Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
239 Cards in this Set
- Front
- Back
|
NMBDs interfere with the transmission of impulses where?
|
At the Neuromuscular Junction
|
|
|
NMBDs should or should not be used to ensure lack of movement in an under-anesthetized patient.
|
Should Not!
|
|
|
Can a patient be paralyzed but not anesthetized?
|
Yes.
|
|
|
Which surgeries have the highest incidence of recall?
|
OB, Trauma, Open heart/Thoracic
|
|
|
Action Potential causes an influx of _____ into the nerve cytoplasm and allows storage vesicles to release _____.
|
Ca++, Acetylcholine
|
|
|
Which 2 of the 5 subunits of nicotinic cholinergic receptors bind AcH for muscle contraction?
|
The 2 Alpha
|
|
|
When given an NMBD, the 2 alpha are taken up and Na/Ca flows in, K flows out. This causes what?
|
Action potential, and eventual muscle contraction.
|
|
|
AcH is very rapidly metabolized by what enzyme?
|
acetylcholinesterase
(aka true cholinesterase) |
|
|
Where is acetylcholinesterase found?
|
In the folds of endplates at the NM junction
|
|
|
What does AcH hydrolyze into?
|
Acetic acid and choline
|
|
|
In action potential of muscle, K goes ___ and Na/Ca go ___.
|
K goes out
Na/Ca go in |
|
|
Two classes of NMBDs are
|
Depolarizers and
NonDepolarizers |
|
|
Depolarizers (ie-Suxx), mimic the action of what?
|
Acetylcholine
|
|
|
Depolarizers act as acetylcholine receptor
|
agonists
|
|
|
The only depolarizing NMBD used today is
|
succinylcholine (Anectine)
|
|
|
What is the onset of action of Succinylcholine?
|
30-60 seconds
|
|
|
Duration of succinylcholine
|
Short (3-10 minutes)
|
|
|
What is the IV dose of Suxx for adults?
|
1-2 mg/kg IV
|
|
|
What is the IM dose of suxx?
|
4-5 mg/kg IM
(for kids, or lost IV) |
|
|
How is Suxx supplied?
|
In red bottles.
200mg/20ml |
|
|
How much Suxx would you give to a healthy 140lb patient?
|
63-126mg IV
|
|
|
Succinylcholine is unlike acetylcholine in that it is metabolized where and by what?
|
In the blood by pseudocholinesterase (aka- plasmacholinesterase)
|
|
|
A small dose of suxx (about 1ml) can be used to break what?
|
laryngospasm
|
|
|
How much of the actual IV dose of suxx actually gets to the receptors?
|
Very little (due to metabolism in the blood)
|
|
|
How does Suxx cause a NM Block?
|
causes the inability of the depolarized post-junctional membrane to respond to acetylcholine
|
|
|
A normal range, one-time dose of Suxx causes what type of block?
|
Phase 1 Block
|
|
|
A single Large dose or repeated doses of Suxx can cause what?
|
A Phase 2 Block
|
|
|
A phase 2 Suxx-induced block resembles what?
|
A nondepolarizer block (it will last longer)
|
|
|
A phase 2 block from Suxx is a result of what dose IV?
|
over 3-5 mg/kg
|
|
|
Which patients can have a decreased amount of plasmacholinesterase?
|
pts with insecticide exposure, atypical plasmacholinesterase, severe liver disease, MG, chemo
|
|
|
Metabolism of Acetylcholine is faster or slower than that of succinylcholine?
|
Faster
|
|
|
What genetic disease makes a patient have a very long block from Suxx?
|
Atypical plasma cholinesterase
|
|
|
Which test can be used to diagnose atypical plasmacholinesterase?
|
Dibucaine test (local anesthetic)
|
|
|
Should you discover atypical plasmacholinesterase during surgery, what is your plan of care?
|
Keep patient tubed/vented until the block wears off.
|
|
|
Which NMBD can lead to hyperkalemia?
|
Succinylcholine
|
|
|
If an patient has a Dibucaine number of less than ____, they can NOT have suxx.
|
20%
|
|
|
What can be inferred if a patient has a dibucaine number of 40-60%?
|
That they have heterozygous atypical cholinesterase and will have a prolonged block (20-40 minutes).
|
|
|
What dibucaine number will a normal patient have?
|
80%
|
|
|
Myoglobinuria, increased IOP, increased ICP, increased IGP and trismus are side effects of what NMBD?
|
Succinylcholine
|
|
|
In which situations would you avoid suxx?
