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Anesthesia Pharm Spring 25 > NMBD Reversal Agents (Exam IV) > Flashcards

NMBD Reversal Agents (Exam IV) Flashcards

(65 cards)

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1
Q

Which NMBD are long acting

A

d-Tubocurarine
Pancuronium

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2
Q

Which NMBD are intermediate acting

A

Vecuronium
Rocuronium
Atracurium
Cisatracurium

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3
Q

How are aminosteroids metabolized?

A

Liver

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4
Q

How are benzylisoquinolines metabolized?

A

Plasma esterases

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5
Q

What is the MOA of NMBD reversal agents?

A

AchE inhibition = more acetylcholine avaliable to bind to the alpha subunits

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6
Q

True/False: Neostigmine and Edrophonium will reverse a deep NM blockade

A

False.

Reversal in deep blockade leads to even further blockade

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7
Q

What is the dose of Neostigmine? Max?

A

40-70mcg/kg
5mg max

He told us we can just remember 50mcg/kg for the dose

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8
Q

What is the dose for Edrophonium? max?

A

0.5-1mg/kg
max: 1mg/kg

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9
Q

Where do NMBD reversal agents work?

A

Preganglionic (SNS & PNS)
NMJ

we are more interested in NMJ

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10
Q

Do AChE inhibitors work with deep neuromuscular blockade?

A

No

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11
Q

Which NMBD reversals have a ceiling effect?

A

Neostigmine and Edrophonium

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12
Q

Reversal of NMJ blockade is dependent on these 5 factors:

A

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

anesthetic agent can cause postop residual NM blockade

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13
Q

Edrophonium OOA and DOA

A

OOA: 1-2min
DOA: 5-15min

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14
Q

Neostigmine OOA and DOA

A

OOA: 5-10min
DOA: 60min

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15
Q

If we are using Neostigmine to reverse d-Tubocurarine or Pancuronium, what should we be concerned about?

A

The DOA of Neostigmine is only 60 min.
The DOA for d-Tubocurarine is 81min and Pancuronium is 86min.

The paralytics DOA is longer than the reversal. Need to redose but dont forget ceiling effect!

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16
Q

What percentage of neostigmine is renally excreted?

A

50%

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17
Q

What percentage of both pyridostigmine and edrophonium are renally excreted?

A

75%

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18
Q

What concerns would we have if a patient has chronic renal failure and we give them neostigmine or edrophonium?

A

CRF decreases plasma clearance so there would be a prolonged action.

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19
Q

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

A

30 - 50% cleared hepatically

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20
Q

The NMBD reversal side effects are caused by what?

A

Increased Nicotinic/Muscarinic activity

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21
Q

What are the major CV side effects of NMBD reversal agents?

A
  1. Bradycardia
  2. Dysrhythmias
  3. Asystole
  4. Decreased SVR
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22
Q

What are the major Pulmonary side effects of NMBD reversal agents?

A

1. Bronchoconstriction
2. Increased airway resistance
3. Increased salivation

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23
Q

What are the major GI side effects of NMBD reversal agents?

A
  1. Hyperperistalsis
  2. Enhanced gastric fluid secretion
  3. PONV
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24
Q

What is the major side effects on the eyes with NMBD reversal agents?

