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161 Cards in this Set
- Front
- Back
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Atracurium aka
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Tracrium
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Cis-atracurium aka
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Nimbex
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Rocuronium aka
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Zemuron
(Esmeron outside the US) |
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Non depolarizing agents are:
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Pancuronium
Vecuronium Atracurium Cis-atracurium Rocuronium |
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Depolarizing agents are:
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Succinylcholine only
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Most commonly used reversal agents are:
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Neostigmine - prostigmine
Glycopyrrolate - robinul |
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Onset means:
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time from drug admin to max effect
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Clinical duration means:
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time from drug admin to 25% recovery of the twitch response
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Total duration of action means:
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Time from drug administration to 90% recovery of twitch response
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Efficacy of muscle relaxants is:
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100%
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Recovery index is:
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time from 25% to 75% recovery of the twitch response
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Train of four compares:
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4th twitch with the 1st one
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Recovery from muscle relaxant is indicated when:
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The fourth twitch is 90% of the first
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Skeletal muscle relaxants are_____ and the work by ______ ?
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antagonists
blocking ach which prevents muscle tone |
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Sequence of relaxation
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Eye lids - double vision
Extremities Chest - intercostals Abdominal muslces Diaphragm |
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Muscles regain function in the following sequence...
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diaphragm
abdominal muscles chest extremities eye lids |
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Where do muscle relaxants work?
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Ns of M
(nicotinic receptors in the muscle) |
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Classification of neuromuscular agents:
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Depolarizing and non depolarizing
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Vecuronium aka
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Norcuron
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Pancuronium aka
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Pavulon
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Nondepolazires are
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all but succs
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Deporalizer means:
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the drug gets into NM junction and depolarizes muscle (muscle contracts) before becoming paralyzed
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Succs is agonist or antagonist?
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Both, agonist because it causes fasciculation and antagonist because it sits on the receptor and block ach (keeps muscle paralyzed).
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Ultra short acting NMB are:
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Succinylcholine
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Long acting nondepolarizers are:
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Pancuronium
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Intermediate acting non - depolarizers are:
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atracurium
cisatracurium vecuronium rocuronium |
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Non - depolarizers act as...
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classic antagonists, blocking ach from coming into the muscle
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Ultra short acting NMB agents last how long?
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15 min or less
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Short acting non - depolarizers are:
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none
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Intermediate acting NMB agents last how long?
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30 - 60 min
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Long acting NMB agents last
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60 - 90 min
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Signs that indicate pt is reversed....
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eyes open
fine throat muscle function returned (gag and swollow) |
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Single twitch test tells you...
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If pt is 100% paralyzed or not
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Single twitch test requires _____ before drug admin?
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baseline
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Single twitch is qualitative test, T/F?
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true
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Train of four tells paralysis bw_____ %?
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70 - 100%
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Series of 4 twitches @2 Hz every 1/2 sec for two seconds is called
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TOF
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When is TOF useful?
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During onset, maintenance, and emergence
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Rapid delicery of a 30,50, or 100 HZ for 5 seconds is called
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Tetanus
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Tetanus used for
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Deep block assessment
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Two short bursts of 50 Hz tetanus separated by 0.75 seconds is called
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Double burst stimulation
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DBS is useful during?
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Onset, maintenance, and emergence
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DBS is better than TOF because
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it is easier to detect fade than with TOF
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Sites used for electrodes?
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Ulnar nerve
Facial nerve Posterior tibial nerve |
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The best way to know if the diaphragm is moving is to check
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facial nerve - orbicularis oculi response
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Upper airway muscles are_____ ______ than peripheral muscles
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more sensitive
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No difference in sensitivity exists bw
______ and _______ muscles |
arm and leg
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When measuring the onset of blockade the nerve most specific is...
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Facial because the blood flow to the head is faster than to the arms
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For normal TOF 4th twitch has to be 90% of the ________ twitch
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first
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1 abolished response =
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75% paralyzed
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2 abolished responses =
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80% paralyzed
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3 abolished responses =
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90% paralyzed
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When all responses are abolished pt is ____ paralyzed?
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100%
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4 responses is
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70 - 75% blockade, TOFR < .9 or 90%
70 % or less, TOFR > .9 or 90% |
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3 responses is
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75-80% blockade
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2 responses is
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80-85% blockade
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1 response is
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90 - 95% blockade
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0 response is
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100% blockade
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4 twitches with significant fade is
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70s %
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How is succs different when checking TOF?
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There is not fade, all twitches all the same
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What is considered back to normal with TOF or DBS?
