RE5: Chapter 12: Neuromuscular Blocking Agents, Reversal Agents, and Their Monitoring Flashcards
Describe neuromuscular depolarization blockade (phase 1 blockade).
- The motor end plate cannot repolarize until the agent leaves the nicotinic receptor
- Because the motor end plate cannot repolarize, it cannot respond to subsequent Ach release
- The agent binds to the nicotinic receptor on the motor end plate and causes depolarization
What is the difference between qualitative vs. quantitative neuromuscular blockade monitoring?
Qualitative monitoring involves visual or tactile response to evoked electrical stimulus as assessed by the clinician. (MOST COMMON METHOD)
Quantitative monitoring is where the stimulator is coupled with a displacement transducer as a movement measuring device and number value is displayed. (PREFERRED BUT LESS COMMON)
Describe neuromuscular non-depolarizing blockade (phase II blockade).
- Agent binds to the nicotinic receptor on the motor end plate, but it does NOT cause a conformation change in the receptor.
- It does, however, prevent Ach from binding to the receptor rendering the muscle effectively “paralyzed”
What is the preferred method of determining the level of neuromuscular blockade?
Contraction of the adductor muscle of the thumb via stimulation of the ulnar nerve.
Where are the electrodes placed to monitor the ulnar nerve?
The electrodes are applied over the ulnar nerve. The distal electrode is placed over the proximal flexor crease of the wrist, and the other electrode is placed over and parallel to the carpi ulnaris tendon.
What muscle groups are the most sensitive to neuromuscular blockers?
Eye muscles are the most sensitive and are the first group to be affected followed by the extremities, trunk, abdominal muscles and finally the diaphragm.
During recovery, which muscle group recovers first?
Diaphragm recovers the first and the eye muscles last!
OPPOSITE DIRECTION!
Which monitoring site is best to measure the onset of neuromuscular blockade? What is the response?
Facial nerve - eyelid movement
Which monitoring site is the best to measure recovery from neuromuscular blockade? What is the response?
Ulnar nerve - thumb adduction
What does it mean if fade is present?
Sign of drug-induced muscle paralysis OR a clinically significant block remains
How does fade occur?
Because the nondepolarizing drugs block presynaptic Ach receptors in addition to their classic antagonist effect at postsynaptic Ach neuromuscular junction sites.
What is a single twitch?
A single supra-maximal electrical stimulus ranging from 0.1 to 1Hz for 0.1 to 0.2 milliseconds
What monitoring test requires a baseline before drug administration?
Single Twitch
What is TOF stimulation?
A series of 4 twitches at 2Hz every 1/2 second for 2sec.
Compares the first twitch to the 4th twitch
Which monitoring test reflects blockade from 70% - 100%
TOF stimulation
What does it mean if the fourth twitch (T4) disappears OR you have 3 twitches?
Disappearance of the third twitch (T4 and T3 absent)? OR you have 2 twitches?
Disappearance of the second twitch (T4, T3, & T2 absent) OR you have 1 twitch?
A block of more than 75%-80%
80%-85%
90%-95%
What is the ideal degree of paralysis?
The ideal degree of paralysis necessary for any procedure with sufficient anesthetic depth is 85% to 95%. That correlates with 1 to 2 twitch responses present on TOF stimulation.
What is double-burst simulation?
Two short bursts of 50Hz tetanus separated by 0.75 sec
Which is easier to detect fade - TOF or double-burst?
Double-burst due to evaluating two twitches rather than four twitches
What indicates significant paralysis with double-burst?
Fade of the second impulse is comparable to TOFR of less than 0.6
What is tetanus?
Generally consists of rapid delivery of a 30-, 50-, or 100Hz stimulus for 5 seconds
Which degree of hertz is more reliable for detecting fade, but is not always specific?
100Hz
What is Posttetanic Count (PTC)?
50-Hz tetanus for 5 seconds, a 3 second pause, then single twitch for 1-Hz
A count less than _____ indicates a deep block, and prolonged recovery is likely
Eight!
**Used only when TOF and Double-burst stimulation is absent
What is the clinical duration of action of neuromuscular blockade?
Time from drug administration to 25% recovery of the twitch response
What is the total duration of action of neuromuscular blockade?
Time from drug administration to 90% recovery of twitch response.
What is the recovery index of neuromuscular blockade?
Time from 25% to 75% recovery of the twitch response
What is the train-of-four ratio?
Compares the 4th twitch of a TOF with the 1st twitch
With TOF, when the 4th twitch is ____% of the 1st twitch, recovery is indicated?
90%
What is Posttetanic potentiation?
With PTC, the extra Ach will transiently reverse the relaxant by competing for the receptor at the local monitoring site. This augmented response will only last a few seconds until the excess Ach dissipates.
What are some key points related to recovery from neuromuscular blockade?
TV at least 5mL/kg No palpable fade with TOF or double-burst Sustained tetanus VC at least 20mL/kg Inspiratory force at least -40cm H2O Head lift x 5 seconds Adequate hand grip Sustained bite (corresponds with TOF of 85%)
How does succinylcholine work?
Depolarization muscle relaxant.
An agonist at the nicotinic receptor and mimics the actions of Ach by depolarizing the motor end plate, followed by desensitization.
How is succinylcholine metabolized?
Hydrolyzed by plasma cholinesterase (pseudocholinesterase) - enzymes found in the plasma, but produced from the liver
How is succ eliminated?
Hydrolyzed succinylcholine results in succinylmonocholine and choline, then plasma cholinesterase further reduces it to succinic acid and choline.
What can a prolonged neuromuscular blockade result from?
Excessive doses of succ in patients with atypical, inhibited or deficient levels of plasma cholinesterase.
What is the ED95 of succ?
Intubating dose?
Time of onset?
Duration of action?
ED95: 0.3mg/kg
Intubating dose: 1-1.5mg/kg
Time to onset: 30-60sec
DOA: 5-15 minutes
What does ED95 stand for?
The dose necessary to provide the desired effect in 95% of the population
What is the onset of action at the larynx of succ?
34 seconds for a 1mg/kg dose
What % of the injected dose actually reaches the neuromuscular junction?
10%
What is the plasma 1/2 life of succ?
2-4 minutes
All muscle relaxants including succ contain?
Quaternary ammonium - this structure renders it WATER SOLUBLE in the body.
Does succ cross the BBB and has direct CNS effects?
FALSE!
How much does succ indirectly increase ICP?
Small and transient rise of 10 to 15 mmHg for 5 to 8 minutes after administration
How does succ effect the CV system?
Slight tachycardia and sudden abrupt bradycardia may result in repeated doses in adults and any dosing in children.
What does the bradycardia result from?
Autonomic ganglia and parasympathetic muscarinic receptor stimulation
How much does an incubating dose of succinylcholine increase serum potassium level?
0.5 - 1 mEq
What may prolong the effects of succ?
Certain types of liver damage since cholinesterase substrates are produced by the liver
What can serve as a sensitive measure of the synthetic capacity of the liver?
pseudocholinesterase (PChE) activity
What other diseases might decrease levels of PChE be found in?
Pts with acute infections, pulmonary embolism, muscular dystrophy, myocardial infarction, pregnancy, and after surgical procedures.
What test can be done to determine whether an atypical enzyme is present and the cause of prolonged apnea experienced in pts after being given succ?
Dibucaine inhibition test - Dibucaine is an AMIDE local anesthetic that inhibits typical or usual PChE, but NOT atypical PChE.