A

Miosis

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25
What drugs would be coupled with NMBD reversal agents to **prevent adverse side effects from these drugs?**
Anti-cholinergic / Anti-muscarinics **Atropine Glycopyrrolate**
26
If you're concerned about someone's cardiac status due to existing disease, which Anticholinergic drug would you use?
**Glycopyrrolate administered slowly over 2-5min**
27
If we are giving Neostigmine or Pyridostigmine for our NMBD reversal, what would we pair with it to offset the side effects?
Glycopyrrolate | Give 0.2 mg per 1 mg of neostigmine or same amount of mLs
28
What NMBD(s) reversal is atropine used with?
Edrophonium
29
What is the dose of Atropine?
**7 - 10 mcg/kg**
30
What common side effects are seen right after atropine administration?
- Mydriasis - Tachycardia
31
What is the dose of glycopyrrolate? Max dose?
**7-15mcg/kg** Max: 1mg
32
What is the mechanism of persistent NM blockade
AchE is maximally inhibited therefore no further anticholinesterase is effective
33
What is the intervention in the case of persistent NM blockade
**Sedation and postop ventilation**
34
What patient conditions can influence NMBD reversal
1. Metabolic acidosis 2. Respiratory acidosis 3. Hypothermia
35
Purified human plasma cholinesterase is the reversal for what drug?
mivacurium
36
What reversal drug is specific to gantacurium?
Cystiene
37
What reversal drug is very specific to rocuronium?
Sugammadex
38
What type of drug is sugammadex?
Selective relaxant-binding agent
39
What should be known about sugammadex's organic structure and physical properties?
- **γ-cyclodextrin** - Dextrose units from starch - Very H₂O-soluble
40
What is the MOA of Sugammadex?
Encapsulates rocuronium via: - Van der Waals forces - H-bonds - Hydrophobic interactions
41
What drugs does sugammadex work with?
**Roc** > Vec > Pancuronium ## Footnote Specifically aminosteroids
42
Where does sugammadex work?
Binds to the free drug in the plasma ## Footnote (does not seek out drug in NMJ or prejunctional site)
43
What is the E ½ time of sugammadex?
2 hours
44
How is sugammedex eliminated? How much is gone in 6hrs? 24hrs?
Urine: - 70% gone in 6 hours - 90% gone in 24 hours ## Footnote (remember it is highly water soluble, hence why it is eliminated in the urine)
45
When is sugammadex contraindicated?
**Renal patients on dialysis**
46
Differentiate a moderate block vs a deep block.
- Moderate: 2/4 twitches on TOF - Deep: No twitches to TOF after 1-2 post tetanic counts
47
What is the Sugammadex dose for a moderate block?
**2 mg/kg**
48
What is the Sugammadex dose for a **deep block?**
**4 mg/kg**
49
What is the sugammadex dose for an extreme (overdose) block?
**8 - 16 mg/kg**
50
True/False: Recurarization is not observed at appropriate doses with sugammadex
True
51
What are the dose related side effects of Sugammadex?
1. N/V 2. Pruritis 3. Urticaria
52
What are the side effects of sugammadex that arent dose related?
1. Marked Bradycardia 2. Anaphylaxis 3. Reports of it not working at all
53
You have reversed with Sugammadex (up to 4mg/kg) 5 minutes ago but now you need to reparalyze. What is the dose of NMBD to be given?
**1.2mg/kg Roc**
54
You have reversed with Sugammadex (up to 4mg/kg) 4 hours ago but now you need to reparalyze. What is the dose of NMBD to be given?
0.6 mg/kg Roc or 0.1 mg/kg Vec
55
What cautions do we have with Sugammadex?
**1. Contraceptives 2. Toremifene 3. Coagulopathy (elevated PTT, PT, INR) 4. Recurarization 5. ESRD/Dialysis (excreted renally)** ## Footnote (recurarization if we give a lower than recommended dose)
56
Why do we worry about oral contraceptives with sugammadex?
Binds with progesterone (7days).
57
Why do we worry about Toremifene (non-steroidal anti-estrogen) with sugammadex?
Displaces NMBD from sugammadex
58
What coagulopathy/bleeding concerns do we have with sugammadex?
When using heparin/LMWH: Elevated PTT, PT, INR
59
What is recurarization?
Resumption of NMJ blockade after period of reversal
60
What symptoms would indicate recurarization? *Say you just brought the patient to PACU*.
**1. ↓ SpO₂ 2. Unresponsive pt 3. Appears "floppy" or uncoordinated 4. ineffective abdominal and intercostal activity**
61
What are 3 specific signs of recurarization?
**1. Verbalize suffocating feeling 2. Unable to sustain head lift or hand grasp 3. Pharyngeal collapse and respiratory obstruction (wrost case)**
62
What do you do when the patient is experiencing recurarization?
Treat urgently and aggressively. 1. re-sedate the patient 2. Give additional reversal agents in divided doses
63
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**
64
What are three patient factors that might be the cause of recurarization? (Case study AANA research). ## Footnote What is innate to the patient and what the patient has control over
1. preexisting conditions 2. lack of disclosure 3. self-medication
65
When looking at team/group factors that could play a role in recurarization of a patient, what are 6 subthemes that fit into this category? (Case study AANA research table)
**1. Situational awareness 2. Communication failure 3. Shared Liability 4. Transfer of care 5. Normalization of deviance 6. Knowledge/skills/qualifications of team members**

Anesthesia Pharm Spring 25 (6 decks)

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