|
History of MH, neuromuscular disorders, spinal injury, paralysis/stroke.
|
|
|
Muscarinic cholinergic stimulation (like with Suxx)can cause what?
|
Bradycardia
|
|
|
What is usually given as an accompaniment to Suxx in children?
|
atropine (due to marked bradycardia)
|
|
|
A hypermetabolic state of skeletal muscle due to a release of excess CA from the Sarcoplasmic Reticulum:
|
Malignant Hyperthermia
|
|
|
What can be inferred from tachycardia--> hypercapnia--> hyperthermia?
|
MH
|
|
|
What do you do upon first suspicion of MH?
|
Stop all inhalants and Suxx immediately, 02, call for help, cooling measures, bicarb, diuresis.
|
|
|
Which meds would you never (ever) give in suspected or hx of MH?
|
Calcium channel blockers
|
|
|
Which test is used to diagnose MH?
|
The caffeine-halothane test
|
|
|
What is the mortality rate of intraop MH, even with an early diagnosis?
|
30-60%
|
|
|
In MH, intracellular Ca increases, causing increased serum K, resulting in:
|
Cardiac Arrest
|
|
|
What do you dilute dantrolene in?
|
Sterile Water
|
|
|
What is the supply of dantrolene?
|
20mg in 50ml of Sterile H20
|
|
|
What is the dose of dantrolene for MH?
|
2.5mg/kg IV Q5Minutes
|
|
|
What is the "max" dose of dantrolene?
|
10 mg/kg
|
|
|
How does dantrolene combat MH?
|
it inhibits the CA ion release from SR
|
|
|
If you have given 10-30 mg/kg of Dantrolene and your pt has not improved, what can be inferred?
|
Might not be MH
(look to other causes for symptoms) |
|
|
What dose of dantrolene is used for repeated doses (like in the unit)
|
1mg/kg Q6H for 24-72 hours
|
|
|
What agents can trigger MH?
|
Inhalational agents (beside nitrous) and Succinylcholine.
|
|
|
Which class of NMBDs compete with AcH to occupy receptors?
|
non-depolarizers
|
|
|
How does a nondepolarizer stop depolarization?
|
It blocks the ion channels.
|
|
|
Steroid-derived nondepolarizing NMBDs end in
|
"onium"
|
|
|
Benzylisoquinolines (NMBDs) end in:
|
"urium"
|
|
|
Steroid-derived NMBDs tend to be:
|
Vagolytic
|
|
|
The two long-acting NMBDs (60minutes) are:
|
pancuronium and
doxacuronium |
|
|
Benzylisoquinoline NMBDs release what?
|
Histamine
|
|
|
Where is pseudocholinesterase made?
|
In the liver (stored in blood).
|
|
|
Intermediate-acting NMBDs (30-60mins) are:
|
Vecuronium
Atracurium cistacurium/Nimbex Rocuronium |
|
|
A short-acting nondepolarizing NMBD:
|
mivacurium
|
|
|
What part of a bypass surgery is a risky time for awareness?
|
The warming phase
|
|
|
Vagolytic means
|
an increase in HR and BP (the opposite of vagal response)
|
|
|
What is the intubation dose of Pancuronium?
|
0.08-0.12 mg/kg IV
|
|
|
Brand name of pancuronium
|
Pavulon
|
|
|
What is the maintenance dose of Pavulon (pancuronium)?
|
0.01 mg/kg IV
|
|
|
Which drugs can stimulate the SNS, block vagus, increase HR?
|
Rocuronium
Vecuronium Pancuronium |
|
|
DTc causes significant release of what?
|
Histamine
|
|
|
What is the brand name of vecuronium?
|
Norcuron
|
|
|
What is the onset of vecuronium?
|
3-5 minutes
|
|
|
What is the duration of action of vecuronium?
|
<60 minutes
|
|
|
The primary excretion route for vecuronium is
|
Biliary
|
|
|
The primary excretion route for pancuronium is
|
Kidneys
|
|
|
What is the intubation dose of vecuronium?
|
0.08-0.12 mg/kg
|
|
|
Vecuronium can be used before suxx administration as a:
|
defasiculation dose
|
|
|
What is the maintenance dose of vecuronium?
|
0.01mg/kg IV
|
|
|
What is the infusion (gtt) dose for vecuronium?
|
1-2 mcg/kg/min IV
|
|
|
Which NMBD can be used for induction?
|
vecuronium
|
|
|
What is the brand name for atracurium?
