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163 Cards in this Set

  • Front
  • Back
what are the short acting NMB?
sux (anectine)
mivacurium (mivacron)
what are the intermediate acting NMB?
*rocuronium (zemuron)
*vecuronium (norcuron)
*atracurium (tracrium)
*cisatracurium (nimbex)
what are th long acting NMB?
*dtubocurarine (dTC)
*pancuronium (pavulon)
what is the ED95 of sux?
what is the ED95 of mivacurium ?
what is the ED95 of roc?
what is the ED95 of atracurium?
what is the ED95 of cisatricurium?
what is the ED95 of dTC?
what is the ED95 of pavulon?
what will ED95 tell you about a NMB?
it is the dose that 95% suppression of single twitch response
*1 ED95 of ANY NMB will suppress twitches for approx 20 minutes
what is the intubating doese of sux?
*1.5-2 w/NDMR)
what is the intubating dose of mivacurium?
0.15-0.25 mg/kg
what is the intubating dose of roc?
0.6-1.2 mg/kg
RSI > = 1.5 mg/kg
what is the intubating dose of vec?
0.08 - 0.1 mg/kg
what is the intubating dose of atracurium?
what is the intubating dose of cisatracurium?
what is the intubating dose of dTC?
what is the intubating dose of pancuronium?
what is the time to intubation w/sux?
what is the time to intubation w/mivacron?
1.5-2 min
what is the time to intubation w/roc?
1-3 min
RSI = 1min
what is the time to intubation w/vec?
2-3 min
what is the time to intubation w/atracurium?
what is the time to intubation of cisatr?
what is the time to intubation of dTC?
3-5 min
what is the time to intubation of pancuronium?
how long does it take to rec 25% of fx w/sux?
how long does it take to rec 25% of fxn w/mivacron?
what are the NMB that have recovery of 25% of fxn w/in 30min?
roc, vec, atracurium
how long does it take for 25% recovery of fxn after cisatricurium?
what is the time frame for 25% rec of fxn w/dTC?
what is the time frame for 25% rec of fxn w/pancuronium?
what is the metabolism of short acting NMB?
plasma cholinesterase
what is the metabolism of cisatricurium?
hoffmann elimination
w/cisatricurium, what effects does the hoffman elimination have?
inc pH = inc effect
what drugs are eliminated via biliary route?
vec & roc
what is the metabolism of atricurium?
ester hydrolysis and hoffman elimination
what is the metabolism of roc?
30% renal 70% liver
what is the metabolism of vec?
20% renal 80% liver
what is the metabolism of dTC?
70% renal 30% liver
what is the metabolism of pancuronium?
80% renal 20% liver
what are the drugs who have renal elimination?
dTC, pancuronium, doxacurium
what drugs are eliminated through metabolism?
sux, atracurium, cisatricurium, mivacurium
what agents increase the block of NMB?
*Beta blockers
*thermal burn injury
what agents decrease the block of NMB?
what is the purpose of NMB paralysis?
*surgical exposure/manipulation
*improve controlled vent
where are the motor nerves located in the SC
*exit ventral cord
what is SAD?
Sensory Afferents Dorsal
what is the primary NT?
Describe the postsynaptic NMJ?
*5 subunits
*Ach combines w/2 alpha nicotinic receptors
what ions are transferred w/an impulse @ the NMJ?
Na & Ca into cell
K out of cell
what happens when ions are exchanged in the postsynaptic NMJ?
depolarization of the motor end plate
how many receptors must be open for a muscle AP to be generated?
What terminates the action of a postsynaptic NT?
what happens when Ach is metabolized?
motor end plate is repolarized
what makes more Ach?
byproduct of Ach breakdown
what are the pharmacokinetics of NMBD?
quaternary ammonium groups
*highly ionized (H2O soluble)
*limited lipid solubility
NMBD have limited lipid solubility; what are the implications of this?
*no BBB cross; no CNS effects
*min renal tubule reabsorption
*no placental transmission
what will affect the Vd of NMBD?
*protein binding
what are the effects of VAA on NMBD?
dec plasma concentration of NMBD needed to produce blockade
what is the depolarizing NMBD?
what is sux composed of?
