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Muscle Relaxants Flashcards

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1
Q

What are 3 ways to cause muscle relaxation?

A
  1. increase volatile anesthetic
  2. regional anesthesia
  3. NMBA
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2
Q

Classes of NMBAs

A
  • depolarizing
  • nondepolarizing (aminosteroids & benzylisoquinolines)
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3
Q

What drug(s) are depolarizing NMBAs?

A

succinylcholine

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4
Q

What drug(s) are nondepolarizing aminosteroids?

A
  • rocuronium
  • vecuronium
  • pancuronium
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5
Q

What drug(s) are nondepolarizing benzylisoquinolines?

A
  • mivacurium
  • atracurium
  • cisastracurium
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6
Q

How does succinylcholine work?

A

binds to 2 alpha subunits of nicotinic cholinergic receptors (like ACh), allowing Na+ and Ca++ to flow in, K+ to flow out, and causing depolarization of the muscle

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7
Q

Succinylcholine mimics the action of __________

A

acetylcholine

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8
Q

When administered succinylcholine, the muscle remains depolarized until ________________

A

succinylcholine diffuses away from the receptor

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9
Q

When is succinylcholine used?

A
  • rapid muscle relaxation
  • routine intubation
  • very short cases
  • OB
  • RSI
  • laryngospasm
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10
Q

T/F: There is a reversal agent for succinylcholine

A

false
there is no reversal agent for succinylcholine; just has to diffuse away

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11
Q

Which NMBA has the potential to trigger malignant hyperthermia?

A

succinylincholine

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12
Q

Succinylcholine has potential to __________ HR due to _____________ stimulation

A
  • decrease HR
  • muscarinic stimulation
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13
Q

What is Phase I of succinylcholine administration?

A

normal expected phase from proper dosing; no fade on TOF

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14
Q

What is Phase II of succinylcholine administration?

A

happens from large or repeated doses of SCh; fade will be seen on TOF

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15
Q

The most common side effect of succinylcholine

A

fasciculations

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16
Q

Fasciculations can cause _____________

A

myalgia (muscle pain)

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17
Q

T/F: Succinylcholine has minimal histamine release

A

true

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18
Q

What are the potential side effects in children when given succinylcholine?

A
  • hyperkalemia
  • bradycardia
  • cardiac arrest
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19
Q

How is succinylcholine metabolized?

A

hydrolyzed in plasma by buyrylcholinesterase aka plasma cholinesterase aka psuedocholinesterase

