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Advanced Pharm 2 For NA > Nagelhout Video 2- Exam 1 > Flashcards

Nagelhout Video 2- Exam 1 Flashcards

(45 cards)

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1
Q

Succinylcholine structure

A

two ACh molecules stuck together

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2
Q

Succinylcholine broken down by

A

plasma cholinesterase

First broken down into:
succinyl-monocholine and choline

Then into
Succinic acid and choline

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3
Q

What is recycled to make new Ach?

A

Choline

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4
Q

What partof sux metabolism is metabolized via the kreb’s cycle?

A

succinic acid

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5
Q

Why does succinylcholine have such a brief duration?

A

rapid hydrolysis in plasma by cholinesterase enzyme to inactive metabolites

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6
Q

all the cholinesterases do the SAME thing which is-

A

break things down via hydrolysis - by adding water

MOST UBIQUITOUS ENZYME IN THE BODY

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7
Q

What are the cholinesterase family of enzymes?

A

hydrolytic enzymes that hydrolyze ACh and ester LAs at the synaptic cleft more quickly than others at other conditions

-allows for proper nerve signalling by preventing overstimulation

names for this family :
acetylcholinesterase (synapse of muscles)
pseudocholinesterase (plasma)

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8
Q

ESTERASE ENZYMES -

2 types of CHOLINESTERASE

A

Acetylcholinesterase (muscle synapse)

Pseudocholinesterase (plasma)

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9
Q

ESTERASE ENZYMES -

Non-specific esterases

A

RBC esterase

Paraxonase

Albumin Esterase

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10
Q

Common esterase dependent anesthesia drugs - Pseudocholinesterase (PChE)

A

Succinylcholine

Mivacurium

Ester local anesthetics (cocaine, procaine, chloroprocaine, tetracaine)

Neostingmine

Edrophonium

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11
Q

Common esterase dependent anesthesia drugs - Non-specific esterases (plasma)

A

Atracurium
Cisatracurium
Remifentanil
Clevidipine

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12
Q

Common esterase dependent anesthesia drugs - RBC esterases

A

Esmolol

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13
Q

Some people have atypical cholinesterase in their bodies what does this mean?

A

Will result in different metabolization rates of succinylcholine and ester LAs

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14
Q

Is atypical cholinesterase a pathologic condition?

A

No its an inherent difference among human beings- most common is Homozygote A (EaEa)
-tested via Dibucaine test

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15
Q

atypical cholinesterase - Homozygote A decreases enzyme activity by

A

> /= 70%, prolongs effects for 4-24 hours

Results in a Dibucaine test number of 16-30

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16
Q

Which test is used to determine if a person is slow to metabolize succinylcholine due to atypical cholinesterase?

A

DIBUCAINE INHIBITION TEST

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17
Q

What is dibucaine?

A

An amide local anesthetic which inhibits typical or usual pseudocholinesterase (PchE) but not atypical

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18
Q

Normal dibucaine number

A

80

Means that 80% of the ACh-esterase activity was inhibited by dibucaine

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19
Q

If dibucaine number is 20

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A

the patient has an atypical enzyme since dibucaine did not inhibit the patient’s enzyme activity

20
Q

If a patient experiences prolonged apnea following succinylcholine or mivacurium administration what must you differentiate between?

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A

Atypical genetic variant of AChE or just low levels of AChE enzyme
-via Dibucaine test

21
Q

Low dibucaine number + normal activity =

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A

atypical enzyme and prolonged apnea

22
Q

Normal dibucaine number + low activity =

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A

Normal enzyme with low levels present and prolonged apnea

23
Q

Normal dibucaine number + normal activity =

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A

normal enzyme and amount (another reason for prolonged apnea must be investigated)

