Pharm Exam IV: Kaitlyn's NMBD Reversal Agents

Question 1

What are the three NMBD Reversal Agents?

Answer 1

Edrophonium
Neostigmine
Sugammadex

Question 2

What are the two Anti-Cholinergic Agents given in conjunction with NMBD reversal agents to prevent unwanted side effects?

Answer 2

Atropine Sulfate
Glycopyrrolate

Question 3

What family does Vecuronium, Rocuronium and Pancuronium belong in?

Answer 3

Aminosteroids

Question 4

What family does Cisatracurium, Mivacurium and Atracurium belong in?

Answer 4

Benzylisoquinolones

Question 5

What are the three MOA/Classifications (aka’s) of NMBD reversal agents?

Answer 5

AcetylcholinEsterase (AchE) Inhibitors
Cholinergic Agents
Competetive Antagonists

Question 6

What NMBD reversals do to reverse paralytics?

Answer 6

-They increase Ach at the NMJ and Preganglionic fibers.
-They do this by blocking AchE, competing for the muscarinic or nicotinic cholinergic receptors at the NMJ alpha subunits.

Question 7

Do AChE inhibitors work with deep neuromuscular blockade?

Answer 7

No - there is a Ceiling effect - you have to wait till it wears off to reverse

Question 8

Reversal of NMJ blockade is dependent on these 5 factors:

Answer 8

-Depth of block
-Drug choice (neo vs edro)
-Dose
-Rate of plasma clearance
-Anesthetic agent and depth

Question 9

What is the max dosage of neostigmine?

Answer 9

40 - 70 mcg/kg

0.04 - 0.07 mg/kg

Question 10

What is the onset and duration of neostigmine?

Answer 10

Onset: 5 - 10 min
Duration: 60 min

Question 11

What is the dosage of edrophonium?

Answer 11

0.5-1 mg/kg

Question 12

What is the onset and duration of Edrophonium (Enlon)?

Answer 12

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

Question 13

What is the dose of Sugammadex?

Answer 13

2-16mg/kg

Question 14

What is the onset and duration of Sugammadex?

Answer 14

Onset: 1-4 min
Duration: 1.5-3hrs

Question 15

Differentiate a moderate block vs a deep block.

Answer 15

Moderate: 2/4 twitches on TOF
Deep: No twitches to TOF, but will have a 1-2 twitch w/ post tetanic stimulation

Question 16

What is the Sugammadex dose for a moderate block?

Answer 16

2 mg/kg

Question 17

What is the Sugammadex dose for a deep block?

Answer 17

4 mg/kg

Question 18

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

Answer 18

8 - 16 mg/kg
Recurarization (reparalyzation): not observed at appropriate doses.

Question 19

What percentage of neostigmine is renally excreted?

Answer 19

50%

Question 20

What percentage of both pyridostigmine and edrophonium are renally excreted?

Answer 20

75%

Question 21

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

Answer 21

30 - 50% cleared hepatically

Question 22

What happens to renal excretion of NMBD reversal agents if someone has chronic renal failure?

Answer 22

Decrease in plasma clearance - prolongs drug action

Question 23

What are the side effects of increase Nicotinic/Muscarinic Activity in the CV system?

Answer 23

Bradycardia, dysrhythmias, asystole, decreased SVR

Question 24

What are the side effects of increase Nicotinic/Muscarinic Activity in the Pulmonary system?

Answer 24

Bronchoconstriction, increased airway resistance, increased salivation

Question 25

What are the side effects of increase Nicotinic/Muscarinic Activity in the GI system?

Answer 25

Hyper-peristalsis, enhanced gastric fluid secretion, PONV

Question 26

What are the side effects of increase Nicotinic/Muscarinic Activity in the Eyes?

Answer 26

Miosis - constriction of the pupil

Question 27

How do you prevent side effects from NMBD reversal agents?

Answer 27

Give Anti-cholinergic/ Anti-muscarinic agents

Question 28

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

Answer 28

Glycopyrrolate

Question 29

How long does glycopyrrolate need to be administered over?

Answer 29

2 - 5 min

Question 30

What AChE inhibitor is glycopyrrolate used with?

Answer 30

Neostigmine Pyridostigmine

Question 31

What NMBD(s) is atropine used with?

