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

What is the clinical duration of response for ND-NMBD?
- Pancuronium
- Rocuronium
- Vecuronium
- Atracurium
- Cisatracurium
- Mivacurium

Answer 2

Pancuronium - 86 mins
Rocuronium - 36 mins
Vecuronium - 44 mins
Atracurium - 46 mins
Cisatracurium - 45 mins
Mivacurium - 16.8 mins

Question 3

Do AChE inhibitors work with DEEP neuromuscular blockade? what is this called?

Answer 3

No
Ceiling effect

Question 4

Reversal of NMJ blockade is dependent on these 5 factors:

Answer 4

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

Question 5

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

Answer 5

Vecuronium

Question 6

What is the max dosage of neostigmine?

Answer 6

40 - 70 mcg/kg

0.04 - 0.07 mg/kg
5mg

Question 7

What is the onset and duration of neostigmine?

Answer 7

Onset: 5 - 10 min
Duration: 60 min

Question 8

What is the dosage of edrophonium?

Answer 8

0.5 - 1 mg/kg

Question 9

What is the max dosage of edrophonium?

Answer 9

1- 1.5 mg/kg

Question 10

What is the onset and duration of edrophonium?

Answer 10

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

Question 11

What percentage of neostigmine is renally excreted?

Answer 11

50%

Question 12

What percentage of both pyridostigmine and edrophonium are renally excreted?

Answer 12

75%

Question 13

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

Answer 13

30 - 50% cleared hepatically

Question 14

What is the major side effect of NMBD reversal agents?
CV, pulmonary, GI, eyes?

Answer 14

↑PSNS activity (from increased nACh and mACh activity)
CV: bradycardia, dysrhythmias, asystole, decreased SVR
Pulm: bronchoCONSTRICTION, increased airway resistance, increased salivation
GI: hyperperistalsis, enhanced gastric fluid secretion, PONV
Eyes: Miosis

Question 15

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

Answer 15

Anti-cholinergic / Anti-muscarinics

• Atropine
• Glycopyrrolate

Question 16

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

Answer 16

Glycopyrrolate

Question 17

What NMBD(s) is glycopyrrolate used with?

Answer 17

• Neostigmine
• Pyridostigmine

Question 18

What NMBD(s) is atropine used with?

Answer 18

Edrophonium

Question 19

What is the dose of Atropine?

Answer 19

7 - 10 mcg/kg

Question 20

What common side effects are seen right after atropine administration?

Answer 20

• Mydriasis
• Tachycardia

Question 21

What is the maximum dose of glycopyrrolate?

Answer 21

1mg max dose

Question 22

How long does glycopyrrolate need to be administered over?

Answer 22

2 - 5 min

Question 23

What reversal drug is specific to mivacurium?

Answer 23

Purified human plasma cholinesterase

Question 24

What reversal drug is specific to gantacurium?

Answer 24

Cystiene

Question 25

What reversal drug is very specific to rocuronium?

Answer 25

Sugammadex

Question 26

What type of drug is sugammadex?

Answer 26

Selective relaxant-binding agent w/ aminosteroids

Question 27

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

Answer 27

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

Question 28

What is the MOA of Sugammadex?

Answer 28

Encapsulates rocuronium via: - Intramolecular (Van der Walls) forces - Thermodynamic (Hydrogen) bonds - Hydrophobic interactions

Question 29

True/False: Sugammadex binds to "free drug" in plasma

Answer 29

TRUE

Question 30

What drugs does sugammadex work with?

Answer 30

**Roc** > Vec > Pancuronium

Question 31

What is the E ½ time of sugammadex?

Answer 31

2 hours

Question 32

How is sugammedex eliminated?

Answer 32

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

Question 33

Differentiate a moderate block vs a deep block.

Answer 33

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

Question 34

What is the Sugammadex dose for a moderate block?

Answer 34

2 mg/kg

Question 35

What is the Sugammadex dose for a deep block?

Answer 35

4 mg/kg

Question 36

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

Answer 36

8 - 16 mg/kg

Question 37

What are the side effects of Sugammadex?

Answer 37

- Bradycardia (get glycopyrrolate and atropine ready) - dose-related N/V - dose-related Pruritis - dose-related Urticaria - anaphylaxis

Question 38

What is the dose of Roc and Vec after reversal for a minimum waiting time of 5 minutes and 4 hours? what NMBD can you give right after reversal w/ sugammadex instead and why?

Answer 38

5 mins: 1.2 mg/kg roc 4 hours: 0.6 mg/kg roc or 0.1 mg/kg vec can give benzylisoquinolone (atracurium, Cisatracurium, mivacurium) right after sugammadex bc not a aminosteroid?

Question 39

What drugs/conditions are relative contraindications to sugammadex?

Answer 39

- Contraceptives - Toremifene (displaces roc from sugammadex) - Coagulopathy - ESRD (excreted renally)

Question 40

How long should does sugammadex bind w/ progesterone? and what should you educate the patient about?

Answer 40

7 days they are fertile for 7 days - so need an alternative form of Birth control

Question 41

What is recurarization?

Answer 41

Resumption of NMJ blockade after period of reversal

Question 42

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

Answer 42

- ↓ SpO₂ - ↓ respiratory effort - Floppy/uncoordinated - Unresponsive - sometimes can verbalize: suffocating feeling - unable to sustain head lift or hand grasp - WORST case: pharyngeal collapse and respiratory obstruction

Question 43

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

Answer 43

- Neostigmine 0.05 mg/kg IV - Longer duration of action Treatment goal: treat urgently and aggressively - resedate the pt - give additional reversal agent in divided doses