24
Q

Low dibucaine number + Low activity =

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A

atypical enzyme with low levels present and prolonged apnea

25
PChE variant - usual Homozygote U (EuEu)
96% frequency Normal enzyme activity Duration of Succinylcholine is normal Dibucaine test number- 70-80
26
PChE variant - Atypical Homozygote A (EaEa)
0.3% frequency Decreased enzyme activity by >/= 70% Duration of succinylcholine is SIGNIFICANTLY prolonged 4-24 hours Dibucaine number is 16-30
27
Succinylcholine side effects
Hyperkalemia Dysrhythmias- hyperK related Myalgia- from fasciculations Myoglobinemia Elevated intragastric pressure Elevated IOP Elevated ICP-from fasciculations and high CVP MH Masseter Spasm-followed by MH sometimes
28
Succinylcholine side effects - Hyperkalemia
Normally serum K+ increased by 0.5 mEq/L secondary to potassium leaking from the depolarized muscle In patients with crush injuries, burns, denerving injuries, MH, K+ levels are much higher
29
Succinylcholine side effects- Dysrhythmias
From hyperK or ganglionic effects of succinylcholine -Wide EKG complexed leading to arrest have been seen in children with dystrophin-deficient muscular dystrophies (duchennes, becker)
30
Succinylcholine side effects - Myalgia
Secondary to fasciculation even though some patients complain of muscle pain without having shown evidence of fasciculation
31
Succinylcholine side effects - Myoglobinemia
Rare complication after extensive fasciculation or MH
32
Succinylcholine side effects - elevated intragastric pressure
can occur from contractions of ab muscles d/t fasciculation The elevation of intragastric pressure seen with succinylcholine are less significant than occur with CO2 insufflation during laparoscopic surgery
33
Succinylcholine side effects - Increase IOP
Ketamine + succinylcholine do this -MOA unknown - seems related to contraction of ocular muscles during fasciculation from sux
34
Succinylcholine side effects - Malignant hypothermia
genetic predisposition -MOA of succinylcholine triggering this is poorly understood
35
Succinylcholine side effects - masseter spasm
More often in kids than adults. **Can be early sign of MH** so when succinylcholine is used with halothane vs when used with thiopental
36
Which patients is succinylcholine contraindicated in?
patients at risk for upregulation of ACh receptors Ex- · Upper or lower motor neuron defect · Prolonged chemical denervation (i.e.) muscle relaxants, magnesium, clostridial toxins) · Direct muscle trauma, tumor, or inflammation · Thermal trauma/ Burns= · Disuse atrophy · Severe infection
37
Contraindications to succinylcholine
Hyperkalemia / hyperkalemia d/t renal failure (not the renal failure itself but the high K+ Burn patients -35% TBSA - 3rd degree Severe muscle trauma Neuro injury - paraplegia / quadplegia Severe sepsis (abdominal) Muscle wasting/ prolonged immobilization MH Denervating diseases Duchenne muscular dystrophy- why we don't give succinylcholine to kids; DMD can be undetected Selected muscle disorders - in general patients with muscle disease shouldn't receive Children under 8 years old - only emergency situations (airway-kids don't show typical signs of issues) Genetic variants of pseudocholinesterase Stains - (?) per nagelhout - ok Allergy
38
Patients with muscle disease & succinylcholine
avoid sux -patients with muscle disease will have increased sensitivity to non-depolarizing muscle relaxants and have lower dose requirements too
39
Cholinesterase enzymes: Acetylcholinesterase (AChE)
known as true, specific, genuine, type 1 membrane bound glycoprotein
40
Cholinesterase enzymes: Pseudocholinesterase (PChE)
known as plasma, serum, benzoyl, false, butryl, nonspecific, type 2 -has over 11 isoenzyme variants
41
Cholinesterase enzymes: Pseudocholinesterase (PChE) locations
plasma liver smooth musc intestine pancreas heart white matter
42
Cholinesterase enzymes: Acetylcholinesterase (AChE) locations
erythrocytes nerve endings lungs spleen gray matter
43
Neostigmine elimination half life
70-80 min It takes 70-80 mins to eliminate the Ne Yo song stuck in my head
44
Edrophonium elimination half life
110 min - healthy pt 300 min - impaired renal function pt -75% excreted by kindeys
45
Which do you give first, AChE inhibitor or anticholinergic/antimuscarinic?
Anticholinergic 1st want to prevent the negative effects of the AChE inhibitor first -could give neostigmine and robinul at same time technically

Advanced Pharm 2 For NA (14 decks)

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