Answer 31

Edrophonium

Question 32

What is the dose of Atropine?

Answer 32

7 - 10 mcg/kg

Question 33

What common side effects are seen right after atropine administration?

Answer 33

Mydriasis - dilation of the pupil Initial Tachycardia

Question 34

What is the dose of glycopyrrolate? What is the max dose?

Answer 34

7 - 15 mcg/kg 1mg max dose

Question 35

What causes persistent NM blockade?

Answer 35

When AchE is maximally inhibited No further anticholinesterase is effective

Question 36

How to treat Persistent NM blockade?

Answer 36

Sedation and postop ventilation

Question 37

When do you test twitches?

Answer 37

Check you baseline twitches before you give paralytic.

Question 38

What Factors Influence NMBD Reversal?

Answer 38

-Intensity of block -Which NMBD did you use? -Continued volatile anesthetic -Which reversal drug are you using -Patient conditions -Metabolic acidosis -Respiratory acidosis -Hypothermia

Question 39

What reversal drug is specific to mivacurium?

Answer 39

Purified human plasma cholinesterase - don't really use anymore for risk of infections

Question 40

What reversal drug is specific to Gantacurium?

Answer 40

Cystiene - expensive

Question 41

What reversal drug is very specific to rocuronium?

Answer 41

Sugammadex

Question 42

What other drugs can Suggamadex can reverse? In which class?

Answer 42

Aminosteroid - vecuronium - metabolized by renal and hepatic system

Question 43

What type of drug is sugammadex?

Answer 43

Selective relaxant-binding agent -γ-cyclodextrin -dextrose units from starch - diabetic issues? -Highly water soluble - contraindicated in renal failure or decreased renal function

Question 44

What is the MOA of Sugammadex?

Answer 44

-intermolecular (van der Walls) forces -thermodynamic (hydrogen) bonds -hydrophobic interactions* very tight reversal by encapsulation and excreted in urine

Question 45

What's another name for Sugammadex?

Answer 45

Bridion

Question 46

What drugs does sugammadex work with?

Answer 46

Roc > Vec > Pancuronium

Question 47

How is sugammedex eliminated?

Answer 47

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

Question 48

When is Sugammadex ABSOLUTELY Contraindicated?

Answer 48

Renal impairment with dialysis

Question 49

What is the E ½ time of sugammadex?

Answer 49

2 hours - if it binds intravascularly, it renders rocuronium non-functional

Question 50

What are the side effects of Sugammadex?

Answer 50

Works on the chemoreceptors trigger zone - aka vomiting center: Dose related: -N/V -Pruritis - Urticaria -marked bradycardia - get glyco and atropine -Anaphylaxis -some people it doesn't work

Question 51

If 1.2 mg/kg of rocuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

Answer 51

5 min

Question 52

If 0.6 mg/kg of rocuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

Answer 52

4 hours

Question 53

If 0.1 mg/kg of vecuronium needs to be re-administered after reversal with sugammedex. What is the minimum waiting time?

Answer 53

4 hours

Question 54

What else could you do if you can't wait to paralyze the patient?

Answer 54

Give a different type of NMBD like a benzylisoquinolone - Atracurium, Cisatracurium at normal doses

Question 55

What drugs/conditions are relative contraindications to sugammadex?

Answer 55

Oral Contraceptives -Binds with Progesterone (7 days) Toremifene (non-steroidal anti-estrogen) - cancer medication -Displaces NMBD from Sugammadex Coagulopathy/Bleeding -Heparin/LMWH; Elevated PTT, PT, INR Recurarization -Lower than recommended doses.

Question 56

What is recurarization?

Answer 56

Resumption of NMJ blockade after period of reversal

Question 57

What s/s would indicated recurarization? Say you just brought the patient to PACU.

Answer 57

-↓ SpO₂ -↓ respiratory effort -Floppy/uncoordinated - can't lift head or grasp hand. -Pharyngeal collapse and respiratory obstruction -Sometimes can verbalize a suffocating feeling to unresponsive

Question 58

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

Answer 58

-Neostigmine 0.05 mg/kg IV -Longer duration of action He also loves physotigmine

Question 59

How do team/group acknowledge mistakes?

Answer 59

Team/group factors.