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Fa: Pharm 3 > 6. Neuromuscular > Flashcards

6. Neuromuscular Flashcards

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1
Q

how to tx neuromuscular disorders

A

corticosteroids

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2
Q

what can cause upregulation of nicotinic NMJ receptors?

A

-motor neuron lesions (MS), -muscle trauma, -burn injury -immobilization, -sepsis / infection ?

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3
Q

how does NDMR dosing change during upregulation of nicotinic NMJ receptors

A

more resistant to NDMR, so need to give more

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4
Q

how does DMR dosing change during upregulation of nicotinic NMJ receptors

A

enhanced response to DMR

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5
Q

what is the risk of DMR during upregulation of nicotinic NMJ receptors

A

lethal hyperkalemia

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6
Q

what is usually contraindicated during upregulation of nicotinic NMJ receptors

A

sux

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7
Q

what can cause downregulation of nicotinic NMJ receptors?

A

-MG, -organophosphate poisoning, -chronic AChE inhibitor exposure

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8
Q

how does NDMR dosing change during downregulation of nicotinic NMJ receptors

A

more sensitive to NDMR

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9
Q

how does DMR dosing change during downregulation of nicotinic NMJ receptors

A

limits the effect of DMR (need higher dosing)

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10
Q

how to determine levels of plasma cholinesterases in preop

A

-pre op plasmapheresis, -pre op acetylcholinesterase inhibitors

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11
Q

what drugs are metabolized by plasma cholinesterases

A

-sux, -mivacurium, -remifentanil, -esmolol

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12
Q

what is pseudohypertrophic muscular dystrophy

A

-progressive deterioration of skeletal muscle strength, -degeneration of cardiac muscle, -chronic weakness of respiratory muscles and accumulation of secretions

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13
Q

what does pseudohypertrophic mean

A

fatty infiltration

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14
Q

risk of anesthesia for patients with pseudohypertrophic muscular dystrophy

A

pulmonary aspiration

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15
Q

how do NDMR affect patients with pseudohypertrophic muscular dystrophy

A

normal response to NDMR (or may be prolonged)

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16
Q

how do DMR affect patients with pseudohypertrophic muscular dystrophy

A

sux is contraindicated due to risk for rhabdomyolysis, hyperkalemia, and cardiac arrest

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17
Q

how do volatile agents affect patients with pseudohypertrophic muscular dystrophy

A

should be avoided!

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18
Q

risk for rhabdomyolysis and arrhythmia cardiac arrest (even w/o sux)

A
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19
Q

pseudohypertrophic muscular dystrophy during anesthesia can look similar to…

A

MH

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20
Q

how to tx pseudohypertrophic muscular dystrophy during anesthesia

A

dantrolene

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21
Q

what is myotonic dystrophy type 1

A

progressive involvement of skeletal, cardiac, and smooth muscle (cardiac conduction abnormalities are common)

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22
Q

use of DMR in myotonic dystrophy type 1

A

sux is contraindicated because causes prolonged skeletal muscle contraction

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23
Q

use of NDMR in myotonic dystrophy type 1

A

NMBs have a normal response

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24
Q

reversal agents of NDMR in myotonic dystrophy type 1

A

-neostigmine could potentially precipitate skeletal muscle contraction, -sugammadex is best

