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NMBA Reversal Agents Flashcards

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1
Q

other name for neostigmine

A

Prostigmin

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2
Q

dose for prostigmin

A

0.04-0.08 mg/kg

*5 mg max (comes in 5 mg vial)

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3
Q

MOA of neostigmine

A

inhibit hydrolysis of ACh by AChE

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4
Q

T or F: the more neostigmine you give, the more it reverses

A

F - has a ceiling effect!

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5
Q

T or F: Prostignmin easily crosses BBB

A

F - it is a quarternary ammonium thus does not cross well (its charged)

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6
Q

what medication (and what dose) is usually given with neostigmine. Why is this given?

A

glycopyrollate

0.2 mg per mg of neostigmine

decrease muscarinic effects of neostigmine

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7
Q

is neostigmine a reversal for depolarizing or non-depolarizing NMBD

A

non-depolarizing

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8
Q

Neostigmine:

onset-

duration-

metabolism-

excretion-

A

onset- 15 min (depend on twitches)

duration- 1-2 hours

metabolism- hepatic

excretion: urinary

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9
Q

other name for edrophonium

A

enlon

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10
Q

dose of enlon

A

0.5-1 mg/kg

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11
Q

what is typically given with edrophonium

A

Atropine
0.014 mg/mg of enlon

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12
Q

dose for enlon plus

A

0.05 - 0.1 mg/kg slowly over 1 minute

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13
Q

MOA of endrophonium

A

inhibit hydrolysis of ACh by AChE

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14
Q

IF you have a profound block, is neostigmine or endrophonium the better reversal agent?

A

neostigmine d/t longer DOA

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15
Q

T or F: Enlon easily crosses BBB

A

F - quarternary amine

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16
Q

Edrophonium

onset -

DOA

A

onset -1-2 min

DOA - very short

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17
Q

other name for pyridostigmine

A

regonol

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18
Q

indications for Regonol

A
  • reversal
  • myasthenia gravis
  • pretreatment for soman nerve gas exposure
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19
Q

typically used in gulf-war as a oral dose prophylactically and if exposed, would take again