2 Ach molecules linked together
where does sux bind?
nicotinic receptors
does sux have single or multiple contractions?
(contracts muscle)
how long is the DOA of sux?
the channel stays open until sux diffuses back into circulation and is metabolized by plasma cholinesterase
what are the other names for plasma cholinesterase?
how long is the blockade of sux?
directly r/t diffusion away from NMJ
what can lead to increased block of sux?
*lvr dz
where is plasma cholinesterase produced?
what does plasma cholinesterase metabolize?
*ester LA
what are the relative Contraindications of sux?
*peds d/t rhabdo, hyperkalemia, masseter spasm
what is a phase I blockade w/sux?
all muscles are contracted at once (or depolarizing NMB)
what is the phase II block of sux?
*large/repeated doses
*repolarized postjunctional membranes are unresponsive to Ach
what does and at what doese does sux resemble?
*dose > 3-5mg/kg
what is the normal sux metabolism?
what is heterozygous atypical plasma cholinesterase?
*1:480 pts
*40-60 metabolism
what is the length of time/dose of sux will last in heterozygous atypical plasma cholinesterase?
30 min
what is the metabolism of homozygous atypical plasma cholinesterase?
*1:3200 pts
*1mg/kg may last 3 hrs
your pt is having an IOL. He is given sux 1mg/kg. The case is completed in less than 1 hr, but your pt does not respond to nerve stimulation. What are the implications?
pt could have a homozygous atypical plasma cholinesterase problem.
what is upregulation SE w/sux?
an increased # of extrajunctional receptors along a muscle (mor Ach receptors)
hyperkalemia is a problem w/some pts. What pt populations is sux contraindicated in?
why would you avoid sux in pts w/increased potassium levels?
*inc of 0.5meq/l in normal pts
*5-10meq/l in upregulated pts (burn, TBI, etc)
what are the SE of sux?
*AV block/sinus arrest
*inc IOP
*inc ICP
*inc intragastric pressure
what are the nondepolarizing NMB?
what is a nondepolarizing NMB?
competitive block to Ach subunits
where do nondepolarizers bind?
nicotinic receptors
how many receptors must be blocked to produce evidence of blockade
what is the ED95 of pancuronium?
what is the intubating dose of pancuronium?
what is the time to intubation w/pancuronium?
what is the duration to 25% recovery of pancuronium?
25-30 min
how is pancuronium eliminated?
80% renal 20% biliary
what is the ED95 of vec?
what is the intubating dose of vec?
what is the time to intubation of vec?
2-3 min
what is the time to 25% recovery w/vec?
how is vec eliminated?
20% renal and 80% biliary
what is a priming dose of NMB?
1/3 of intubating dose given ~ 3 min before intubation; occupies receptors and dec time to intubation by 50%
which NMB produce histamine?
what NMB produce autonomic ganglionic block?
why does sux cause bradycardia?
*stimulates the muscarinic receptors of the SA node
what NMB cause tachycardia?
what NMB cause hypotentsion?
what NMB cause hypertension?
what is MH?
an inherited myopathy w/a hypermetabolic state after exposure to a triggering agent.
what is the test for definitive dx of MH?
caffeine & halothane contracture test
what are the triggering agents of MH?
what is the cause of MH?
defect in sarcoplasmic reticulum --> dec Ca uptake
how much does ECF Ca increase in MH?
500%; leads to sustained muscle contraction, glycolysis, and heat production
how many kids/adults are affected by MH?
1:15,000 kids
1:50,000 adults
what is the first sign of MH?
inc ETCO2
what are other s/s of MH?
*met acidosis by ABG
*hyper - kalemia, calcemia, phosphatemia
what is the Cr kinase level in MH?
>1000 iu
what is a sign a child has MH?
Massiter muscle rigidity
*controversial as to whether to proceed w/case
what is the tx fo MH?
*CALL for Help
*turn off all VAA/anesth agents
*100% O2/hyperventilate
*Dantrolene 2.5mg/kg Q5min
*lasix, mannitol
what is the cardiac drug that is used in MH?