|
Tracurium
|
|
|
Which NMBD is contraindicated in asthmatics?
|
atracurium
|
|
|
Which NMBDs undergo Hoffman elimination?
|
Nimbex (cisatracurium)
Tracrium (atracurium) |
|
|
Which NMBD is good for renal patients?
|
atracurium
|
|
|
Which NMBD causes excessive/massive histamine release?
|
atracurium
|
|
|
What is the intubation dose of Tracrium?
|
0.5mg/kg IV slow push
|
|
|
What is the maintenance dose of atracurium?
|
0.1mg/kg IV
|
|
|
What is the infusion (gtt) dose of atracurium?
|
5-10 mcg/kg/min IV
|
|
|
What is the brand name of cisatracurium?
|
Nimbex
|
|
|
Nimbex is a cis-isomer of atracurium and has what benefits?
|
Slower onset with less histamine release
|
|
|
What is the intubation dose of Nimbex?
|
0.1-0.15 mg/kg IV
|
|
|
What is the infusion (gtt) dose of Nimbex?
|
1-2 mcg/kg/min IV
|
|
|
Why is rocuronium so unique?
|
Because it has an extremely rapid onset (30 seconds).
|
|
|
What two NMBDs can be used for RSI?
|
succinycholine and
rocuronium |
|
|
What is the intubation dose for rocuronium?
|
0.6-1.2 mg/kg IV
|
|
|
What are advantages of rocuronium?
|
low side effect profile
little metabolism |
|
|
What is the brand name of Rocuronium?
|
Zemuron
|
|
|
Which class of meds reverse NMBDs?
|
Anticholinesterases
|
|
|
What is the brand name of mivacurium?
|
Mivacron
|
|
|
The reversal of a blockade depends on what?
|
gradual diffusion
redistrubution metabolism excretion |
|
|
The primary use of what class of drugs is reversal of NMBDs?
|
anticholinesterases
|
|
|
How do reversal (NMBDs) agents work?
|
they inhibit Acetylcholinesterase, increasing the AcH level (more to compete), reestablishing neurotransmission
|
|
|
Which NMBD med do we not reverse, and why?
|
Succinylcholine because it will intensify the block
|
|
|
Bradycardia, bronchospasm, N/V can all result from reversal of:
|
NMBDs
|
|
|
What class of med do we give with anticholinesterases?
|
anticholinergics
|
|
|
Why do we give anticholinergics with anticholinesterases?
|
to avert the s/s like bradycardia, bronchospasm
|
|
|
What class of meds contains atropine and glycopyrolate?
|
Anticholinergics
|
|
|
Which anticholinergic has quickest onset?
|
Atropine
|
|
|
What do we base our reversal of NMBD on?
|
Patient status and
twitch count |
|
|
What drug is used for treatment of anticholinergic toxicity?
|
physostigmine
|
|
|
For every mg of Neostigmine you give, how much glycopyrolate would you give?
|
0.2mg
(dose for neostigmine is 0.03mg/kg) |
|
|
What effect does anticholinesterase overdose produce?
|
Weakness
|
|
|
For a reversal dose of 0.15-0.35 mg/kg pyridostigmine, how much glycopyrolate would you give?
|
0.05 mg per mg of pyridostigmine
|
|
|
For every mg of edrophonium, give how many mg of atropine?
|
0.014mg
|
|
|
Which cholinesterase inhibitor crosses the blood/brain barrier?
|
physostigmine
|
|
|
Miosis, salivation, bradycardia, weakness, seizures, and coma are s/s of what?
|
cholinergic syndrome
|
|
|
What causes cholinergic syndrome?
|
Excessive use of cholinesterase inhibitors
or organic insectides |
|
|
What is the drug/dose for cholinergic syndrome?
|
Atropine 35-70mcg/kg
|
|
|
Anticholinergic syndrome develops as a result of:
|
high doses of atropine and scopolamine
|
|
|
Benzodiazepines will cause the seizure threshold to do what?
|
Increase
|
|
|
What are the s/s of anticholinergic syndrome?
|
restlessness, delirium, tachycardia, flushed skin, hypotension
|
|
|
The drug/dose for treatment of anticholinergic syndrome is what?
|
Physostigmine 15-60mcg/kg IV
|
|
|
What is the name of the new med, not released yet that will reverse Rocuronium, specifically?
|
Sugammadex
|
|
|
What drug class contains all exogenous substances that bind to receptors to produce morphine-like effects?