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20
Q

Succinylcholine Dosing

A

1 - 1.5 mg/kg for RSI
20 mg for laryngospasm

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21
Q

Succinylcholine onset and duration

A

Onset: 30-60 sec
Duration: < 10 min

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22
Q

Succinylcholine IM Dosing

A

3-5 mg/kg

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23
Q

Succinylcholine IM onset and duration

A

Onset: 2-5 min
Duration: 10-30 min

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24
Q

____________ is a weak active metabolite of succinylcholine

A

succinylmonocholine

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25
What can prolong blocking effects of succinylcholine?
anything that can cause decreased levels of pseudocholinesterase (pregnancy, liver disease) and pseudocholinesterase abnormality
26
T/F: Pregnancy can prolong blocking effects of succinylcholine
true pregnancy decreases pseudocholinesterase levels, causing decreased metabolism of SCh
27
What are the triggers for MH?
- succinylcholine - volatile inhalational agents
28
T/F: Nitrous oxide can trigger MH
false
29
What are the first signs of MH?
- unexplained increase in CO2 - unexplained increase in temp - masseter spasm/rigidity - unexplained sudden tachycardia
30
How do nondepolarizing NMBAs work?
compete with and block ACh at the alpha subunits of the nicotinic receptors on the motor endplate, inhibiting depolarization
31
When are nondepolarizing relaxants used?
muscle relaxation for surgery or for intubation
32
How are aminosteroid nondepolarizing NMBAs metabolized and excreted?
- primarily liver breakdown - kidney excretion
33
T/F: nondepolarizing NMBAs have the most reported allergic reactions
true nondepolarizing relaxants have potential for allergic reactions
34
What is the most commonly used NMBA?
rocuronium
35
Rocuronium Dosing
Routine induction: 0.6 mg/kg RSI: 1.2 mg/kg
36
_____ mg of rocuronium can be used as a _______________ dose for succinylcholine
- 5 mg - defasciculating dose
37
What is the maintenance/repeat dose for rocuronium?
0.1 - 0.2 mg/kg
38
Rocuronium onset and duration
Onset: 1-2 min Duration: 30 min
39
Rocuronium is primarily eliminated/metabolized by _______________
the liver
40
Vecuronium Dosing
0.08 - 0.1 mg/kg
41
What is the maintenance/repeat dose for vecuronium?
0.01 mg/kg
42
Which agent can you pretreat with 10% of the intubation dose 3 minutes before intubation?
vecuronium
43
T/F: vecuronium has minimal histamine release
false vecuronium has NO histamine release
44
Vecuronium onset
- good intubating conditions: 2-3 min - maximal blockade: 3-5 min
45
Vecuronium has potential to precipitate with _____________
thiopental
46
Does vecuronium have great cardiac effects?
no vecuronium is fairly cardiac stable
47
Pancuronium Dosing
0.08 - 0.12 mg/kg
48
Pancuronium maintenance dose
0.01 mg/kg
49
Pancuronium onset and duration
Onset: 2-3 min Duuration: 60-100 min
50
Pancuronium is a __________ acting NMBA
long acting
51
T/F: there is NO histamine release with pancuronium
true
52
What are the CV effects from pancuronium?
- increased HR (tachycardia) - increased BP - incrased CO
53
Must be careful in administering pancuronium in _________ patients
cardiac may not be able to tolerate increase in HR, BP, and CO
54
When is pancuronium used?
in situations where patient can be paralyzed for extended period of time due to long acting duration. not typically used for surgery, unless going to ICU intubated
55
How does pancuronium cause tachycardia and high BP?
antimuscarinic stimulation --> norepinephrine release and reduced uptake of norepi by adrenergic nerves
56
How are benzylisoquinoline NMBAs metabolized?
- Hofmann Elimination - ester hydrolysis - plasma cholinesterase
57
What is Hofmann Elimination?
spontaneous, non-enzymatic, non-organ dependent chemical breakdown; dependent on temperature and pH
58
In regards to Hofmann elimination, what factors increase metabolism?
- increased temp - increased pH (alkalosis)
59
In regards to Hofmann elimination, what factors decrease metabolism?
- decreased temp - decreased pH (acidosis)
60
Which NMBAs are associated with histamine release?
- rocuronium - mivacurium - atracurium - succinylcholine
61
Which NMBAs have NO histamine release?
- vecuronium - pancuronium - cisastracurium
62
Mivacurium Dosing
Induction: 0.15 - 0.2 mg/kg Infusion: 4-10 mcg/kg/min
63
Mivacurium onset and duration
Onset: 1 min Duration: 10-20 min
64
Mivacurium is associated with ____________ when given quickly and can cause ____________
- HISTAMINE RELEASE - flushing, hives
65
Spontaneous recovery from mivacurium is rapid or slow?
rapid
66
How is mivacurium metabolized?
plasma cholinesterase
67
Mivacurium has the same mechanism of metabolism as which agent? What is this mechanism of metabolism?
- Succinylcholine - plasma cholinesterase
68
Atracurium Dosing
0.3 - 0.6 mg/kg
69
Atracurium onset and duration
Onset: 2-3 min Duration: 20-35 min (25%), or 60-70 (95%)
70
How is atracurium metabolized?
- Hofmann elimination - nonspecific ester hydrolysis
71
What is the effect of atracurium on BP?
small decrease in BP
72
What is the primary metabolite of atracurium?
laudanosine
73
____________ is the primary metabolite of atracurium and has potential to cause ___________ since it can ______________
Laudanosine is the primary metabolite of atracurium and has potentail to cause seizures since it can cross the BBB
74
Cisatricurim Dosing
0.1-0.15 mg/kg
75
Cisatrcurium onset, peak, and duration
Onset: 2-3 min Peak: 3-5 min Duraiton: 40-70 min (25%); 20-35 min to begin recovery; 93 min (90%)
76
What are the top 5 drugs that cause anaphylaxis during surgery?
1. sugammadex 2. rocuronium 3. antibiotics 4. local anesthetics 5. propofol

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