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157 Cards in this Set
- Front
- Back
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what is the time to 25% recovery with succinylcholine
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5-10 min
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what is the time to 25% recovery with d-Tubucuraine
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60-90 min
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what is the time to 25% recovery with pancuronium
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80-100 min
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what is the time to 25% recovery with vecuronium
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25-30 min
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what is the time to 25% recovery with rocuronium
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30 min
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what is the time to 25% recovery with cis-atracurium
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40 min
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what is the time to 25% recovery with atracurium
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25-30 min
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what is the elimination route for succinylcholine
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plasma cholinesterase
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what is the elimination route for d-Tubocurarine
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70% renal
20% biliary |
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what is the elimination route for pancuronium
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80% renal
20% biliary |
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what is the elimination route for vecuronium
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20% renal
80% biliary |
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what is the elimination route for rocuronium
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30% renal
70% biliary |
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what is the elimination route for cis-atracurium
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hoffman elimination
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what is the elimination route for atracurium
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ester hydrolysis
hoffman elimination |
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choices of NMB agent are based on what
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1-pharmacodymnamics
2-pharmacokinetics |
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speed on onset of a NMB is (directly or inversely) proportionate to the potency of the drug
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INVERSELY
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high or low ED95 is predictive of rapid onset
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HIGH (low potency)
(b/c there is a higher dose given with a lower potency NMB and so more molecules to diffuse from central compartment to effect compartment) |
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the type of binding that low-potency drugs have to receptors means what type of duration of action
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a weaker binding by low-potency drugs = SHORTER duration of action
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what do NMB do for intubation
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create OPTIMAL conditions
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what is THE drug of choice for RSI
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succinylcholine
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what are some "disadvantages" of the priming technique
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*risk of aspiration
*diff swallowing and visual disturbance associated with the subtle block are uncomfortable for the pt |
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why is the priming technique used
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it is used in an attempt to effect a rapid onset of NMB while avoiding use of succinylcholine
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what is a priming dosage
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10% of the Ed95 dose
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how do you perform the priming tech
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*give 10% of the ED95 dose
*wait 4 min-pre oxygenate the pt during this period b/c NO + pressure breath will be given *then give 2-3 x the ED95 dose |
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what drug(s) do fasiculations occur with
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ONLY the depolarizer succinylcholine
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what are things that MUST be performed when doing an RSI
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1-hyperoxygenate (any o2 > 21%) x 4 min
2-denitrogenate (w/ 100% 02 tight fit x 4 min) |
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what is the priming tech with vecuronium
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1-give 0.01 mg/kg vec
2-wait 4 min 3-give IV induction agent 4-give 0.1 mg/kg vec |
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what does the priming tech with vecuronium provide
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a FASTER onset but PROLONGED duration of action
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when is is ok to ventilate a pt (manipulate the airway)
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when there is loss of lid reflex
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what should you ALWAYS do prior to giving NMB unless it is an RSI
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make sure you can ventilate
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what is the rationale for the priming tech
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*the priming dose decreases the margin of safety by blocking some receptors
*provides a deeper block *s/e of succinylcholine are avoided |
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what is the process for RSI
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1-preoxgenation MUST be performed
2-give adequate dose of IV drugs to ensure pt is adequately anesthetized 3-apply cricoid pressure (sellicks maneuver) prior to injection of induction agent |
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with RSI within what time frame is intubation considered acceptable
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60-90 sec
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low-dose muscle relaxants for tracheal intubation have what use
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*are NOT for RSI
*used for ROUTINE tracheal intubation |
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low-dose relaxants for tracheal intubation do what to recovery time
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shorten it
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what do low-dose relaxants for tracheal intubation do for the need/requirement for anticholinesterase drugs
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REDUCE the requirement
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of the low-dose relaxants used for tracheal intubation what has the shortest onset time?
how long is it? |
rocuronium
75 sec |
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what is the low-dose dosage for tracheal intubation for rocuronium
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0.5 mg/kg (1.5 ED95)
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autonomic s/e from NMB are d/t what
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varying affinities for nicotinic and muscarinic receptors
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how do depolarizing MR work
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bind to and activate sustained depolarization of nicotinic receptors
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are depolarizers agonist or antagonists
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agonists
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which class of NMB exhibits phase I and phase II blocks
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depolarizing
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what may lessen cardiac arrythmias, myalgias and elevations of intraocular and intragastric pressures with succinylcholine
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pre-treatment with a NON-depolarizer
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T or F
Pretreatment with a NON-depolarizer WILL decrease potassium release from cells with admin of succinylchoine |
FALSE
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potassium release with admin of succinylcholine is closely tied to what factor
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depolarization
-more Ach receptors = more depolarized cell membrane = more K+ release |
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what type of pt is at the greatest risk for hyperkalemia with admin of succinylcholine
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pts who are upregulated (denervation injury)
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how do NON-depolarizing MR work
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they bind to post synaptic nicotinic Ach receptors and COMPETITVELY inhibit action of Ach
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what amt of Ach receptors must be blocked to impair motor nerve conduction
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greater than 75%
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at what amt of receptors blocked is surgical relaxation appreciated
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> 90%
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at what amt of receptors blocked is intubation facilitated
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95%
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at what amt of receptors blocked is total flaccidity appreciated
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99%
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what decreases the usefulness of curare
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*slow onset
*long duration |
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what is a use for curare
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precurarization (defasiculating dose)
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what are the side effects of curare
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*hypotension (r/t histamine and autonomic ganglionic blockade)
*sympathetic & vagal blockade (bradycardia most often seen) |
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what is pancuroinium beneficial for
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*long duration paralysis needs
*inexpensive |
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what type of sx is pancuronium often used in
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cardiac sx
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how is the vagolytic property of pancuronium beneficial
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the increased HR balances narcotic induced bradycardia
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what are the s/e of pancuronium
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*increased HR d/t vagolysis at post ganglionic nerve terminal, muscarinic blockade & catecholamine release
*inhibits plasma cholinesterase |
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vecuronium has an intermediate duration why
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because of redistribution
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which NMB is the MOST CV stable
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vecuronium
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which NMB is suitable for ischemic heart dz because it has no effect on HR or BP
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vecuronium
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which NMB is suitable for ambulatory surgeries
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vecuronium
(b/c of intermediate duration) |
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which NMB has a lower incidence of residual muscle paralysis
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vecuronium
(b/c of intermediate duration) |
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what are the s/e of vecuronium
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*minimal to NO side effects
*low individual variability |
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rocuronium is how potent compared to vecuronium
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1/7 the potency
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what is the #1 used NON-depolarizing NMB used in north America
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rocuronium
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which NON-depolarizing NMB has rapid sequence ability
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rocuronium
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is rocuronium CV stable
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YES
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which NON-depolarizing can replace succinylcholine for rapid onset
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rocuronium
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what is the rapid onset (60 sec) dosage for rocuronium
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1.2 mg/kg
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what are the s/e of rocuronium
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*minimal to none
*slight increase in HR (less than pancuronium) *low individual variability |
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what is atracurium composed of
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10 isomers possessing muscle relaxant properties
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what is the parent drug to cis-atracrium
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atracurium
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what is the duration of atracurium
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SHORT
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what NON-depolarizer has NO cumulative effects and allows continuous infusion
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atracurium
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what type of CV effects does atracurium have
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NONE
(void of CV effects) |
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what are the side effects of atracurium
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*histamine release DOSE dependent
*metabolite laudanosine causes cerebral excitation in animals (? human significance) |
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what type of duration and recovery does cis-atracurium have
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short duration and rapid recovery
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which NMB has organ INDEPENDENT metabolism
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*cis-atracurium
*mivacurium |
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what is cis-atracutium composed of
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single isomer of 10 isomers that compose the MR atracurium
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what is hoffman elimination dependent on
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it is pH and temp dependent
-elimination INCREASES with an INCREASE in pH or body temp |
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what does alkalosis do to hoffman elimination
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INCREASES it
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what NMB need to be refrigerated
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*succinylcholine
*cis-atracurium |
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what does acidois do to hofmann elimination
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it SLOWS it
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what does a DECREASE it body temp < 37 degrees do to hofmann elimination
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SLOWS it
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which NMB is an excellent choice for renal failure
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cis-atracurium
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which NMB can be given as a continous infusion d/t rapid recovery
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mivacurium
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which NON-depolarizing NMB has a short duration and is beneficial for very short procedures
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mivacurium
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which NMB may you skip reversal with when wanting to avoid N/V with reversal agents
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mivacurium
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what are the s/e of mivacurium
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*SIGNIFICANT histamine release that is speed of injection and dose dependent
*may unmask plasma cholinesterase deficiency |
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if a dz or drug weakens a muscle or neuronal membrane what does it do to a NMB
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POTENTIATES it
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more Ach receptors (up regulation) have what response to NMB
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tend to RESIST nmb
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what do depolarizing NMB do to a weakened or dz muscle
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cause a massive depolarization
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what drugs POTENTIATE depolarizers and NON-depolarizers by depressing NMJ function
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*aminoglycosides(mycins)
-polymixins, neomycin and streptomycin are the most potent |
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what other drugs POTENTIATE NMB b/c they are membane stablilizers
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*IA
*LA *VAA *dantrolene *Mg *Ca channel blockers |
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what are the reasons for relaxing or paralyzing muscles
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*to obtain adequte intubating conditons
*to facilatate surgical exposure or manipulation *to improve mech ventilation *to compensate for inadequate or light anesthesia |
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which muscles are the MOST sensitive to NDMR
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upper airway muscles
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which muscles are the LEAST sensitive to NDMR
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diaphragm
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which muscle should you twitch when monitoring
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the one that correlates with the area that you want paralyzed
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what are RELIABLE assessments of recovery
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*sustained head lift x 5 sec
*sustained tongue depressor test *sustained leg lift (children) *max inspiratory pressure > 50 |
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what are UNRELIABLE clinical assessments of recovery
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*sustained eye opening
*protrusion of tongue *normal VC *max inspiratory pressure <25 |
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negative inspiratory pressures can lead to what
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pulm edema
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a single twitch from a nerve monitor is how many Hz
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o.1-0.15
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a train of four delivers how much Hz how long apart
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2 Hz 0.5 sec apart
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how much Hz does tetanus deliver and how long apart
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50 Hz and 100 Hz 5 sec apart
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what is double burst stimulation
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50 Hz 2 sets of 3 bursts appear as two twitches
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what is the purpose of nerve monitoring
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to evaulate the degree of muscle paralysis or recovery from muscle paralysis
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what does double burst do
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accentuates fade that is present on TOF
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what is post tetanic stimulation
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displacement of molecules that were still on a few Ach receptors
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phase 1 and phase 2 blocks are seen with what type of NMB
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DEPOLARIZING
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what type of NMB exhibit fade on train of four
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NON-depolarizing
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what may happen to fade if enough NDMR is given
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may progress to NO twitches
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with R4 it decreases at what amt of receptors blocked
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75%
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with R3 it decreases at what amt of receptors blocked
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85%
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with R2 it decreases at what amt of receptors blocked
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90%
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with R1 it decreases at what amt of receptors blocked
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95%
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what percentage of NMB is there before motor function is impaired
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75-100%
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what type of block is seen as 4/4 TOF but with LESS amplitude
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phase I
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what type of block is often seen as 0/4 TOF (NO twitches)
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phase II block
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what are the nerves that you can monitor
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*ulnar
*facial *post tibial |
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what muscle does the ulnar nerve correspond to
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adductor pollicis
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what muscle does the facial nerve correspond to
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currigator supercilli
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what muscle does the post tibial nerve correspond to
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flexor hallucis
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what is the reason we stimulate a nerve
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to observe a muscle response
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to ensure a block twitch which nerve
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facial
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for wake up test twitch what nerve
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ulnar
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the facial nerve is what cranial nerve
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7
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what branches is the facial nerve composed of
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5
*temporal *zygomatic *maxillary *mandibular *buccal |
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for post tibial nerve monitoring where are the leads placed
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behind the medial malleolus
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stimulation of the post tibial nerve causes what to occur
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flexion of the big toe by contraction of the flexor halucis
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what is the post tibial nerve composed of
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sciatic nerve branches at popliteal fossa
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which muscle related to nerve monitoring is relatively resistant to blockade
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corrugator supercilli
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which muscle r/t nerve blockade is similar to diaphragm resistance
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corrugator supercilli
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which nerve should be monitored for intubating conditions and abd rectus paralysis
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facial nerve
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which muscle should be monitored for extubation adequacy
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adductor pollicus (ulnar nerve)
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why is the ulnar nerve beneficial for monitoring
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*ease of place and access
*contralateral innervation of the monitored muscle allows for discrimination b/t direct muscle stimulation & direct nerve stimulation |
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in addtion to the main muscle that it innervates what other muscle does the ulnar nerve innervate that is also relatively resitant to blockade
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hypothenar muscles
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the posterior tibial nerve allows for what kind of monitoring
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monitoring on pts who you have limited access to places on their body
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with a normal tidal volume test what percent of receptors may be blocked
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0-80%
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with hold tetanus 5o Hz what percent of receptors may be blocked
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0-75 to 80%
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with equal TOF and double burst what percent of receptors may be blocked
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0-75 to 80%
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with holds tetanus 100 Hz what percent of receptors may be blocked
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0-50%
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with head lift x 5 sec what percent of receptors may be blocked
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0-33%
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what does single twitch monitoring allow for
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continual evaulation of depolarizing block (must know baseline)
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what does TOF monitoring allow for
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allows estimation of DEGREE of NON-depolarizing block
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what does double burst stimulation allow for
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easier visual evaulation of fade
(gives same info as TOF) |
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what would you use to evaulate a "shallow" block
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twitch, TOF, tetanus
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what would you use to evaulate a "profound" block
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post-tetanic count and post tetanic stimulation
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which type of block has a degree of neuromuscular junction fuction that remains intact
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shallow
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what type of block is a deep block that causes complete muscle paralysis/laxity
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profound
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what is post-tetanic stimulation count (PTC)
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*allows for quantification of block if NO TOF present
*estimates what CI reversal drugs may achieve for you |
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what is post tetanic facilitation
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release of large amt of Ach floods the NMJ and ACCENTUATES subsequent twitch responses
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physical assessment range for neuromusclar block is what percent of receptors blocked
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0-50%
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tetanus evaulates what percent of receptors blocked
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50-75%
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train of four evaulates what percentage of receptors blocked
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75-95%
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PTC evaulates what percentage of receptors blocked
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95-100%
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twitch monitors themselves can evaulate blocks in what percentage range
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50-100
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