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43 Cards in this Set
- Front
- Back
PHASE II BLOCK
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-post junctional membrane repolarizes but does not respond normally to ACh
-usually doses > 3-5 mg/kg IV -resembles non depolarizing block |
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ATYPICAL PLASMA CHOLINESTERASE
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-gene, unable to hydrolyze the ester bonds in drugs like Sux, mivacurium
-usually don't know until given Sux and block time prolonged -test with dibucaine |
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2 CHEMICAL CLASSIFICATIONS OF NON DEPOLARIZERS
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STEROID DERIVATIVES-Pan, Roc, Vec, Pipercuronium *vagolytic usually (increase HR)
BENZYLLISOQUINOLINES-d-tubo, atracurium, mivacurium* tend to release histamine |
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DIBUCAINE TEST
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-local anesthetic that will inhibit normal plasma cholinesterase by 80% (normal is 80)
-40-60 heterozygous atypical prolonged block (20-40) -20-40 Block >60 min homozygous atypical |
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LONG ACTING NON DEPOLARIZERS
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Pancuronium longest, Doxacurium,pipe, d-tubo, metocurine and gallamine
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SIDE EFFECTS OF SUX
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-can also stimulate muscarinic receptors causing bradycardia
-Fasiculations can cause myalgia -prevent fasiculations by giving subparalyzing dose 3-5% of ED95 non depolarizing drug -hyperkalemia from sustained opening of channels and K out -don't use in burns, upper motor neuron lesions, musc. dystrophy |
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MORE SIDE EFFECTS OF SUX
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myoglobinuria from fasiculations, Increase IOP, increase ICP, increase IGP, Trismus in children -jaw doesn't relax, may be a sign of suseptibility to MH,
-trigger for MH |
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INTERMEDIATE NON DEPOLARIZER
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Vec, atracurium, cisatracurium, Roc
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SHORT ACTING NON DEPOLARIZER
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mivacurium
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PAVULON (PANCURONIUM)
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LONG ACTING
-DOSE intub. .08-.12 mg/kg main. .01 mg/kg ONSET 3-5 min DURATION 60-90 min EXCRETION primarily renal (only one) ***can stimulate and block vagus -> increase HR, CAD caution |
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NUROMAX (Doxacurium)
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LONG ACTING
DOSE intub. .05 mg/kg main. .005 mg/kg ONSET 4-6 min |
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ARDUAN (Pipercuronium)
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LONG ACTING
DOSE intub. .06-.1 mg/kg **hypotension, bradycardia |
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EDROPHONIUM
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ANTICHOLINESTERASE
onset like atropine trade names TENSILON, ENLON, REVERSOL DOSE 0.5-1 mg/kg give with atropine 0.014 mg per mg of edrophonium |
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PROSTIGMIN, VAGOSTIGMIN (Neostigmine)
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ANTICHOLINESTERASE
DOSE .037-0.07 MG/KG give with glycopyrrolate 0.2 mg per mg of neostigmine |
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PHYSOSTIGMINE
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ANTICHOLINESTERASE
-tertiary amine crosses BBB -used to tx anticholinergic toxicity NOT USED FOR REVERSAL ***too much anticholinesterase will cause weakness and blockade due to excessive ACh in NMJ -this drug will prolong/potentiate the block of Sux |
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TRACURIUM (Atracurium)
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INTERMEDIATE
-DOSE intub. .5 mg/kg over 30-60 sec main .1mg/kg infusion 5-10 mcg/kg/min EXCRETION hoffman elimination, spontaneous non enzymatic degredation (at normal temp and pH), 2nd non specific tissue esterases. -can cause seizures -good for renal pts -Laudanosine product of metab. CNS stimulant -if push too fast histamine release |
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CHOLINERGIC SYNDROME (CRISIS)
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-excessive use of cholinesterase inhibitors or organic insecticides
-excessive ACh peripherally or centrally -s/s miosis, salivation, brochoconstriction, bradycardia, abd. cramping -weakness CNS dysphoria, confusion, seizures, coma (inhibits parasympathetic, CNS excitatory) |
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NIMBEX (cisatracurium)
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INTERMEDIATE ACTING
-stereoisomer of atracurium -slower onset less histamine DOSE intub. .1-.15 mg/kg infusion 1-2 mcg/kg/min EXCRETION Hoffman elimination Laudanosine but less than atracurium |
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ANTICHOLINERGIC SYNDROME
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-develops in response to increased doses of atropine and scopolamine
s/s CNS restless, shiver, mania, hallucinations, delerium, drowsiness, agitation disorientation -peripheral - blurred vision, dry mouth, Increase HR, dry flushed skin, hypoTN, rash on face, neck and upper chest |
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TREATMENT FOR CHOLINERGIC SYNDROME
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Atropine 35-70 mcg/kg
