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KM (Spring 2024) Anesthesia Pharm ** > *NMBD Reversal Agents (Exam IV) > Flashcards

*NMBD Reversal Agents (Exam IV) Flashcards

(62 cards)

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1
Q

What are the 3 classifications of NMBD Reversal Agents?

A
  1. AcetylcholineEsterase (AchE) Inhibitors
  2. Cholinergic Agents
  3. COMPETITIVE ANTAGONISTS

S9

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2
Q

What is the MOA if AChE

A
  • Rapid hydrolysis (catalyze) of Ach

Inhibition of Esterase enzyme = more Acetylcholine available → Ach binds to alpha subunits

S9

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3
Q

Where is AChE available at?

A
  • Preganglionic (SNS & PNS)
  • NMJ: neuromuscular junction

S9

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4
Q

Do AChE inhibitors work with deep neuromuscular blockade?

A

No

S10

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5
Q

What do we do when patient has deep NM blocked according to Dr. Castillo?

A

WAIT
until we get a TOF and Tetany

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6
Q

What is the max dosage of neostigmine?

A

40 - 70 mcg/kg

0.04 - 0.07 mg/kg

S10

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7
Q

What is the max dosage of edrophonium?

A

1 mg/kg

S10

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8
Q

Reversal of NMJ blockade is dependent on these 5 factors:

A
  1. Depth of block
  2. AChE Inhibitor choice (neo vs edro)
  3. Dose
  4. Rate of plasma clearance
  5. Anesthetic agent choice and depth

S11

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9
Q

What is the ED50 and ED90 of Pancuronium?

A

ED50 = 0.036

ED90 = 0.067

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10
Q

What is the ED50 and ED90 of Rocuronium?

A

ED50 = 0.147

ED90 = 0.305

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11
Q

What is the ED50 and ED90 of Vecuronium?

A

ED50 = 0.027

ED90 = 0.043

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12
Q

What is the ED50 and ED90 of Atracurium?

A

ED50 = 0.12

ED90 = 0.21

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13
Q

What is the ED50 and ED90 of Cisatracurium?

A

ED50 = 0.026

ED90 = 0.040

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14
Q

What is the ED50 and ED90 of Mivacurium?

A

ED50 = 0.039

ED90 = 0.067

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15
Q

What is the onset and duration of neostigmine?

A

Onset: 5 - 10 mins
Duration: 60 mins

S14

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16
Q

What is the dosage of edrophonium?

A

0.5 to 1 mg/kg

S14

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17
Q

What is the onset and duration of edrophonium?

A

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

S14

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18
Q

What percentage of neostigmine is renally excreted?

A

50%

S16

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19
Q

What percentage of both pyridostigmine and edrophonium are renally excreted?

A

75%

S16

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20
Q

How does Chronic Renal Failure affect NMBD reversal agents?

A

decreases plasma clearance
→ prolonged action

S16

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21
Q

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

A

30 - 50% cleared hepatically

S16

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22
Q

What is the major side effect of NMBD reversal agents?

A

Increased Nicotinic/Muscarinic Activity

S17

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23
Q

What CV side effects of NMBD Reversal Agents?

A
  • Bradycardia
  • dysrhythmias
  • asystole
  • ↓SVR

S17

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24
Q

What pulmonary side effects of NMBD Reversal Agents?

A
  • Bronchoconstriction
  • increased airway resistance
  • increased salivation

