NMB: Part 1

Question 1

what are the uses of NMB?

Answer 1

Facilitate tracheal intubation
IMprove surgical working conditions
Mechanical ventilation of lungs
laryngospasm

Question 2

In terms of ED95, how much NMB should be given for intubation?

Answer 2

2xED95

Question 3

How do volatile anesthetics affect NMBD?

Answer 3

Decrease ED95

Question 4

NMBD effects __________(small/large), ________ (rapidly moving, Slowly moving) muscles first

Answer 4

small, rapidly moving muscles are affected first

Question 5

ONset of block depends on _______ type and _____receptor density

Answer 5

Fiber, ACh

Question 6

Which is more sensitive to NMBD, fast or slow fibers?

Answer 6

fast

Question 7

Obicularis occuli is useful for predicting paralysis of _____________, while the adductor pollicis is more reflective of ___________.

Answer 7

vocal cords, diaphragm

Question 8

Are NMBD lipid soluble? What is the volume of distribution?

Answer 8

Highly ionized therefore limited lipid solubility with limited volume of distribution

Question 9

What effects do NMBD have on CNS, renal and fetus?

Answer 9

none, since they are ionized, they cant cross lipid membranes

Question 10

How does age affect NMBD clearance?

Answer 10

Elderly pts have less blood flow to the liver and therefore clear NMBD more slowly. Volatile anesthetics also decrease bf and will slow clearance

Question 11

Benzylisoquinolinium drugs end in ________ and aminosteroid drug names end in ___________.

Answer 11

-curium, -ronium

Question 12

how do NMBD bind? at the neuromuscular junction block to interrupt transmission of nerve impulses?

Answer 12

the + nitrogen binds to the - alpha subunit of the receptor

Question 13

besides the neuromuscular junction, where else might NMBD have effects?

Answer 13

cardiac muscarinic receptors

autonomic ganglia nicotinic receptors

Question 14

Acetylcholine is stored in ________ aka ________

Answer 14

packets, quanta

Question 15

Which subunit of the nicotinic receptor does succinylcholine attach to?

Answer 15

alpha

Question 16

What is the dose of sux?

Answer 16

1-2 mg/kg

Question 17

what is onset and duration of sux?

Answer 17

30-60s, 3-5 min

Question 18

How is sux metabolized?

Answer 18

plasma cholinesterase

Question 19

Extremely high doses of sux may _________ duration.

Answer 19

increase

Question 20

what does the TOF look like in phase I blockade?

Answer 20

4 twitches that may be decresed, but have no fade
TOF 4 ration >0.7
Decreased amplitude during tetany
NO posttetanic facilitation

Question 21

What happens when you give anticholinesterase to reverse sux?

Answer 21

Enhances block, since cholinesterase breaks down sux too.

Question 22

What does a phase 2 blockade look like?

Answer 22

Resembles non depolarizing NMB

has fade and posttetanic potentiation

Question 23

How do repeated doses of sux manifest?

Answer 23

tachyphylaxis

Question 24

Is the transition from phase I to phase II fast or slow?

Answer 24

abrupt

Question 25

What drugs may decrease plasma cholinesterase activity?

Answer 25

Anticholinesterases | Metoclpramide

Question 26

what is the normal dibucaine number?

Answer 26

80

Question 27

What are examples of patients that are susceptible to hyperkalemia from sux?

Answer 27

``` Burns Skeletal muscle trauma Intrabdominal infection Muscle atrophy Muscular dystrophy T4-T6 lesions ```

Question 28

How does sux affect ICP and IOP?

Answer 28

increases both

Question 29

Why should you avoid sux for patients with small bowel obstruction, pyloric stenosis, or bleeding varices?

Answer 29

Sux causes increase intragastric pressure

Question 30

What are the characteristics of NDPNMB?

Answer 30

``` Decresed single twitch Fade with tetanus TOF <0.7 Post tetanic potentiation Antagonized by anticholinesterase ```

Question 31

What is the mechanism of NDPNMB?

Answer 31

Compet with ACh at alpha subunits at postjunctioal nicotinic receptor. Also has some action at pre-junctional receptor

Question 32

What effect does Sux have on HR?