|
Opioids
|
|
|
What are the two indications for opioid use in anesthesia practice?
|
Preop to blunt the SNS response to laryngoscopy
and postop for analgesia |
|
|
What is the pre-op opioid dose called?
|
The pre-emptive dose
|
|
|
What are the two naturally-occuring opium derivatives?
|
morphine and papaverine
|
|
|
Semisynthetic opioids include heroin and what two others?
|
Dilaudid and
Thebaine (precursor to oxy meds) |
|
|
Demerol, methadone, fentanyl, butorphanol and pentazocine are in what class of drugs?
|
Synthetic opioids
|
|
|
Which class of meds elicit a full morphine-like effect?
|
Opioid agonists
|
|
|
Agonist/antagonist or partial meds bind to mu receptors to produce what?
|
Partial, limited or no
analgesic effect |
|
|
Name two agonist/antagonist meds:
|
Nubain and Stadol
|
|
|
How do opioid antagonists work?
|
they bind to a receptor to block it
|
|
|
Which antagonists can be "knocked off" the receptor?
|
Competitive
|
|
|
What makes the non-competitive opioid antagonists have a strong effect?
|
are not easily displaced from receptor
|
|
|
In what 3 body areas are the opioid receptor sites?
|
brain, spinal cord and periphery
|
|
|
Where specifically on the spinal cord are the opioid receptors located?
|
In the substantial gelatinosa of the dorsal horn
|
|
|
What is the mechanism of action of opioids?
|
they block the transmission of pain by acting like agonists at the opioid receptors
|
|
|
Endogenously, what are the opioid receptors activated by?
|
endorphins, enkephalins, and dynorphins
|
|
|
Opioids mimic the actions of endogenous ligands by binding to the opioid receptor, activating what?
|
pain modulating systems
|
|
|
What is the principal effect of opioid receptor activation?
|
a decrease in presynaptic neurotransmitter release
|
|
|
What are the names of the opioid receptors?
|
Mu1, Mu2, delta and kappa
|
|
|
Our anesthesia and opioid meds primarily work on whcih receptors?
|
Mu1 and Mu2
|
|
|
Which of the receptors is primarily spinal (not supraspinal)?
|
Mu2
|
|
|
Euphoria, Miosis and decreased urine output are associated with which class of receptor?
|
Mu1
|
|
|
Which receptor is primary cause for repiratory depression?
|
Mu2
|
|
|
Which receptor is primarily stimulated by opioids?
|
Mu1
|
|
|
Physical dependence, marked constipation and bradycardia are most closely associated with which receptor?
|
Mu2
|
|
|
Which opioid receptors cause sedation and dysphoria?
|
Kappa
|
|
|
Which induction med acts on Kappa receptors?
|
Ketamine
|
|
|
Which receptor can cause some resp. depression and physical dependence but not as much as Mu2?
|
Delta
|
|
|
Where is the chemoreceptor (nausea/vomiting) trigger zone?
|
In the brainstem (the 4th ventricle)
|
|
|
What would you give if your patient developed acute opioid-induced biliary spasm?
|
glucagon or nitro
|
|
|
What kind of response to hypercapnia does opioid admin produce?
|
A decrease (the CO2 response is lessened)
|
|
|
What is the prototype opioid agonist?
|
Morphine
|
|
|
What does morphine cause a release of?
|
Histamine
|
|
|
What is the intraop dose of Morphine?
|
0.1- 1 mg/kg IV
|
|
|
What is the post-op IV dose of Morphine?
|
0.03-0.15 mg/kg IV
|
|
|
What are signs and symptoms of histamine release?
|
itching, hypotension, tachycardia, flushing
|
|
|
What are the 2 active metabolites of Morphine?
|
3-glucuronide and
6-glucuronide |
|
|
In what 2 patient populations would you use caution with the admin of Morphine?
|
asthma and renal failure
|
|
|
What is the IM post-op dose of Morphine?
|
0.05-0.2mg/kg IM
|
|
|
What was the 1st completely synthetic opioid?
|
demerol
|
|
|
What opioid can be used for post-op shivering?
|
demerol
|
|
|
What are the side effects of demerol?
|
tachycardia and
mydriasis (unique) |
|
|
What is the IV intraop dose of demerol?
|
0.2-0.5 mg/kg IV
|
|
|
Do not give demerol if the patient is taking what type of meds?
|
MAOIs - causes delerium, seizures and death
|
|
|
Demerol can be neurotoxic, causing
|
myoclonus and seizures
|
|
|
What is the brand name of Fentanyl?