S17

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25
What GI side effects of NMBD Reversal Agents?
* Hyperperistalsis * enhanced gastric fluid secretion * PONV ## Footnote S17
26
What opthalmic side effects of NMBD Reversal Agents?
Miosis ## Footnote S17
27
What drugs would be coupled with NMBD reversal agents to prevent adverse side effects from these drugs?
Anti-cholinergic / Anti-muscarinics - Atropine - Glycopyrrolate ## Footnote S18
28
If you're concerned about someone's cardiac status due to existing disease, which Anticholinergic drug would you use?
Glycopyrrolate ## Footnote S18
29
What NMBD Reversal(s) is glycopyrrolate used with?
- Neostigmine - Pyridostigmine ## Footnote S18
30
What NMBD Reversal(s) is atropine used with?
Edrophonium ## Footnote S18
31
What is the dose of Atropine?
7 - 10 mcg/kg ## Footnote S18
32
What common side effects are seen right after atropine administration?
- Mydriasis - Tachycardia ## Footnote S18
33
What is the maximum dose of glycopyrrolate?
1mg max dose ## Footnote S18
34
How long does glycopyrrolate need to be administered over?
2 - 5 min administer SLOWLY ## Footnote S18
35
What is the mechanism when there is persistent NM blockade?
- *Acetylcholine*sterase is maximally inhibited - No further *anticholine*sterase is effective ## Footnote S20
36
What is the intervention for persistent NM blockade?
Sedation and postop ventilation ## Footnote S20
37
What do you need to do before giving paralytics during Induction according to Dr. Castillo?
CHECK YOUR BASELINE TOF!! (make sure to test the TOF and it has adequate batteries also)
38
What factors influencing NMBD Reversal?
* Intensity of block * Which NMBD did you use (renal vs liver)? * Continued volatile anesthetic? * Which reversal drug are you using? * Patient conditions -Metabolic acidosis -Respiratory acidosis -Hypothermia ## Footnote S21
39
What to do when titrating down Glycopyrrolate according to Dr. Castillo?
Be careful with titrating down and DO NOT go below 50% ## Footnote NMBD Reversal Agents
40
What reversal drug is specific to mivacurium?
Purified human plasma cholinesterase ## Footnote S22
41
What reversal drug is specific to Gantacurium?
Cystiene ## Footnote S22
42
What reversal drug is very specific to rocuronium?
Sugammadex ## Footnote S22
43
What type of drug is sugammadex?
Selective relaxant-binding agent ## Footnote S22
44
What should be known about sugammadex's organic structure and physical properties?
- γ-cyclodextrin - Dextrose units from starch - Very H₂O-soluble ## Footnote S24
45
What is the MOA of Sugammadex?
Encapsulates rocuronium via: - Intermolecular (Van der Waals forces) - Thermodynamic (H-bonds) - Hydrophobic interactions ## Footnote S25
46
What drugs does sugammadex work with?
**Roc** > Vec > Pancuronium ## Footnote S25
47
Where does Sugammadex binds to?
The "free drug" in plasma ## Footnote S25
48
What is the E ½ time of sugammadex?
2 hours ## Footnote S26
49
How is sugammedex eliminated?
Urine: - 70% gone in 6 hours - 90% gone in 24 hours Renal impairment: cleared with dialysis ## Footnote S26
50
What is the Sugammadex dose for a moderate block?
2 mg/kg ## Footnote S27
51
What is the Sugammadex dose for a deep block?
4 mg/kg ## Footnote S27
52
Differentiate a moderate block vs a deep block.
- Moderate: 2/4 twitches on TOF - Deep: No twitches to TOF ## Footnote S27
53
What is the sugammadex dose for an extreme (overdose) block?
8 - 16 mg/kg ## Footnote S28
54
What are the side effects of Sugammadex?
- dose-related Pruritis - dose-related Urticaria - dose-related N/V - Anaphylaxis - Bradycardia ## Footnote S31
55
What is the NMBD and dose to administer after waiting 5 minutes after Reversal?
1.2 mg/kg ROCuronium ## Footnote S32
56
What is the NMBD and dose to administer after waiting 4 hours after Reversal?
0.6 mg/kg ROCuronium or 0.1 mg/kg VECuronium ## Footnote S32
57
What drugs/conditions are relative contraindications to sugammadex?
- **Contraceptives** - **Toremifene** (displaces NMBD from sugammadex) - **Coagulopathy** - **ESRD** (excreted renally) - **Recurarization** (lower than recommended dose) ## Footnote S33
58
What is Recurarization?
aka REPARALYZED the patient Resumption of NMJ blockade after period of reversal ## Footnote S36
59
What s/s would indicate recurarization? *Say you just brought the patient to PACU*.
- ↓ SpO₂ - Unresponsive - Floppy/uncoordinated - ineffective abdominal and intercostal activity ## Footnote S36
60
What drug and dose would be a good choice for a recurarizing patient in the PACU? Why might this be a good choice?
- Neostigmine 0.05 mg/kg IV - Longer duration of action ## Footnote S38
61
What *specific* s/s of Recurarization?
* sometimes can verbalize: suffocating feeling * unable to sustain head lift or hand grasp * worst case: pharyngeal collapse and respiratory obstruction ## Footnote S40
62
What are treatments goals of Recurarization?
**Treat urgently and aggressively** * Re-sedate the patient * Give additional reversal agents in divided doses (Neostigmine 0.05 mg/kg IV = longer duration of action). ## Footnote S40

KM (Spring 2024) Anesthesia Pharm ** (101 decks)

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