NMBDs

Question 1

Pancuronium

Aminosteroid

Answer 1

0.08-0.12mg/kg intubation
0.01mg/kg maintenance
Onset: 3-5 minutes
Duration: 60-90 minutes
CV Effects: increase HR, MAP and COP
Clearance: Renal

Question 2

Atracurium

Benzylisoquinolinium

Answer 2

0.5 mg/kg
Onset: 3-5 minutes
Duration: 20-35 minutes
Clearance: Hoffman, ester hydrolysis, pH dependent
Side Effects: Histamine release, CV
Clinical Considerations: pH and temperature
Faster pediatric block
Longer lasting on elderly
Laudanosine CNS stimulant metabolite cleared by the kidney.

Question 3

Cisatracurium

Benzylisoquinolinium

Answer 3

0.1-0.15mg/kg
Infusion: 1-2mcg/kg/min
Onset:3-5 minutes
Duration: 20-35 minutes
Histamine RElease
Metabolism: Hoffman degredation
- time, temp, pH

Question 4

Vecuronium

Aminosteroid

Answer 4

0.08-0.12mg/kg
0.01 mg/kg q 15-20 minutes
1-2mcg/kg/min
Clearance: Renal and hepatic

Question 5

Rocuronium

Aminosteroid

Answer 5

0.6-1.2mg/kg
5-12mcg/kg/min
0.1mg/kg maintenance
Onset: similar to sux
Duration: 20-30 minutes
Clearance: Renal, no metabolism
Effects: no histamine release

Question 6

Mivacurium

Benzylisoquinolinium

Answer 6

0.15-0.2 mg/kg
4-10mcg/kg/min
Duration: Increased with atypical cholinesterase
Clearance: Plasma cholinesterase

Question 7

Renal Failure Options

Answer 7

Mivacurium
Cisatracurium
Atracurium

Question 8

Long Case Option

Answer 8

Pancuronium

Question 9

Pseudocholinesterase Deficient

Answer 9

Rocuronium

Vecuronium

Question 10

Succinylcholine

Answer 10

Attaches to alpha subunit of nicotinic
Dose: 1-2 mg/kg
Onset: 30-60s
Duration: 3-5 min
Metabolism: Plasma cholinesterases

Question 11

Neostigmine

Anticholinesterase

Answer 11

Dose: 0.04-0.07 mg/kg
Onset: 5-10 minutes
Peak: 10 minutes
Duration: 1 hour
Excessive doses can prolong block
Max dose is not 5 mg
Potentiates sux phase 1 block
Cause PONV

Question 12

Edrophonium

Anticholinesterase

Answer 12

0.5 mg/kg

Fast reversal but doesn’t last long enough ~1hr. Some relaxants could overcome towards the end.

Question 13

Pyridostigmine

Anticholinesterase

Answer 13

0.21mg/kg
Slower onset than neostigmine
Lasts over 2 hours

Question 14

Anticholinergics

Answer 14

Prevent Ach from binding to muscarinc receptors
Reversible bond to receptor
Can be overcome with increased Ach

Question 15

Anticholinergic Effects

Answer 15

Sedation (IM scopolamine)
Antisialagogue
Heart Rate
Relax Smooth Muscle
Mydriasis
Prevention of Motion Sickness
Decrease Gastric Secretion

Question 16

Atropine Effects

Answer 16

Minimal sedation
Minimal antisialogogue
Maximum increased HR
Moderate smooth muscle relax
Minimal mydriasis
Minimal PONV prevention
Minimal GI reduction

Question 17

Scopolamine Effects

Answer 17

Maximum sedation
Maximum antisialogogue
Minimum increased HR
Minimum smooth muscle relax
Maximum mydriasis
Maximum PONV prevention
Minimal GI reduction

Question 18

Glycopyrrolate Effects

Answer 18

No sedation
Moderate antisialogogue
Moderate increased HR
Moderate smooth muscle relax
No mydriasis
No PONV prevention
Minimal GI reduction

Question 19

Pre-med Sedation

Answer 19

Scopolamine is the most potent
Works at reticular activating system
Causes amnesia
Patients can go the other way and get restless

Question 20

Pre-med antisialogogue

Answer 20

Scopolamine most potent
3x more potent than atropine
Glycopyrrolate
2x more potent than atropine
Used when sedation undesired

Question 21

Pre-med treat bradycardia

Answer 21

Blocks ach @ SA node

Glyco=atropine in effectiveness

Question 22

Bronchodilation

Answer 22

Mechanism
Muscarinic receptors
Smooth muscle of medium/large A/W
Decrease resistance and increase deadspace
Ipratropium: Combivent (albuterol and ipratropium)

Question 23

Other uses

Answer 23

Biliary/ureteral relaxation
Mydriasis/cycloplegia
Gastric Acid Cessation
Motion induced N/V prevention

Question 24

Central Anticholinergic Syndrome

Answer 24

Symptoms: Restlessness/hallucinations
Somnolence/unconsciousness
Treatment: Physostigmine - crosses BBB
Who: Children and elderly

Question 25

Anticholinergic OD

Answer 25

Rapid onset: Dry mouth, blurred vision, tachycardia, increased temp, flushing, irritability.
Effect: Seizures, coma, ventilatory paralysis
Treatment: Physostigmine

Question 26

Reversal Criteria (sort of)

Answer 26

TOF >0.7
Tetanus with 100Hz
Grip strength
Negative inspiratory pressure >20cmH2O
Sustained head lift = 5s

Question 27

Sugammadex

Answer 27

New frontier in NDNMD reversal
Independent of Ach level
No twitches can be reversed
Cleared renally
No need for muscarinic antagonist
Some evidence of anaphylactic reaction