.

S9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Checking a twitch in which muscle will assess the diaphragm and laryngeal muscle blockade.

A

Orbicularis Oculi

If there are no twitches to the facial nerve, the diaphragm and laryngeal muscles are adequately blocked. Best indicator of intubating conditions.

S10

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

The orbicularis oculi underestimates _____________.

A

residual paralysis.

S10

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Is checking a twitch in the adductor pollicis a good indicator for laryngeal relaxation?

A

No, it is not a good indicator of laryngeal relaxation.

Checking a twitch of the adductor pollicis is a good indicator or peripheral recovery.

S10

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which muscle is the gold standard to check a twitch on for recovery?

A

Adductor pollicis (Ulnar Nerve)

S10

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the placement of electrodes on ulnar nerve?

What will the response be?

A

S11

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

SLIDE 12

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

SLIDE 13

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is a defasciculating dose of NMBD?

What symptoms will the patient experience with a defasciculating dose?

A

Where 20% of intubating dose is given early (primer) to prevent fasciculation.

Blurred Vision
Ptosis (droopy eyes)
Diplopia (double vision)

Mandibular weakness
Dysphagia

Increased hearing acuity - people need to be quiet

Let patient know they might start to feel week and get blurry vision. Encourage them to close their eyes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

A single twitch nerve stimulator starts at _____ Hz/second decreasing to ______ Hz/10 secs.

A

1 Hz/sec to 0.1 Hz/10 secs

S15

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

With an onset of a block a single twitch will ______.

A

fade with each stimulus

S15

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Double burst stimulator is _____ short bursts followed by ______ short bursts.

The double burst stimulator setting uses ________ Hz

A

2, 3

50 Hz (supramaximal current)

S16

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Why was the double burst stimulator developed?

A

Developed to improve detection of residual block (fade).
Fade in 2nd response vs 1st response.
Qualitatively better than TOF.

S16

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Train of Four is ________ stimuli at _______ Hz with ______ seconds between each burst.

A

4 stimuli at 2 Hz with ½ seconds between each burst

S17

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

TOF reflects events at _________ membrane.

A

Presynaptic

S17

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Prior to NMBD what will be your twitches on the TOF?

What will be the TOF ratio (Twitch 4 : Twitch 1)?

A

4/4 twitches

Ratio 1

S17

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Experienced anesthetist are unable to qualitatively detect the fade of a TOFR > ______.

A

0.4

The twitch will have to go from unblocked to completely blocked in order to tell a difference

S17

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

There will be significant residual block with a TOFR of ______ to _____.

A

0.7 to 0.9

You will not feel a fade, but there will still be blockade at the NMJ. Patient will still need reversal agent.

S17

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Tetanic stimulation is very rapid, it will be ________ Hz for _____ seconds.

A

50 Hz for 5 seconds

S18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

If a _____ NMBD is given, a tetanic stimulation will result in a sustained muscle response.

A

Depolarizing NMBD (Succinylcholine)

S18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

If a _____ NMBD is given, a tetanic stimulation will result in a non-sustained muscle response (fade).

A

Nondepolarizing NMBD (Roc/Vec)

The fade is a result of presynaptic depletion of ACh or inhibition of release

S18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What is post-tetanic stimulation?

A

Single twitch 3 seconds after tetanic stimulation.

The post-tetanic stimulation will occur d/t accumulation of calcium during tetany, the excess calcium will stimulate ACh release.

S19

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

No response in post-tetanic stimulation will mean ______.

A

intense blockade

S19

42
Q

What kind of blocks are in column A, B, and C?

What kind of nerve stimulation is performed in row 1 through 4?

A

S20

43
Q

S22

A
44
Q

A study performed showed that _____ % of patients that were not given anticholinesterase drugs for NMBD reversal and no use of nerve stimulator had post-op blockade once extubated.

A

42%

S21

45
Q

A study performed showed that less than ____ % of patients that were given anticholinesterase drugs for NMBD reversal and use of nerve stimulator had post-op blockade once extubated.

A

<4%

S21

46
Q

The presynaptic motor neuron is large and _________ which helps with transmission of nerve impulses.

A

myelinated

S23

47
Q

The motor nerve ending is ________ and innervates single muscle fibers.

A

unmyelinated

S23

48
Q

The presynaptic motor neuron is responsible for what three things involving ACh?

A
  • ACh synthesis
  • ACh uptake and storage in vesicles
  • ACh release and uptake of choline

S23

49
Q

The synaptic cleft is _______ nm wide with fluid that contains ________ and _________.

A

20-50 nm
Collagen and acetylcholinesterase (plasma cholinesterase, butyrylcholinesterase)

S24

50
Q

ACh release is dependent on what electrolyte?