A

pyridostigmine

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20
Q

Regonol

onset-

DOA-

A

O- 2-5 min

DOA- 2-3 horus

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21
Q

T or F: Regonol does not easily cross BBB

A

T - its a quatenary amine

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22
Q

other name for physostigmine

A

antilirium

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23
Q

the only anticholinesterase that crosses BBB

A

physostigmine

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24
Q

dose of physostigmine

A

IV - 1-2 mg

*may repeat Q1-2 hour

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25
indications for antilirium
- treatment for central anticholinergic syndrome - treat anticholinergic toxicity - not generally used as a reversal agent
26
MOA of physostigmine
inhibits cholinesterase
27
CNS effects of physostigmine
- agitation - restless - disoriented - shivers
28
Physostigmine onset- DOA-
o- 5 min DOA- 1-2 hours *metabolism is rapid and may require repeat dosing
29
other name for sugammadex
bridion
30
dosage of bridion
routine: 2 mg/kg TOF2 4 mg/kg no TOF but 1-2 PTC emergent reversal of RSI: 16 mg/kg
31
indications for suggamadex
reversal of zemuron and vecuronium
32
MOA of suggamadex
selective relaxant binding agent that encapsulates roc, vec, or pancuronium preventing their effects/actions
33
side effects of Suggamadex
**At high dose** = Bradycardia Hypotxn, Cardiac arrest, Headache, N/V, Anaphylaxis and Hypersensitivity May hinder effects of birth control and some antibiotics up to 7 days (Hormonal contraceptives and Toremifene)
34
contraindications (use caution in) of suggamadex
renal impairment wait 24 hours before re-adminstering Roc/Vec/Panc
35
what meds are bridion incompatible with
- verapamil - zofran - ranitidine
36
onset of action for Bridion
~ 3 min
37
Suggamadex is modified ______________
y- cyclodextrin
38
How does Sugammadex alter coagulation?
Increases risk of coagulopathy and bleeding --> increases aPTT and PT, especially in those patients who were being treated with heparin or LMW heparin for thromboprophylaxis
39
Which drug increases a patient's risk for coagulopathy and bleeding by increasing aPTT, and PT (especially in patients being treated with heparin or LMW heparin for thromboprophylaxis)?
sugammadex
40
Which drug interacts with hormonal contraceptives?
sugammadex
41
Sugammadex metabolism:
NOT metabolized; excreted UNCHANGED by kidneys, so take caution in patients with renal failure
42
N/V, hypotension, and headache are common adverse reactions to which NMB reversal agent?
Sugammadex
43
How can we prevent Sugammadex-induced bradycardia?
Give 100 mg over 1 min, then give the next 100 mg, etc.
44
Sugammadex dose (with TOF of 2): conc: time until recovery:
2 mg/kg (100 mg/cc) 2 mins until recovery
45
Sugammadex dose (with 1-2 PTC and no TOF twitches): conc: time until recovery:
4 mg/kg (100 mg/cc) 3 mins until recovery
46
Sugammadex dose (just after administering RSI dose of Rocuronium): conc: time until recovery:
16 mg/kg (100 mg/cc) 1.5 mins until recovery
47
Physostigmine dose to treat anticholinergic toxicity:
give 1-2 mg every 1-2 hrs, as needed
48
What drugs may cause anticholinergic toxicity?
- atropine - scopolamine - antihistamines - antipsychotics - cyclic antidepressants
49
Anticholinergic toxicity s/s:
flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status, fever and urinary retention CNS: restlessness, shivers, agitation, disoriented
50
Cholinergic Syndrome crisis treatment:
Atropine, benzos (versed/valium), oximes (pralidoxime, obidoxime) --> oximes free AChAse from the anticholinesterase that is bound to it
51
Enlon-plus dose:
0.05-0.1 mg/kg IV SLOWLY OVER 1 MIN
52
Edrophonium dose: conc: onset: duration:
0.5-1 mg/kg IV (10 mg/cc) For every 1 mg of edrophonium, mix with 0.014 mg atropine (to prevent bradycardia) onset: 1-2 mins duration: short
53
Edrophonium is used for (light/moderate/deep) block reversal.
moderate
54
Edrophonium is a (tertiary amine/quaternary ammonium) and, therefore, (does/does not) cross the BBB.
quaternary ammonium; DOES NOT
55
___ is a mixture of Edrophonium and atropine together in the same vial.
Enlon-Plus
56
Edrophonium is administered with ___ in order to prevent ___ caused by the rapid ___ of Edrophonium.
Atropine bradycardia onset
57
Neostigmine dose: conc: onset: duration:
0.05 mg/kg IV (max 5 mg) (1 mg/cc) for every 1 mg of Neostigmine, administer 0.2 mg Glycopyrrolate (0.2 mg/cc) to decrease muscarinic side effects (and GIVE GLYCO FIRST in case something happens between; we can handle tachycardia better than bradycardia) onset: starting at 15 mins (twitch dependent) duration: 1-2 hrs
58
Neostigmine is used for (light/moderate/deep) block reversal. How do we know when to use?
deep (use when 4 tactile TOF counts are present at adductor pollicis) (more effective with moderate blocks)
59
What is our max dose of Neostigmine?
5 mg --> d/t ceiling effect
60
Neostigmine is a (tertiary amine/quaternary ammonium) compound and, therefore (does/does not) cross the BBB.
quaternary ammonium does not
61
Neostigmine is used with ___ to decrease the ___ side effects of Neostigmine.
glycopyrrolate (anticholinergic) muscarinic
62
Neostigmine blocks AChAse at ____________, causing (parasympathetic/sympathetic) effects.
ALL **cholinergic** synapses parasympathetic
63
Physostigmine --> drug class:
acetylcholinesterase inhibitor (crosses BBB)
64
Edrophonium --> drug class:
acetylcholinesterase inhibitor
65
Neostigmine --> drug class:
acetylcholinesterase inhibitor
66
Sugammadex drug class:
selective relaxant binding agent
67
Which drugs are our acetylcholinesterase inhibitors?
Neostigmine Edrophonium Physostigmine (crosses BBB)
68
What side effects are caused by the administration of acetylcholinesterase inhibitors?
Think --> TOO MUCH ACh!! SLUDGE (**PNS** activation) Increased bronchial secretions/bronchospasm Bradycardia caused by slowing conduction velocity of the cardiac impulse through the AV node **CNS excitement (physostigmine only)**
69
Acetylcholinesterase inhibitors are used for what 3 purposes?
reversal of NMBs myasthenia gravis (diagnosis and treatment) treatment of central anticholinergic syndrome
70
___ is the enzyme responsible for the rapid hydrolysis of released acetylcholine.
Acetylcholinesterase
71
What are the two ways to reverse a patient from NMBs?
spontaneously reversal drug
72
What 5 factors affect the reversal of NMBs?
1. intensity of the block 2. dose and choice of NMB 3. drug interactions 4. choice of reversal agent 5. disease process (liver failure)

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