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2nd twitch (or 4th) should be 90% of the 1st twitch
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Sustained tetanus is
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when hand stays contracted for 5 senconds (normal)
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Tetanic fade is seen when
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pt is paralyzed
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PTC is useful for assessing the blockade when
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all other tests don't work
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Number of posttetanic counts tells you
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minutes until recovery
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Depolarizing (phase I) block
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1. fasciculation of blockade - face to feet
2. no fade with tetanic stimulation 3. no PTC or fade with TOF or DBS 4. block antagonized by pre-tx with non depolarizer 5. block potentiated by anticholinesterase drugs |
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Non - depolarizing (phase II) block
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1. absence of muscle fasciculation
2. tetanic fade, post-tetanic potentiation, stimulation, or facilitation 3. TOF and DB fade 4. reversal with anticholinesterase drugs (neostigmine) 5. may be produced by an OD and desensitation with succs at doses > 6 mg/kg (rare) |
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When pt is pretreated with non - depolarizer prior to admin of succs pt needs _____, bc_____-
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20% more succs
they antagonize each other |
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% paralyzed during the case should be
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90 - 95%
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Which muscles are the most sensitive and last to return?
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neck and oral
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Succs is broken down by:
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cholinesterase by hydrolysis
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Cholinesterase breaks down:
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Succs
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Pseudoesterase is located
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in blood
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Most rapid acting enzyme in the body is
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cholineserase
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Hydrolytic enzymes
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cholinesterase
and non esterase specific: paraoxonase albumin esterase RBC esterase |
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Major function of cholinesterase is
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to terminate the action of ach
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2 types of cholinesterase and location
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AchE - NM junction and organs
PChE - blood and organs |
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PChE breaks down
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succs
cocaine procaine chloroprocaine tetracaine neostigmine endrophonium |
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Non - specific esterases break down
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atracurium
cisatracurium remifentanyl clevidipine |
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RBC esterases break down
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esmolol
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Succinylcholine side effects:
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Hyperkalemia
Dysrhythmias Myalgia Myoglobinemia Elevated intragastric pressure Elevaed intracranial pressure Elevated intraoccular pressure MH Masseter spasm |
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Dibucaine inhibition test tests for
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atypical cholinesterase which inhibits typical or usual PchE, but not atypical
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Two results of dibucaine test are:
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Dibucaine number and enzyme level
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Normal dibucaine number
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70-80
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Slightly prolonged dibucaine number
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50-69
due to decreased enzyme activity and 3% of population |
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Low dibucaine number + normal activity =
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atypical enzyme and prolonged apnea
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Normal dibucaine number + low activity =
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normal enzyme with low levels present and prolonged apnea
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Low dibicaine number + low activity =
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atypical enzyme with low levels present and prolonged apnea
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Normal dibucaine number + normal activity =
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another reason for prolonged succs effect
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In what patients should you avoid succs d/t hyperkalemia
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crush injuries
30 percent, 3rd degree burn denervating injuries MH |
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When can a pt develop dysrhyhmias with succs
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secondary to hyperkalemia or ganglionic effect of succs
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Why do pt's get myalgia with succs?
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Secondary to fasciculation, even if some people do not fasciculate.
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Myoglobinemia develops with admin of succs when
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pt has extensive fasciculation or in MH
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Elevated intragastric pressure with succs is related to
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Contractions of abdominal muscle during fasciculation and is generally irrelevant
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Elevated ICP with succs is related to?
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fasciculation of neck muscles
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Masseter spasm is...
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phenomenon in which following admin of succs pt's mouth remains tight
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CI for the use of succs
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- hypekalemia
- severe burns - severe muscle trauma - neuro injurt - hyperkalemia dt renal failure - severe sepsis - muscle wasting - prolonged immobilization - muscle denervation - MH - muscle dystrophy and DOs - allergy - kids < 8, unless laryngospasm |
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When is succs used in kids < 8
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Laryngospasm
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Why is pretreatment used and what is given?
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to decrease fasciculation and pain
small dose of non - depolarizer |
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Side effect of atracurium
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histamine release
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Benzylisoquinoline relaxants are:
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artacurium and cisatracurium
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How are atracurium and cisatracurium broken down
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ester hydrolysis (non esterase dependent hydrolysis)
Hoffman elimination |
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Steroidal relaxants are:
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Vecuronium
pancuronium rocuronium * end with UM :) |
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Steroid muscle relaxants are broken down
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in liver
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Which muscle relaxants have active metabolites?