A

Calcium

S24

51
Q

What does Acetylcholinesterase do to ACh?

A

Hydrolyze ACh to acetic acid and choline

S24

52
Q

Post-synaptically, the membrane has multiple _______.

Post-synaptically, the resting membrane potential is _______.

Membrane potential is largely maintained by what two electrolytes?

A

folds

-90 mV

Na+ and K+

S25

53
Q

How many subunits are on a transmembrane nicotinic acetylcholine receptor (nAChR)?

Name them.

A

Five subunits. (Pentameric unit)

2 alphas, beta, delta, gamma

S26/27

54
Q

If NMBD (non-depolarizer) binds to nACh, there will be no __________ change and no ion flow.

A

conformational change

S27

55
Q

Succinylcholine only requires binding at one ________ subunit. It is postulated that this will cause ________ before total blockade.

A

one alpha subunit

fasciculation

S29

56
Q

_________ is the only depolarizing NMBD in clinical practice.

What are two unique characteristics of this drug?

What is this NMBD most useful for?

What is the downside of this NMBD?

A
  • Succinylcholine
  • Provides very intense and rapid paralysis
  • Offsets of effects prior to hypoxia
  • Rapid Sequence Induction
  • Histamine Release (tachycardia, rash, welps)

S29

57
Q

What is the dose of Succinylcholine?
Onset:
Duration:

A

Dose: 1 mg/kg IV
Onset: 30-60 seconds
Duration: 3-5 minutes

S30

58
Q

What is the MOA of succinylcholine (Sch)?

A
  • **Attaches to one or both alpha subunits **of the nAChR.
  • Mimics the effect of ACh, but has a sustained opening of the receptor channel (hydrolysis is slower than ACh).

S31

59
Q

SCh will cause how much increase in serum K+?

A

0.5 mEq/L

S31

60
Q

What are characteristics of a phase I block?

A

Decrease contraction to single twitch stimulation.
Decrease amplitude to continuous stimulation.
TOF ratio > 0.7 (no fade)
Absence of post-tetanic facilitation
Skeletal muscle fasciculation

S32

61
Q

Phase II Blocks are typical of ___________ NMBD.

A

non-depolarizing

S33

62
Q

How can a Phase I block transition to a Phase II block?

A

Essentially an overdose

  • Large dose of SCh (2-4 mg/kg)
  • Lack of/ poorly functioning pseudocholinesterase

S33

63
Q

Succinylcholine is hydrolyzed by __________.

A

Butyrylcholinesterase (plasma cholinesterase)

S34

64
Q

What factors can decrease pseudocholinesterase activity?

A
  • Hepatic disease
  • Drugs (neostigmine, reglan, chemo)
  • Genetics
  • CKD
  • Estrogen (think pregnancy)

S34

65
Q

What factor can increase pseudocholinesterase activity?
What does this mean clinically?

A
  • Obesity
  • Higher dosing of succinylcholine is necessary for obese patients.

S34

66
Q

What does dibucaine number mean?

What does it mean in extremely simple terms?

A

Dibucaine number reflects the quality of the enzyme that inhibits the breakdown of butyrylcholinesterase.

  • ↑ Dibucaine number = Fast succinylcholine metabolism
  • ↓ Dibucaine number = Slow succinylcholine metabolism

S35

67
Q

What is normal dibucaine number?

A

80
More butyrylcholinesterase will stick around and break down Sch

S35

68
Q

What will a dibucaine number of 20 mean for Sch?

A

1 mg/kg of SCh will last 3 hours

Less butyrylcholinesterase will stick around

S35

69
Q

What are the side effects of Succinylcholine?

A
  • Cardiac dysrhythmias
  • Hyperkalemia
  • Myalgia
  • Myoglobinuria
  • ↑ Gastric pressure
  • ↑ IOP
  • ↑ ICP
  • Masseter spasm

S36

70
Q

What is the pre-treatment to the side effects of SCh?

A
  • Pre-treatment with non-depolarizing NMBD (5mg of Roc).

This defasciculating dose either decreases, prevents, or mask the side effects of SCh.

S36

71
Q

What dysrhythmias can occur with succinylcholine administration?

A
  • ↓HR
  • Junctional Rhythm
  • Sinus Arrest

S38

72
Q

Cardiac dysrhythmia’s will usually present on the 1st dose of succinylcholine. T/F?

A

False. If dysrhythmias occur, it will be with the 2ⁿᵈ dose.

S38

73
Q

What are succinylcholine’s actions at the ANS ganglia?

A
  • ↑HR
  • mimic ACh

This usually occurs with large doses.

S38

74
Q

Patient’s with _________ sites will have true hyperkalemia when given SCh.

A

Extrajunctional NMJ sites (more ion channels)

S39

75
Q

What patient populations are more susceptible to the hyperkalemic effects of succinylcholine?