Pralidoxime 15 mg/kg IV Q 20min (reactivates acetylcholinesterase) ****then treat s/s |
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ZEMURON (Rocuronium)
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INTERMEDIATE ACTING
-low s/e profile, alternate for Sux for RSI DOSE intub. .6 mg/kg RSI double the intub dose- will make onset more rapid and longer duration EXCRETION little metab. largely excreted unchanged in the urine |
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MIVACRON (Mivacurium)
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SHORT ACTING
DOSE intub. .15-.2 mg/kg infusion 4-10 mcg/kg/min EXCRETION hydrolysis via plasma cholinesterase * so if atypical plasma cholinesterase increases block time -histamine release- push slowly -spontaneous recovery need for reversal controversial |
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REVERSAL AGENTS
ANTICHOLINESTERASES |
-inhibit the enzyme that breaks down ACh (acetylcholinesterase)
-Therefore INDIRECTLY increase the amoung of ACh available to compete with the non depolarizing agent which will therefore reestablish neuromuscular transmission |
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PHASE I BLOCK
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-depolarizing NMB
-"fasiculations" |
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DTc d-tubocurarine
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not used for NMB but pre tx for sux to prevent fasiculations
DOSE 3 mg IV 3-5 min before sux ***causes histamine release |
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TREATMENT FOR ANTICHOLINERGIC SYNDROME
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Physostigmine 15-60mcg/kg
crosses the BBB |
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ANTICHOLINESTERASES SIDE EFFECTS
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-increase in ACh affects more than nicotinic receptors of skeletal muscle
CV Brady, RESP bronchospasm GI N/V so give with anticholinergic agents |
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NORCURON (Vecuronium)
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INTERMEDIATE ACTING
DOSE intub. .08-.12 mg/kg main. .01 mg/kg infusion 1-2 mcg/kg/min ONSET 3-5 min DURATION 20-60 min under an hour EXCRETION prim biliary, 2nd renal (25%) |
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ULNAR NERVE
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adductor pollicis, adduction of thumb,
ASSESS FOR READY TO EXTUBATE comes back last |
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MANDIBULAR NERVE
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masseter muscle, electrode in front of and below zygomatic arch and forehead
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POST TIBIAL NERVE
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plantar flexion of big toe
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FACIAL NERVE
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ASSESS FOR READY TO INTUBATE
-first to go down first to come back -orbicularis oculi -has similar sensitivity to NMB as diaphragm and laryngeal -recover sooner than adductor pollicis, orbicularis, diaphragm, rectus abdominus, and laryngeal |
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POST TETANIC FACILITATION
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-response to TOF following tetanus is increased yet still fades as before
-typical of non dep block usually means you can start reversal |
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DOUBLE BURST
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-3 short high frequency bursts 50 Hz separated by 0.2 msec followed by another 3 or 2 750 msec later
-considered gold standard easier to assess -depolar 2 twitches diminished no fade -non depolar 2 twitches with fade |
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TETANY
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-sustained 5 sec 50-100 Hz
-sustained without fade indicates adequate recovery from block |
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TOF
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-4 stimuli at 2 Hz delivered Q 0.5 sec
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SINGLE TWITCH
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-frequency 1 Hz
-used as control twitch |
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RECEPTOR BLOCKADE
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-100%- flaccid no response
-95%- no twitches but diaphragm may move -90%- 1 twitch adequate for abd. surg. -70%- 75%- 4 twitches TOF, VC and TV can be normal -50%- can pass inspriatory pressure test (NIF) -30%- head lift and hand grasp sustained |
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MIOSIS
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CONSTRICT
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MYDRIASIS
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DILATE
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CHOLINERGIC CRISIS
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-too much anticholinesterases
AKA muscarinic crisis s/s abd pain, n/v, blurred vision, bronchial hypersecretion TX PRALIDOXIME 15 MG/KG Q 20 min (reactivates acetylcholinesterase ATROPINE 35-70 MCG/KG |
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ANTICHOLINERGIC SYNDROME
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-opposite of cholinergic syndrome ( TOO MUCH ANTIMUSCARINICS, atropine, glycopyrolate, pralidoxime)
s/s Increase of SNS efffects Increase HR, blurred vision, rash neck, face, and chest TX PHYSOSTIGMINE 15-60 MCG/KG CROSSES BBB |
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PYRIDOSTIGMINE
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ANTICHOLINESTERASE
DOSE 0.15- 0.35 mg/kg give with glycopyrrolate 0.05 mg per pyridostigmine |