Exam 4: NMBD Reversals

Question 1

Benzolisoquinoline and metabolized in the _____​

Answer 1

plasma

Question 2

Aminosteroids are metabolized in the ____

Answer 2

liver

Question 3

what is the drug class of edrophonium and neostigmine

Answer 3

AcetylcholineEsterase (AchE) Inhibitors​

a.k.a. Cholinergic Agents​

a.k.a. COMPETITIVE ANTAGONISTS​

Question 4

what is the MOA of the AchE-I?

Answer 4

inhibiting AchE at the NMJ and leaving more Ach avaliable

Ach binds to the alpha subunits

Available @ the Preganglionic (SNS & PNS)​ To propagate action potential​

NMJ: neuromuscular junction

Question 5

Will neostigmine or edrophonium work with a deep NM blockade?

Answer 5

no

Question 6

If you give a reversal to someone with 0/4 twitches, what will happen?

Answer 6

you will prolong the NM blockade

ChatGPT said it will do this because the flooding of Ach at the NMJ when there is no where for it to bind will inhibit further Ach release and prolong the blockade

Question 7

What is the preferred Neo dose according to Dr. Jose

Answer 7

50mcg/kg

or 40-70mcg/kg

Question 8

What is the max dose of Neo?

Answer 8

5mg

Question 9

what is the max dose of edrophonium?

Answer 9

1mg/kg

Question 10

reversal of blockade depends on what 5 factors?

Answer 10

1. depth of NM block
2. AchE inhibitor choice
3. dose given
4. rate of plasma clearance of NMB
5. anesthesia agent choice and depth

RAADD

Question 11

With a longer acting NMB, what could you expect do have to do if you give a reversal?

Answer 11

redose the reversal

Question 12

List the order of duration of the NMB agents we spoke about

Answer 12

Pancuronium
atracurium
cisatracurium
Vec
Roc
Mivacurium

Poop And Cats Very Rarely Miss

Question 13

Edrophonium dose
onset
duration

Answer 13

0.5-1mg/kg

1-2 min

DOA 5-15min

Question 14

what will you give before you give edrophonium?

Answer 14

atropine so the pt HR does decrease to like…..dead

Question 15

Neostigmine dose
onset
duration

Answer 15

50mcg/kg

5-10 min

60 min

Question 16

do you give glyco and then Neo?

Answer 16

nope. give glyco after

Question 17

During a case, at what time would you give Neo?

what will the surgoen be doing?

Answer 17

when the surgeon is putting in the second to last stitches

Question 18

Answer 18

50mcg X 100kg = 5000mcg​

5000mcg = 5mg​

5mls

Question 19

If you give your pt a reversal and they have chronic kidney disease, what do you expect to happen to the reversal?

Answer 19

prolong DOA

Renal Excretion​
-Neostigmine 50%​
-Pyridostigmine and Edrophonium 75%​

CRF decreases plasma clearance​
 prolonged action​

Hepatic Clearance​
30 to 50% if no renal function​

Question 20

NMBD reversal agents increase ___ and ____ activity

Answer 20

Nicotinic/Muscarinic Activity

Question 21

increase Nicotinic/Muscarinic Activity causes what CV. Pulm, GI, and Eye issues?

Answer 21

CV: Bradycardia, dysrhythmias, asystole, ↓SVR​

Pulmonary: Bronchoconstriction, increased airway resistance, increased salivation​

GI: Hyperperistalsis, enhanced gastric fluid secretion, PONV​

Eyes: Miosis (contraction)

Question 22

atropine dose with edrophonium

Answer 22

Atropine: 10 µg/kg (mydriasis & initial tachycardia)​

Matches profile of Edrophonium (used for bronchodilation)

Question 23

Glyco dose with neo

Answer 23

Glycopyrrolate: 10 µg/kg (1 mg maximum)​

Matches profile of both Neostigmine and Pyridostigmine

Question 24

How many mental break downs per week are you allowed to have if you are in CRNA school?

Answer 24

as many as you want

its 12:34pm and I’ve already had 4

Question 25

is Atropine or glyco preferred with cardiac disease?

Answer 25

glyco give slowly over 2-5 min

Question 26

MATH: How much glyco will you give to a 100kg patient if it is available at 0.2mg/ml?

Answer 26

10mcg X 100kg = 1000mcg​ 1mg/5ml

Question 27

Sugammadex only works on _____

Answer 27

aminosteroids

Question 28

Which NMBD are aminosteroids

Answer 28

pancuronium, vecuronium, and Roc

Question 29

Describe the structure of sugammadex?

Answer 29

γ-cyclodextrin​ dextrose units from starch​

Question 30

Is sugammadex water soluble?

Answer 30

Very, excretion in the kidney

Question 31

What is the MOA of sugammadex?

Answer 31

very tight reversal by encapsulation and Binds to ‘free drug” in plasma**​ Stays in the plasma not at the NMJ​ Does not bind with plasma proteins

Question 32

What interactions are used with sugammadex? *think chemistry

Answer 32

intermolecular (van der Walls) forces, thermodynamic (hydrogen) bonds, hydrophobic interactions

Question 33

T/F Sugammadex works in the NMJ

Answer 33

false, works in the plasma

Question 34

T/F Sugammadex does not bind to plasma proteins

Answer 34

T

Question 35

Sugammadex works best on ____, then______, and the least on _____

Answer 35

Rocuronium > Vecuronium >> Pancuronium

Question 36

Sugammadex Major route of elimination is the Urine​ 70% is eliminated in _ hours​ 90% is eliminated in _ hours

Answer 36

6; 24 Renal impairment: C/I with dialysis

Question 37

what is the E1/2 time of sugammagex

Answer 37

2 hr

Question 38

Your pt has 2/4 twitches. What is the dose of sugammadex?

Answer 38

2mg/kg

Question 39

your pt has 0/4 twitches and has 1-2 posttetanic twitches, what is the sugammadex dose?

Answer 39

4mg/kg

Question 40

WHat is the sugammadex dose with an extreme block?

Answer 40

8-16 mg/kg

Question 41

What are the dose related SX of sugammadex?

Answer 41

Nausea/vomiting​ Pruritus​ Urticaria​ Anaphylaxis​ Marked bradycardia​ Doesn’t work

Question 42

After roc is reversed, how quickly can you give a 1.2mg/kg dose of roc?

Answer 42

5 min

Question 43

After roc is reversed, how quickly can you give a 0.6 mg/kg dose of roc or 0.1mg/kg dose of vec?

Answer 43

4 hours

Question 44

What if you cant wait the recommended time to redose roc? What do you do?

Answer 44

Give a benzylisoquinoline (miva, cis, atra)​ Then you can reverse with cholinergic medications

Question 45

What would you tell your pt if you gave the sugammadex and they are on birth control?

Answer 45

Pt will need to use alternative contraception Encapsulating effects on oral contraceptives high in progesterone​ Binds with Progesterone (7 days)​

Question 46

Toremifene (non-steroidal anti-estrogen) does what to sugammadex?

Answer 46

Displaces NMBD from Sugammadex

Question 47

is RECURARIZATION​ (aka Reparalized Patient) common with sugammadex?​

Answer 47

no

Question 48

What are signs of RECURARIZATION​?

Answer 48

Signs & Symptoms:​ Decreased 02 sats​ unresponsive patient ​ appears “floppy” or uncoordinated​ ineffective abdominal and intercostal activity​

Question 49

What is the treatment for recurarization?

Answer 49

Treat urgently and aggressively​ Re-sedate the patient​ Give additional reversal agents in divided doses (Neostigmine 0.05 mg/kg IV = longer duration of action). Can give physostigmine​