*mag is also used 2-5mg/kg
what labs should be followed for 48hrs after MH?
creatine kinase
*urn myoglobin
what reverses nondepolarizers?
what is the MOA of anticholinesterases?
inc Ach @ NMJ by dec activity of acetylcholinesterase
*dec hydrolysis of Ach
what do anticholinesterases do?
inc speed of recovery from NMB
when are anticholinesterases given?
when spontaneous recovery has begun
where do anticholinesterases work?
both nicotinic and muscarininc receptors
what is the goal of NMB reversal?
maximize nicotinic transmission
*minimize muscarinic transmission
what are the SE of Ach @ muscarinic receptors?
*CV: dec HR/dysrhythmia
*pulm: bronchospasm/inc secretions
*GI: inc peristalsis/gland secretions
GU: inc bladder tone
Eye: pupillary constriction
what is the SLUDGE response?
s: salivation
l: lacrimation
u: urination
d: defication
g: gastro
e: eye
r/t muscarinic SE of anticholinesterases
what is the most commonly used combo of anticholinesterases and anticholinergics?
neostigimine & glycopyrolate
what is the dose of neostigmine & robinol?
0.05-0.07mg/kg + 0.2mg
(for every 1mg of neostigmine add 0.2mg of glycopyrolate)
when do we use nerve stimulators?
*emeregence of anesthesia
how is the frequency of nerve stimulation stated?
hertz (Hz)
what is 10Hz?
10 stimuli/second
in a single twitch, what happens when 80% of the receptors are blocked?
decrease in the height of the twitch
what are the problems w/a single twitch?
*you need control twitch before NMB given
*you have to remember height of control twitch
what is the TOF?
4 twitches given @ 0.5sec over 2 seconds
what happens w/TOF and nondepolarizers?
there is fade of the twitch
what happens w/TOF and depolarizers?
all four twitches are the same height
to test a depolarizer, how are nerves stimulated?
*repeated @ 1,2,3, & 4 min
in a depolarizer (sux) what does the TOF look like?
the intensity, not the character of the response, is changed
what are the advantages of the TOF?
*more sensitive than single twitch
*no control necessary
*differentiate b/w depolarizer & nondepolarizer
*detects Phase II block of sux
what is double burst stimulation?
3 0.2 ms stims separated by 750ms
what is the primary use of double burst?
detect residual NMB
compare DBS & TOF?
fade is more rapidly detected in double burst
what is post tetanic stimulation?
50 or 100Hz single stim for 5 sec
how does post tetanic stim show in deplarizers?
depressed amplitude
how does post tetanic stim show in nondepolarizers?
what Hz will NMJ show max effort?
how often should post tetanic stim be repeated?
what does post tetanic facilitation show?
how adequately reversed the pt is
the TOF post tetanic will indicate what?
the strength of the twitches is inversely proportional to the depth of the block
what is Wedensky inhibition?
poorly sustained tetanic response in interval 2 of checking nerve stim
what happens in interval 2 of post tetanic stim?
initial response of 1 TOF rapidly diminishes and may disappear completely, tetanus is poorly sustained, inc TOF stim post-tetanic
what happens in interval 3 of post tetanic stim?
Wedensky inhibition is harder to detect visually, but post-tetanic facilitation is clearly visible
what happens in interval 4 of post tetanic stim?
Wedensky inhibition is almost impossible to detect visually, but post-tetanic stim can be detected
what is the std for NMB reversal?
whenever a nondepolarizer has been used in the past 4hrs, reversal should be administered
what needs to be illicited for a reversal agent to be given?
1 strong twitch of the TOF
what are cyclodextrines?
*starch molecule w/high stereoselectivity for target drug (in this case Roc)
what is the brand name for the cyclodextrine?
Sugamadex (made by same company as Roc)
what does sugamadex do?
encapsulates the NDMR reversing the effects of the paralysis rapidly & independently of degree of block
how doe we measure the speed of block ?
small skeletal muscles block before abdominal
the orbicularis oculi will indicate block where?
the adductor pollicis will indicate block where?
induction = ?
emergence = ?
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