NMBD Reversals - test 4

Question 1

In a study performed, what percent of patients had post-op residual blockade when there was no NM monitoring or reversal given?

Answer 1

33%

Question 2

In a study performed, what percent of patients had post-op residual blockade when NM monitoring ad reversal was used?

Answer 2

4%

Question 3

Do AChE inhibitors work with deep NM blockade?

Answer 3

No

Question 4

Max neostigmine range:

Answer 4

40-70 mcg/kg

Question 5

Max edrophonium dose:

Answer 5

1 mg/kg

Question 6

Reversal of NM blockade depends on 5 factors:

Answer 6

1. Depth of the NM block
2. AchE inhibitor choice
3. Dose administered
4. Rate of plasma clearance of NMBD
5. Anesthesia agent choice and depth - Postoperative Residual NM Blockade

Question 7

Onset and duration of neostigmine:

Answer 7

Onset: 5-10 minutes
Duration: 60 minutes

Question 8

Onset and duration of Edrophonium:

Answer 8

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

Question 9

Dose for edrophonium:

Answer 9

0.5-1 mg/kg

Question 10

What percentage of neostigmine is renally excreted?

Answer 10

50%

Question 11

What percentage of pyridostigmine and edrophonium is renally excreted?

Answer 11

75%

Question 12

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

Answer 12

Hepatic clearance - 30-50%

Question 13

What is the major side effects of NMBD reversal agents?

Answer 13

*Increased Nicotinic/muscarinic activity

Question 14

CV side effects from NMBD reversal agents:

Answer 14

• Bradycardia
• Dysrhythmias
• Asystole
  -↓SVR

Question 15

Pulmonary side effects from NMBD reversal agents:

Answer 15

• Bronchoconstriction
• increased airway resistance
• Increased salivation

Question 16

GI side effects of NMBD reversal agents:

Answer 16

• Hyperperistalsis
• Enhanced gastric fluid secretion
• PONV

Question 17

What is a side effect that happens in the eyes after NMBD reversal agents?

Answer 17

Miosis

Question 18

What drugs would be given with NMBD reversal agents to prevent side-effects?

Answer 18

Anti-cholinergic/Anti-muscarinic
- Atropine (7-10 mcg/kg)
- Glycopyrrolate (7-15 mcg/kg)

Question 19

Atropine matches profile of ___:

Answer 19

Edrophonium

Question 20

Glycopyrrolate matches profile of ____ and ____:

Answer 20

Neostigmine and Pyridostigmine

Question 21

Which anti-cholinergic would you use if you were concerned about someone with a pre-existing cardiac disease?

Answer 21

Glycopyrrolate - give slowly, over 2-5 minutes

Question 22

What happens in persistent NM blockade?

Answer 22

• Acetylcholinesterase is maximally inhibited
• No further anticholinesterase if effective

Question 23

Intervention for persistent NM blockade:

Answer 23

Sedation and post-op ventilation

Question 24

What side effects can be seen right after atropine administration?

Answer 24

Mydriasis and initial tachycardia

Question 24

What 5 factors influence NMBD reversal?

Answer 24

- Intensity of block - Which NMBD you use - Continues volatile anesthetic - Which reversal drug are you using - Patient conditions (met. acidosis, resp. acidosis, hypothermia)

Question 25

What reversal agent is used for mivacurium?

Answer 25

Purified human plasma cholinesterase

Question 26

What reversal agent is used for gantacurium?

Answer 26

Cystiene

Question 27

What reversal agent is used for roc (aminosteroid)?

Answer 27

sugammadex

Question 28

What type of drug is sugammadex?

Answer 28

Selective relaxant-binding agent

Question 29

Sugammadex organic and physical properties:

Answer 29

-γ-cyclodextrin - dextrose units from starch - highly water soluble

Question 30

MOA of sugammadex:

Answer 30

Very tight reversal by encapsulation of - intermolecular forces - thermodynamic bonds - hydrophobic interactions *binds to free drug in plasma

Question 31

What drugs do sugammadex work on?

Answer 31

Rocuronium > vec >> pancuronium

Question 32

Sugammadex major route of elimination: __ in 6 hours __ in 24 hours

Answer 32

Urine; 70%; 90% *renal impairment: C/I with dialysis

Question 33

What is the E 1/2 time of sugammadex?

Answer 33

2 hours

Question 34

Moderate vs. Deep block:

Answer 34

- Moderate: 2/4 twitches on TOF - Deep: No twitches to TOF, but will have a twitch w/ post tetanic stimulation

Question 35

Sugammadex dose for a moderate block:

Answer 35

2 mg/kg

Question 36

Sugammadex dose for a deep block:

Answer 36

4 mg/kg

Question 37

Sugammadex dose for an extreme block:

Answer 37

8-16 mg/kg

Question 38

Side effects of sugammadex:

Answer 38

- Dose related N/V - Dose related pruritus - Dose related urticaria - Anaphylaxis - Marked bradycardia - Doesn't work

Question 39

Re-administration of Roc or Vec after reversal:re

Answer 39

Question 40

How does sugammadex interact with oral contraceptives?

Answer 40

Binds with progesterone (7 days)

Question 41

How does sugammadex interact with toremifene?

Answer 41

Displaces NMBD from sugammadex

Question 42

Sugammadex cautions for coagulopathy/bleeding:

Answer 42

Heparin/LMWH; elevated PTT, PT, INR

Question 43

Sugammadex cautions for recurarization:

Answer 43

Lower than recommended doses

Question 44

What is recurarization?

Answer 44

Re-paralyzing the patient after a period of reversal

Question 45

Signs and symptoms of recurarization:

Answer 45

- 02 sats - unresponsive patient - appears “floppy” or uncoordinated - ineffective abdominal and intercostal activity - sometimes can verbalize suffocating feeling - unable to sustain lift or hand grasp - worst case = pharyngeal collapse and respiratory obstruction

Question 46

Treatment goal for recurarization:

Answer 46

*treat urgently and aggresively - Re-sedate the patient - Give additional reversal agents in divided