Answer 32

dysrythmias bradycardia from sux mimicing ACh at cardiac muscarinic cholinergic receptors, especially if a second dose is given 5 minutes after first (Tachycardia and increased BP may occur if sux mimic ACh at autonomic nervous system ganglia)

Question 33

Side effects from NDPNMB are ______. (rare/common)

Answer 33

rare

Question 34

Which NMB is associated with histamine release?

Answer 34

atricurium

Question 35

Which NMB is associated with tachycardia?

Answer 35

pancuronium--vagolytic

Question 36

Pancuronium has a _____ autonomic margin of safety.

Answer 36

low

Question 37

Name drugs that enhanece NDNMB (6)

Answer 37

``` Volatile anesthetics Amino glycosides Local anesthetics Anti dysrhythmics Diuretics Ganglionic blockers (trimethaphan) ```

Question 38

How do phenytoin and other seizure meds affect NMB?

Answer 38

Increased metabolism, may need to use a drip

Question 39

Hypokalemia and hypothermia _________ blockade

Answer 39

prolong

Question 40

How do thermal injury/burns affect blockade (nondepolarizing)

Answer 40

resistant

Question 41

How does magnesium affect NM blockade?

Answer 41

Magnesium inhibits ACh release so therefore potentiates block

Question 42

What happens if you mix a steroid relaxant with a Isoquinolone relaxant?

Answer 42

they are synergistic. YOu can get a real long block

Question 43

What if you give roc before the sux has worn off?

Answer 43

synergistic. always check twitches

Question 44

What is the onset and duration of pancuronium?

Answer 44

3-5 minutes, 60-90 minutes

Question 45

What are the CV effects of pancuronium?

Answer 45

Increased HR, MAP and CO

Question 46

The dose for pancuronium is the same as_______

Answer 46

vecuronium

Question 47

Clearance of pancuronium is decreased up to ___% with renal failure

Answer 47

50

Question 48

What is the onset and duration of Atracurium?

Answer 48

3-5 minutes, 20-35 minutes

Question 49

How is atracurium cleared?

Answer 49

Hoffman elimination and ester hydolysis | not dependent on kidney or liver

Question 50

What are the side effects of atracurium

Answer 50

Histamine release -may lead to bronchoconstriction, should avoid in asthmatics Cardiovascular effects-vasodilation

Question 51

How does metabolism of atracurium differ in peds vs elderly?

Answer 51

No different since it is not dependent on liver BF

Question 52

What is the metabolite of atracurium and what effect does it have?

Answer 52

Laudanosine--CNS stimulant--probably not clinically significant

Question 53

What is the dose of cisatracurium?

Answer 53

0.1-0.15 mg/kg | infusion 1-2 ug/kg/min

Question 54

Does cisatracurium cause histamine release?

Answer 54

No

Question 55

How is Cisatracurium metabolized?

Answer 55

Hoffman degradation

Question 56

How does pH and temperature affect hoffman degradation?

Answer 56

INcreased pH increases elimination | decreased body temperature decreases elimination

Question 57

What is the intra op dose of vecuronium?

Answer 57

0.01mg/kg q 15-20 min for maintenance | INfusion: 1-2 mcg/kg/min

Question 58

How is vecuronium metabolized and cleared?

Answer 58

predominantly metablolized and excreted by liver.

Question 59

What is the RSI and maintenance dose for roc?

Answer 59

0.6-1.2 mg/kg 0.1 mg/kg maintenance 5-12mcg/kg/min infusion

Question 60

How is roc metabolized and cleared?

Answer 60

No metabolism | All is cleared in bile and kidneys

Question 61

Mivacurium is a _________-acting NMBD that is no longer in production

Answer 61

short

Question 62

How is mivacurium cleared?

Answer 62

plasma cholinesterase

Question 63

Which NMBD would you use for renal or severe hepatic failure?

Answer 63

Mivacurium, cisatracurium, atracurium

Question 64

Which NMDB would be the best choice for long cases?

Answer 64

Pancuronium

Question 65

Which NMDB would you choose for plasmacholinesterase deficient cases?

Answer 65

roc/vec