NMBD Reversal Agents (Exam IV)

Question 1

How long, generally, until NMJ blockade is fully reversed with neostigmine?

Answer 1

20-30 min

Question 2

Do AChE inhibitors work with deep neuromuscular blockade?

Answer 2

No

Question 3

Reversal of NMJ blockade is dependent on these 5 factors:

Answer 3

1. Depth of block
2. Drug choice (neo vs edro)
3. Dose
4. Plasma clearance
5. Anesthetic agent and depth used

Question 4

Which paralytic has to be reconstituted with 10mL of H₂O ?

Answer 4

Vecuronium

Question 5

What is the max dosage of neostigmine?

Answer 5

40 - 70 mcg/kg

0.04 - 0.07 mg/kg

Question 6

What is the onset and duration of neostigmine?

Answer 6

Onset: 5 - 10 min
Duration: 60 min

Question 7

What is the dosage of edrophonium?

Answer 7

0.5 - 1 mg/kg

Question 8

What is the max dosage of edrophonium?

Answer 8

1.5 mg/kg

Question 9

What is the onset and duration of edrophonium?

Answer 9

Onset: 1-2 min
Duration: 5-15 min

Question 10

What percentage of neostigmine is renally excreted?

Answer 10

50%

Question 11

What percentage of both pyridostigmine and edrophonium are renally excreted?

Answer 11

75%

Question 12

How are NMB reversal agents cleared if the patient has no innate renal function?

Answer 12

30 - 50% cleared hepatically

Question 13

What is the major side effect of NMBD reversal agents?

Answer 13

↑PSNS activity (from increased nACh and mACh activity)

Question 14

What drugs would be coupled with NMBD reversal agents to prevent adverse side effects from these drugs?

Answer 14

Anti-cholinergic / Anti-muscarinics

• Atropine
• Glycopyrrolate

Question 15

If you’re concerned about someone’s cardiac status due to existing disease, which Anticholinergic drug would you use?

Answer 15

Glycopyrrolate - anticholinergic with minimal cardiac effects. It does not cross blood brain barrier, so it is less likely to cause tachycardia, but it does prevent bradycardia

Question 16

What NMBD(s) is glycopyrrolate used with?

Answer 16

• Neostigmine
• Pyridostigmine

Question 17

What NMBD(s) is atropine used with?

Answer 17

Edrophonium

Question 18

What is the dose of Atropine?

Answer 18

7 - 10 mcg/kg

Question 19

What common side effects are seen right after atropine administration?

Answer 19

• Mydriasis
• Tachycardia

Question 20

What is the maximum dose of glycopyrrolate?

Answer 20

1mg max dose

Question 21

How long does glycopyrrolate need to be administered over?

Answer 21

2 - 5 min

Question 22

What reversal drug is specific to mivacurium?

Answer 22

Purified human plasma cholinesterase

Question 23

What reversal drug is specific to gantacurium?

Answer 23

Cystiene

Question 24

What reversal drug is very specific to rocuronium?

Answer 24

Sugammadex

Question 25

What type of drug is sugammadex?

Answer 25

Selective relaxant-binding agent

Question 26

What should be known about sugammadex's organic structure and physical properties?

Answer 26

- γ-cyclodextrin - Dextrose units from starch - Very H₂O-soluble

Question 27

What is the MOA of Sugammadex?

Answer 27

Encapsulates rocuronium via: - Van der Waals forces - H-bonds - Hydrophobic interactions

Question 28

What drugs does sugammadex work with?

Answer 28

**Roc** > Vec > Pancuronium

Question 29

What is the E ½ time of sugammadex?

Answer 29

2 hours

Question 30

How is sugammedex eliminated?

Answer 30

Urine: - 70% gone in 6 hours - 90% gone in 24 hours

Question 31

Differentiate a moderate block vs a deep block.

Answer 31

- Moderate: 2/4 twitches on TOF - Deep: No twitches to TOF

Question 32

What is the Sugammadex dose for a moderate block?

Answer 32

2 mg/kg

Question 33

What is the Sugammadex dose for a deep block?

Answer 33

4 mg/kg

Question 34

What is the sugammadex dose for an extreme (overdose) block?

Answer 34

8 - 16 mg/kg

Question 35

What are the side effects of Sugammadex?

Answer 35

- Bradycardia - dose-related N/V - dose-related Pruritis - dose-related Urticaria - Anaphylaxis

Question 36

What drugs/conditions are relative contraindications to sugammadex?

Answer 36

- Contraceptives (binds them for 7 days) - Toremifene (selective estrogen receptor modulator (SERM) displaces roc from sugammadex) - Coagulopathy - ESRD (excreted renally)

Question 37

What is recurarization?

Answer 37

Resumption of NMJ blockade after period of reversal

Question 38

What s/s would indicate recurarization? *Say you just brought the patient to PACU*.

Answer 38

- ↓ SpO₂ - ↓ respiratory effort - Floppy/uncoordinated - Unresponsive

Question 39

What drug and dose would be a good choice for a recurarizing patient in the PACU? Why might this be a good choice?

Answer 39

- Neostigmine 0.05 mg/kg IV - Longer duration of action