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Steroid
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Do muscle relaxants have fetal/CNS effects?
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no
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Atracurium is metabolized by
and eliminated by |
Hoffman elimination and non specific esterase hydrolysis
non organ dependent elimination |
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Cis-atracurium metabolized by ____ and eliminated by_____
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Hoffman elimination and non specific esterase hydrolysis
kidneys 16% - not significant |
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Rocuronium is metabolized by
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liver and kidneys
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Rocuronium is eliminated by
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liver and kidneys
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Vecuronium is metabolized by
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kidneys and liver
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Vecuronium is eliminated by
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liver
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Pancuronium is metabolized by
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kidneys
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Pancuronium is eliminated by
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kidneys
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Atracurium cardiac effects are
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hypotension and tachycardia from histamine release
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The amt of histamine release is related to
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dose and speed of administration
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Atracurium is CI in what patients?
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With asthma
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Effects of the pancuronium on the heart
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tachycardia from slight catecholamine release (indirect sympathomimetic effect).
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Succs effects on the heart:
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slight tachycardia and sudden abrupt bradycardia can also happen in adults with repeated doses and kids with any dose
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Cis-atracurium is drug of choice in which pt?
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Renal and kidney disease
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What is the main pathophysiologic cause for prolonged paralysis?
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Hypothermia
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Which antihypertensives may lead to prolonged paralysis?
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Ganglionic blockers
Beta blockers Calcium channel blockers Lasix |
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Antidysrhytmics that may lead to prolonged paralysis
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quinidine
bretylium procainaminde local anesthestics in lg doses |
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Antibiotics that may lead to prolonged paralysis:
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aminoglycosides
polymyxin b clindamycin tetracycline PCN |
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Mics drugs that can prolong paralysis:
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cyclosporine
steroids volatile anesthetics dandrolene magnesium lithium |
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What is the intubating dose for muscle relaxants?
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ED 95 X 3
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Standard intubating dose for succs?
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100 mg
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Succs ED 95?
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0.3 mg/ kg
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Succs intubating dose in mg/kg?
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1 - 1.5
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Rocuronium standard intubating dose?
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70 mg
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Rocuronium intubating dose in mg/kg?
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0.6-1.2
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Which relaxants should not be used for intubation?
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Atracurium - histamine release
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Which drugs have Ed 95 of 0.05?
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cis-atracurium
vec pancuronium |
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Intubating dose for all relaxants (average)
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0.1 mg/kg
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What is the dose for pretx when using succs?
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0.9 ml of whatever non-depolarizer you are using :)
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What is the rule for reversing a pt?
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Pt should have some twitches back
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Which drug is mostly used for reversal?
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Neostigmine
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Main side effect of neostigmine
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PONV
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Which drugs block cholinesterase
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Neostigmine
Edophonium Pyriostigmine |
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Which drugs have to be uses with reversal agent and why?
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Atropine or robinul because they prevent anticholinergic (vagal) response
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What happens when cholinesterase is inhibited?
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Ach will become more concentrated than relaxer causing reversal
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What happens if reversal is given alone?
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Vagal response, including:
- bronchoconstriction - increases secretions - bradycardia - increased gi motility |
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Why is robinul used over atropine for reversal?
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it doesn't cause as much tachycardia
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Muscurinic receptors are blocked by?
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atropine and robinul
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How much cholinesterase can you inhibit?
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100%
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Max reversal dose of neostigmine is?
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5 mg
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Edrophonium reversal dose
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1mg/kg
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Which reversal agent has the shortest duration and onset?
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Edrophonium
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Which reversal agent has the longest duration and onset?
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pyridostigmine
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Which reversal agent has the intermediate duration and onset?
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neostigmine
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Which reversal is not useful for reversing deep block?
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edrophonium because of its rapid onset and duration
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What is the safest approach if pt is not reversing?
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Sedate, ventilate, wait for relaxant to wear off.
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Sugammadex is used for reversal of what drug?
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Rocuronium
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What is the best place to look for offset of relaxants?
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hand
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What is the best place to look for onset of relaxants?
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face
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What synthesizes ach?
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cholineacytalase
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Which drug should not be given with succs?
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phospholine iodide
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How do you tx (intubate) pt with open eye injury?
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give prop first and then succs
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Fade in response to high frequency stimulation is a characteristic of?
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Non depolarizers
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The main site of action of nmb agents is?
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On the nicotinic cholinergic receptors at the endplate of muscle
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What are relaxants used for?
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ease tracheal intubation
immobility during surgery facilitate mechanical ventilate |