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25
what is guillain-barre syndrome (acute idiopathic polyneuritis)?
sudden onset of skeletal muscle weakness or paralysis, usually triggered by an infectious process (usually starts in legs and spreads up)
26
SE of guillain-barre syndrome
-bulbar involvement (bilateral facial paralysis): diff swallowing, pharyngeal muscle weakness, -paresthesia (sensory problems) and pain, -ANS dysfx (cardiovascular probs, arrhythmias)
27
management of guillain-barre syndrome
-supportive respiratory and cardiovascular, -plasma exchange / pheresis or IVIG infusions
28
what is multiple sclerosis
chronic demyelinating inflammatory disease of the CNS
29
sx of MS
-Visual disturbances, -sensory disturbances, -pain, -motor deficits, -spasticity
30
tx of MS
-immunomodulating agents, -corticosteroids, -IVIG, -plasmapheresis
31
what can trigger MS
stress and hyperthermia
32
use of DMR in MS
avoid sux due to upregulation of N receptors
33
use of NMDR in MS
variable response, titrate carefully
34
where to perform NM monitoring in MS
in the limb that is not affected / least affected
35
how is MG classified
based on skeletal muscles involved and symptom severity
36
type I MG
extraocular movement
37
type IIa MG
slowly progressive; skeletal muscle weakness spares muscles of respiration
38
type IIb MG
faster progression, more severe weakness
39
type III MG
acute onset with rapid deterioration
40
type IV MG
severe weakness from progression of type I or II
41
MOA of MG
-antibodies to alpha 1 subunit of nicotinic R channel complex, -receptors crosslink, -lysis of postsynaptic membrane, -binding to nicotinic R and inhibiting fx, (antibodies block ACh from binding R... loss of action causes loss of receptors)
42
symptomatic tx of MG
-acetylcholinesterase enzyme inhibitors (edrophonium, pyridostigmine, neostigmine)
43
chronic immunomodulating tx of MG
-glucocorticoid, -immunosuppressant (azathioprine, cyclosporine, methotrexate, mycophenolate, tacrolimus, rituximab)
44
rapid immunomodulating tx of MG
-IVIG, -plasmapheresis
45
what drugs can potentiate weakness in MG
-magnesium, -NMBs, -aminoglycosides (some other abxs, macrolides), -Na channel blocking drugs (lidocaine, procainamide, quinidine), -CCB
46
how to manage chronic meds of MG before surgery
take chronic meds up to and including morning of surgery (pyridostigmine, neostigmine)
47
how will chronic MG meds affect NDMR and DMR agents
response to reversal agent may be unpredictable or insufficient
48
what can happen if you withhold chronic MG meds
makes bulbar sx more severe
49
onset, DOA, and peak of pyridostigmine
-rapid onset 15-30 min, -peak in 2 hours, -lasts 3-4 hours
50
oral dose of pryidostigmine
start with 30 mg and titrate as needed
51
IV dose of pyridostigmine
ratio of IV to PO is 1 mg to 30 mg
52
if patients take chronic glucocorticoids for MG, what can this cause intraop?
HPA suppression and adrenal insufficiency
53
for pts that do not have underlying primary adrenal insufficiency, how should the dose of glucocorticoids be before surgery
take usual daily dose of glucocorticoid
54
for pts that do not have underlying primary adrenal insufficiency, when is a stress dose NOT needed
-steroid taken less than 3 weeks, -daily dose
55
if patients appear cushingoid, what should they receive before surgery
stress dose of glucocorticoids
56
how to manage daily dose of a superficial procedure (dental or biopsy)
take usual morning steroid dose
57
stress dose ofa superficial procedure (dental or biopsy)
none
58
how to manage daily dose of a minor procedure or surgery under LA (inguinal hernia repair)
take usual morning steroid dose
59
stress dose of a minor procedure or surgery under LA (inguinal hernia repair)
not needed or 25 mg IV just prior to procedure
60
how to manage daily dose of a moderate surgical stress (LE revascularization, total joint replacement, cholecystectomy, colon resection)
take usual morning steroid dose
61
stress dose of a moderate surgical stress (LE revascularization, total joint replacement, cholecystectomy, colon resection)
-hydrocortisone 50-75 mg IV just before procedure and 25 mg of hydrocortisone q8h for 24 h, -resume usual dose after
62
how to manage daily dose of a major surgical stress (esophagogastrectomy, total proctocolectomy, open heart surgery)
take usual morning steroid dose
63
stress dose of a major surgical stress (esophagogastrectomy, total proctocolectomy, open heart surgery)
-hydrocortisone 100-150 mg IV just before procedure and 50 mg of hydrocortisone q8h for 24 h, -taper dose by half per day to maintenance level
64
use of NMB agents in MG intraop
avoid if possible! and reverse with sugammadex if possible!
65
premedication for MG pts
-avoid if possible, -if needed, 0.5 mg IV versed with continuous monitoring
66
what is the best induction for MG pt
regional, neuraxial when possible
67
use of inhalational agents in MG pt
if provide adequate VA, may not need NMB
68
what is commonly used for induction for MG pt
propofol (2 mg/kg) + remi (4-5 mcg/kg)
69
for MG pt, how to tx bradycardia and hypotension
ephedrine 10 mg IV as needed
70
if needed, what are the preferred NMB agents for MG
roc and vec
71
how to MG pt respond to DMR
somewhat resistant
72
how do MG pt respond to NMDR
very sensitive to NMDR
73
ED 95% of sux for pts with MG
2.6 x normal
74
dosing range of sux for MG pt
higher end (1-2 mg/kg), *if 2 mg/kg, expect prolonged duration
75
how is sux metabolized
plasma cholinesterases
76
what can acetylcholinesterase inhibitors (pyridostigmine) do to sux in MG pt
prolong effect of sux
77
how to dose NDMR in MG pt
small doses, 0.1-0.2 times the ED95 and titrate
78
sugammadex dosing in MG pt
2-4 mg/kg IV
79
does pyridostigmine affect sugammadex
no
80
does pyridostigmine affect neostigmine
yes, effect is unpredictable
81
what can neostigmine cause in MG pt
-cholinergic crisis (weakness with other signs of cholinergic excess)
82
what is lambert eaton syndrome (myasthenic syndrome)
-autoimmune disorder of neuromuscular junction, -antibodies directed against presynaptic voltage gated calcium channels, -muscle weakness due to reduced ACh release from presynaptic nerve terminals
83
how do NDMR affect lambert eaton syndrome
very sensitive to NDMR
84
how do DMR affect lambert eaton syndrome
very sensitive to DMR
85
how do sx of lambert eaton syndrome compare to MG
-more autonomic dysfx, -less bulbar sx
86
is lambert eaton syndrome responsive to AChE inhibitors
no
87
is lambert eaton syndrome or MG more sensitive to NDMR
lambert eaton syndrome
88
effects of neostigmine on lambert eaton syndrome
ineffective, avoid!
89
what can happen with induction agents for pt with lambert eaton syndrome
excessive hypotension

Fa: Pharm 3 (10 decks)

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