A
  • Individuals with unrecognized muscular dystrophy (Duchenne’s)
  • Unhealed 3rd degree burns
  • Denervation of Skeletal Muscles (bed-ridden patients)
  • Upper motor lesions

S39

76
Q

Who will experience myalgia with Sch?

Where will the myalgia be located?

S40

A

Young adults

Neck, back, abdomen

S40

77
Q

S40 with soreness

A
78
Q

Pediatric patients more frequently experience this with succinylcholine administration.

A

Myoglobinuria (damaged to skeletal muscles), usually found later to have MH or muscular dystrophy.

No succinylcholine for children

S41

79
Q

Sch will increase intragastric pressure and LES pressure, this will increase risk of _______.

A

Aspiration

This is related to the intensity of the fasciculation and the direct increase in vagal tone.

S42S

80
Q

Sch will increase intraocular pressure _________ minutes (range) after administration and last _________ minutes (range).

A

2-4 minutes after admin
last 5-10 minutes

S43

81
Q

Sch will be contraindicated in ______________ chamber injury.

A

open anterior

S43

82
Q

Succinylcholine will increase ICP transiently, how can this effect be attenuated?

A

By hyperventilating the patient, the PaCO2 will decrease leading to cerebral vasoconstriction. This will decrease CBF and decrease ICP before Succinylcholine administration.

S44

83
Q

Sustained skeletal muscle contraction, incomplete jaw relaxation, and/or masseter muscle spasm d/t Sch could be an indication of what conditions?

A

Early indicator of Malignant Hyperthermia

Inadequate dosage given in children

S45

84
Q

What is the hereditary rhabdomyolysis associated with all volatile anesthetics and SCh?

A

Malignant Hyperthermia (MH)

S47

85
Q

If MH is untreated what can it lead to?

A

Muscle destruction
Hyperkalemia
Acidosis
Dysrhythmia
Renal Failure
DIC

S47

86
Q

MH causes mutations in what receptor that causes excessive calcium release from the SR?

A

Ryanodine Receptor (RyR1)

S49

87
Q

What ethnicity/nationality are susceptible to MH?

A

Native Americans

plus people from Wisconsin area

S49

88
Q

MH testing

A

S49

89
Q

What are the symptoms of MH?

A

An acute increase in skeletal muscle metabolism
Increase O2 consumption
Lactate formation
Heat Production
Rhabdomyolysis (Spiked increase ETCO2, Increase temp 1C/5mins, arrhythmias, rigidity.)

S50

90
Q

What are the emergency ABCDs of malignant hyperthermia?

A

S51

91
Q

Dantrolene has decreased the mortality of MH from 80% to ________%.

A

10%

S52

92
Q

What is the dose of dantrolene?

A

2mg/kg IV
Repeat doses until symptoms subside or 10mg/kg IV

S52

93
Q

How does dantrolene work?

How is dantrolene metabolized?

A
  • Inhibits the Ca2+ release from the SR and produces a muscle relaxant effect.
  • Dantrolene is metabolized in the liver to 5-hydroxydantrolene

S52

94
Q

Patients on calcium channel blockers (verapamil, Cardizem) that receive dantrolene as a treatment can result in __________

A

Cardiovascular Collapse (d/t synergistic effects)

S52

95
Q

What are the most common side effects of dantrolene?

What are less common S/Es?

A

Most Common: Weakness, Phlebitis, Respiratory Failure, GI upset

Less Common: Confusion, Dizziness, Drowsiness

S53

96
Q

What autoimmune disease develops Antibodies against the ACh receptor?

Symptoms (Sx)

Treatment (Sx)

A

Myasthenia Gravis (MG)

Sx:
Increasing weakness and fatigue throughout the day
Diplopia
Ptosis
Extremity and Resp muscle weakness

Tx: Cholinesterase Inhibitor

S54

97
Q

What part of the day would a Myasthenia Gravis patient be scheduled for surgery?

A

Should be the first of the day. When they have the most ACh and their ACh receptors are not worn out.

S54

98
Q

Myasthenia Gravis patients are _________ to Succinylcholine. Why?

What is the dose of SCh for MG patients?

A

Resistant to SCh. More SCh is needed because the ACh receptors that are left do not function as well.

1.5-2.0 mg/kg

S54

99
Q

What is Lambert-Eton (LE) disease?

LE has an increased sensitivity to which type of NMBD?

A

Autoimmune disease: LE can produce antibodies against calcium channels and decrease the release of ACh pre-junctionally.

LE has a sensitivity to both depolarizing and nondepolarizing NMBD.

S55

100
Q

Why does Lambert-Eton disease often develop?

A

Often results from small-cell lung cancers.

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

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions