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126 Cards in this Set
- Front
- Back
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Pancuronium
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Pavulon
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Vecuronium
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Norcuron
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Atracurium
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Tracrium
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Cis-atracurium
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Nimbex
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Rocuronium
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Zemuron
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Succinylcholine
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Anectine, Quelicin
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Neostigmine
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Prostigmine
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Edrophonium
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Enlon, Tensilon
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Glycopyrrolate
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Robinul
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Sugammadex
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Bridion
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In this system the nerves go all the way to the muscle. There is no ganglion.
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Somatic system (nerve)
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What are type of drug are muscle relaxants?
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anticholinergic ;antinicotinic; nicotinic antagonist
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What muscles are not affected by muscle relaxants?
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cardiac and smooth muscle
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Ultra short acting depolarizing muscle relaxant
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succinylcholine
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Intermediate acting nondepolarizing muscle relaxant
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atracurium
cisatracurium vecuronium rocuronium |
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Long acting nondepolarizing muscle relaxant
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pancuronium
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How does succinylcholine work?
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first its an agonist-mimics ACh and depolarizes the muscle
then is an antagonist and sits on the receptor for about 10 min until it is metabolized and eliminated |
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How do the nondepolarizing muscle relaxants work?
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they sit on the nicotinic receptor blocking ACh which keeps the muscle from initiating an action potential
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What % of paralyzation allows you to still breath normally?
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80% paralyzed
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What 2 questions should you always ask yourself before extubating a patient?
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are they going to vomit and aspirate?
will they breath okay? |
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Think of relaxants in regards to ...
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% paralyzed
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A single supramaximal electrical stimulus ranging from 0.1-1.0 Hz.
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Single Twitch
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A series of four twitches at 2 Hz every half second for two seconds
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Train of four
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consists of rapid delivery of a 30, 50, or 100 Hz stimulus for 5 sec
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Tetanus
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Two short bursts of 50 Hz tetanus separated by 0.75 seconds
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Double burst stimulation
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Requires baseline before drug administration
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Single Twitch
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Reflects blockade from 70-100%; useful during onset, maintenance, and emergence
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Train of four
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Should be used sparingly for deep block assessment, painful
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Tetanus
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Similar to train of four; useful during onset, maintenance, and emergence; may be easier to detect fade than with train of four; tactile evaluation
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Double burst stimulation
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time from drug administration to maximum effect
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onset time
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time from drug administration to 25% recovery of the twitch response
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clinical duration
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time from drug administration to 90% recovery of twitch response
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total duration of action
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time from 25% to 75% of the twitch response
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recovery index
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compares the fourth twitch of a TOF with the first twitch. when the fourth twitch is 90% of the first, recovery is indicated
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train of four ratio
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Stimulation of which nerve gives a better indication about whether the diaphram is moving and why?
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facial nerve because they upper airway muscle are more sensitive than the peripheral muscles
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Where do you place the electrodes to stimulate the facial nerve?
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#1 in front of the tragus of the ear and #2 just below and slightly posterior
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Which muscle is stimulated with the facial nerve?
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orbicularis oculi
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which muscle is stimulated with the ulnar nerve?
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adductor pollicis
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What is the better nerve to monitor during the onset of NM blockade?
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facial nerve
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What sequence do the muscles in the body become paralyzed?
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1. eye lids
2. extremeties 3. chest-intercostals 4. abdominal muscles 5. diaphragm |
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What sequence do the muscles in the body regain function?
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1. diaphragm
2. abdominal muscles 3. chest-intercostals 4. extremeties 5. eye lids |
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Why is the facial nerve more indicative of onset than the ulnar nerve?
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it takes longer for the drug to distribute to the fingertips than to the face because of the path of blood flow to the trunk of the body and then to the periphery
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What is the hardest muscle to paralyze?
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diaphragm
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4 equal twitches on the TOF is what % paralyzed
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70% or less
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4 twitches that are not equal (with fade) is what % paralyzed?
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70-75%
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What is the target when using a NMR?
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getting the person to 90% paralyzed-1 twitch on the TOF
-paralyzed enough but not over paralyzed |
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On the TOF when you have abolished 1 response, what % of paralysis have you reached?
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75-80% blockade
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On the TOF when you have abolished 2 responses, what % of paralysis have you reached?
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80-85% blockade
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On the TOF when you have abolished 3 responses, what % of paralysis have you reached?
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90-95% blockade
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How does succinylcholine behave differently with the nerve stimulator?
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no TOF fade. It is all or nothing
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What TOF ratio is considered back to normal?
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90% or the fourth twitch is 90% the size of the first twitch
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What type of block: Phase I or II?
muscle fasciculation precedes the onset of neuromuscular blockade |
Phase I
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What type of block: Phase I or II?
sustained response to tetanic stimulation |
Phase I
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What type of block: Phase I or II?
absence of posttetanic potentiation, stimulation or facilitation |
Phase I
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What type of block: Phase I or II?
lack of fade to TOF or DBS |
Phase I
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What type of block: Phase I or II?
block antagonized by prior administration of nondepolarizer as pretreatment (requires 20% more depolarizer) |
Phase I
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What type of block: phase I or phase II?
block potentiated by anticholinesterase drugs |
Phase I
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What type of block: phase I or phase II?
Absence of muscle fasciculation |
Phase II
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What type of block: phase I or phase II?
Appearance of tetanic fade and posttetanic potentiation, stimulation or facilitation |
Phase II
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What type of block: phase I or phase II?
TOF and DBS fade |
Phase II
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What type of block: phase I or phase II?
Reversal with anticholinesterase drugs |
Phase II
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What percentage of blockade is TOF test reliable?
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70-100%
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What percentage of receptors can be occupied by muscle relaxant when the patient still has a normal tidal volume?
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80%
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When a patient is able to lift their head, squeeze your hand, and have a sustained jaw clenched down on a tongue blade what percentage of receptors are likely occupied by NMR?
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50% or less
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What are the very last muscles in the body to return?
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the protective airway muscles of the pharynx and upper esophagus
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What is the best nerve to stimulate during emergence?
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the ulnar nerve
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When there is only one response to TOF stimulation, successful reversal can take as long as...
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30 minutes
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A TOF count of 2-3 responses following the administration of a long acting relaxant may take up to...
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10-12 minutes
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A TOF of 2-3 responses following the administration of a intermediate acting relaxant may take as long as ...
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4 -5 minutes
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What are the two end products of succinylcholine metabolism?
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succinic acid and choline
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What is succinylcholine metabolized by?
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cholinesterase
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Where is pseudocholinesterase found?
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plasma, liver, smooth muscle, intestines, pancreas, heart and white matter of the brain
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Where is acetylcholinesterase found?
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NMJ synapse, erythrocytes, nerve endings, lungs, spleen, and grey matter of the brain
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What are the 3 types of nonspecific esterases?
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paraoxonase
albumin esterase RBC esterase |
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Esters in the body are broken down by...
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cholinesterase or
nonesterase dependent enzymes |
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What are the other names for AChE?
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true, specific, genuine, or type 1
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What are other names for PChE?
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plasma, serum, benzoyl, false, butyryl, nonspecific, or type 2
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A moderate decrease (30-50%) in PChE is found in what patient population?
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acute and chronic (long standing) hepatitis
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A severe decrease (50-70%) in PChE is found in what patient population?
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advanced cirrhosis and some carcinomas with metastases to the liver
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Patients develop neuromuscular symptoms at what percentage of normal PChE activity?
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60% of normal activity
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Serious neuromuscular effects are seen at about what % of normal PChE activity?
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20% of normal activity
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What can happen in relation to PChE in patients with end stage liver disease?
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they have low levels of PChE because they are unable to synthesis it
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What drugs are affected in patients with atypical cholinesterase?
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Succinylcholine
Ester local anesthetics: -cocaine -procaine -chloroprocaine -tetracaine Neostigmine Edrophonium |
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What drugs are metabolized by nonspecific esterases?
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atracurium
cisatracurium remifentanil clevidipine |
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What is esmolol metabolized by?
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RBC esterases
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What does a dibucaine # of 80 mean?
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a normal test indicating that 80% of the cholinesterase activity was inhibited by dibucaine
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How does the dibucaine inhibition test work?
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Dibucaine is an amide local anesthetic that inhibits normal (typical) PChE. The larger the dibucaine number means the more normal PChE molecules that are present because they were inhibited.
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What 2 things do you need to know when finding out the results of the dibucaine inhibition test?
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the dibucaine #
the enzyme level (percent activity) |
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If you have a dibucaine # of 50-60 what can you expect your response to succinylcholine will be?
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prolonged response of about 50-100%
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If you have a dibucaine # of 20-30 what can you expect your response to succinylcholine will be?
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prolonged response from 4-24 hrs
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Low dibucaine number and normal activity
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classic atypical enzyme and prolonged apnea
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normal dibucaine number and low activity
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normal enzyme and low levels of enzyme present with prolonged apnea
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low dibucaine number and low activity
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atypical enzyme and low levels present with prolonged apnea
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normal dibucaine number and normal activity
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normal enzyme and level-investigate another reason for prolonged apnea
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side effects of succinylcholine
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hyperkalemia
dysrhythmias myalgia myoglobinemia elevated intragastric pressure elevated IOP elevated ICP malignant hyperthermia masseter spasm |
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Why is hyperkalemia a problem with succinlycholine?
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serum K levels will rise up to 0.5 mEq/l secondary to potassium leakage from the depolarized muscle
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What are some pathologic conditions with potential for hyperkalemia with succinylcholine?
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-upper or lower motor neuron defect
-prolonged chemical denervation -direct muscle trauma, tumor, or inflammation -burn injuries -disuse atrophy -severe sepsis |
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Why is there such an exaggerated response in burn patients or those with muscle injury, etc:
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due to upregulation of muscle receptors. Damaged muscle increases the number of muscle receptors to help get things back to normal.
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Contraindications to the use of succinylcholine
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-hyperkalemia
-burn patients -severe muscle trauma -neurological injury (ie paraplegia) -severe sepsis -muscle wasting, prolonged immobilization -malignant hyperthermia -duchenne muscular dystrophy -children under 8 (except in emergent situations) -atypical cholinesterase -allergy |
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What are the 2 types of benzoisoquinolone relaxants?
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atracurium and cisatracurium
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What are the 2 processes by which they are metabolized by the body?
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nonesterase dependent hydrolysis &
hofmann elimination |
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What is hofmann elimination?
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chemical reaction that occurs with a change in temperature and PH of the environment that causes the chemical to metabolize itself
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What are the steroidal relaxants?
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vecuronium
pancuronium rocuronium |
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What chemical structure do the steroidal relaxants contain? what is the significance of this?
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quaternary nitrogen molecule-always has a positive charge which makes it always 100% ionized in the body
-means it doesn't cross the placental or the BBB |
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Where is vecuronium metabolized? what disease would it be contraindicated with?
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Liver (30-40%)
Kidney (40-50%) contraindicated in liver and kidney disease |
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Where is rocuronium metabolized?
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<70% in the liver
10-25% kidney |
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Where is pancuronium metabolized?
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Kidneys 85%
Liver 10-20% |
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Which muscle relaxant causes histamine release and therefore produces hypotension and tachycardia?
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atracurium
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Which muscle relaxant is vagolytic and causes slight catecholamine release (indirect sympathomimetic) producing tachycardia?
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pancuronium
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Which drug can cause sudden abrupt bradycardia as a result of repeat dosing?
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Succinylcholine
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Which receptor when stimulated causes
-increased capillary permeability -bronchoconstriction -intestinal contraction -negative dromotropic effects |
H1 receptors
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Which receptor when activated causes
-increased gastric acid production -systemic and cerebral vasodilation -positive inotropic effects -positive chronotropic effects |
H2 Receptors
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With endogenous histamine release which receptors are activated?
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both H1 and H2 receptors
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Prophylaxis against histamine release requires administration of what?
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both H1 & H2 receptor blockers such as:
benadryl cimetidine |
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Why is succinylcholine contraindicated in children under the age of 8?
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due to the possibility for Duchenne's muscular dystrophy-if they have this it can cause severe hyperkalemia and lethal arrythmia may follow
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What drugs when given with a muscle relaxant can cause prolonged paralysis?
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-antiobiotics
-steroids -dantrolene -magnesium -lithium |
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What is the maximum reversal dose for neostigmine?
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5 mg total
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What is the maximum reversal dose for edrophonium?
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1mg/kg
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What is a common side effect of neostimine?
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PONV
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What ACh antagonist is typically paired with edrophonium and why?
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atropine due to its rapid onset; edrophonium has rapid onset and short duration
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What are the problem areas for business records?
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[1] Does the exception apply? Usually turns on whether entry is germane to the business. If it’s germane, it applies.
[2] Multiple Hearsay Problem – assume the entry is germane to the business so that the biz records exception ordinarily applies. But suppose the record contains w/in it a statement made by someone outside the business. Reconsider the rationale and purpose of the exception. e.g. excessive-force complaints by citizens against an arresting officer on trial that went in his personnel file are not business records b/c they were submitted by members of the public and not created by an employee w/ responsibility for reporting or recording such information. |
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What is the reversal dose, onset and duration for edrophonium?
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dose: 500-1000 mcg/kg
onset: 5-10 min duration: 30-60 min |
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What is the usual dose, onset and duration for atropine?
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dose: 15 mcg/kg
onset: 1-2 min duration: 1-2 hr |
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What is the dose, onset and duration for robinol?
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dose: 10-20 mcg/kg
onset: 2 min duration: 2-4 hr |
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Why is it necessary to give a anticholinergic along with a anticholinesterase drug when reversing the muscle relaxant?
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during the reversal with the anticholinesterase drug, ACh builds up in the sympathetic as well as the parasympathetic system. The parasympathetic build up can cause a vagolytic response. The anticholinergic drug is given to counteract the parasympathetic response.
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What muscle relaxant works faster the more potent or the less potent?
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The less potent works faster because you have to give a much larger dose. The increased number of molecules spreads through the body faster
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