|
Sublimaze
|
|
|
What is the intraop dose of fentanyl?
|
2-10mcg/kg IV
|
|
|
What is the post-op dose of fentanyl?
|
0.5-1.5 mcg/kg IV
|
|
|
What is an important but rare side effect of fentanyl?
|
chest wall rigidity
|
|
|
What is the dosage range of Fentanyl for cardiothoracic surgery?
|
30-50 mcg/kg IV
|
|
|
How is fentanyl supplied?
|
1ml equals 50mcg
|
|
|
Name an example of MAOI:
|
nardil
|
|
|
What is the "big momma" of opioids that is 10 times the potency of fentanyl?
|
sufentanyl
|
|
|
What is the intraop dose of sufentanyl?
|
0.2-0.8mcg/kg
|
|
|
What is the intraop dose of alfentanyl?
|
10-100 mcg/kg
|
|
|
Fentanyl is how many times stronger than morphine?
|
100 times stronger
|
|
|
What is the intraop cardiothoracic dose of Sufenta?
|
10-30 mcg/kg
|
|
|
Which opioid is best for long, painful cases (ie-tram flaps)?
|
Sufentanyl
|
|
|
Which two opioids are good for outpatient surgeries/ quick turnover?
|
Alfentanyl and
Remifentanyl |
|
|
Whcih opioid med has extremely rapid onset and recovery (15-30mins)
|
remifentanyl
|
|
|
Which opioid med has a similar potency to fentanyl?
|
remifentanyl
|
|
|
Opioids shift the CO2 curve in what direction?
|
Right
(it takes a higher CO2 to stimulate ventilation) |
|
|
A remifentanyl gtt can be good if you need to wake up a patient during the case. The dose is:
|
0.05-2 mcg/kg min
|
|
|
What is the IV intraop dose of remifentanyl?
|
1 mcg/kg slow push
|
|
|
What opioid agonist is good for cardiovascular stability?
|
Fentanyl
|
|
|
The IV opioid antagonist Narcan works how?
|
it blocks opioid receptors
|
|
|
What is the brand name of nalaxone?
|
Narcan
|
|
|
What can you use to reverse respiratory depression induced by opioids?
|
Narcan
|
|
|
Is Narcan a competitive or non competitive antagonist?
|
Competitive
|
|
|
A competitive antagonist can reverse unconsciousness while still maintaining what?
|
Analgesia
|
|
|
What is the peak and duration of IV narcan?
|
1-2 minutes
30-45 minutes |
|
|
Abrupt opioid reversal can cause excessive SNS stimulation, resulting in:
|
Vtach, MI, tachycardia, hypertension, N/V, pulm edema
|
|
|
What is the dosage and mix for Narcan admin?
|
Mix 1 amp (0.4mg) with 9ml NS. Give 1ml (40mcg) at a time.
|
|
|
What is the name of a PO opioid antagonist given to addicts?
|
Trexan (naltrexone)
|
|
|
"Partial agonists" are also known as what?
|
agonist-antagonists
|
|
|
What is the brand name for butorphanol?
|
Stadol
|
|
|
What is the IV dose of Stadol?
|
0.5-3 mg
|
|
|
What is the brand name of nalbuphine?
|
Nubain
|
|
|
What is the IV dose for Nubain?
|
5-10 mg
|
|
|
Which causes more sedation; stadol or nubain?
|
Stadol
|
|
|
Whcih partial antagonist will reverse resp. depression but sustain analgesia?
|
Nubain
|
|
|
What opioid med can be used for postop shivering (besides demerol)?
|
stadol
|
|
|
What is the IV dosage for romazicon?
|
0.2- 1mg
|
|
|
What partial opioid agonist can cause withdrawal symptoms in addicts?
|
Nubain
|
|
|
If a patient develops itching after epidural morphine, what can you give?
|
Nubain
|
|
|
Which partial agonist does not increase intrabiliary pressure?
|
Stadol
|
|
|
ALL muscle relaxants act where?
|
the neuromuscular junction
|
|
|
Succinylcholine recovery time is in minutes, whereas acetylcholine recovery is measured in what?
|
milliseconds
|
|
|
Non-depolarizing NMBDs occupy the AcH receptor sites, thereby doing what?
|
blocking the ach from binding
|
|
|
Succinylcholine (and acetylcholine) cause depolarization at the end plate, resulting in what?
|
muscle relaxation
|
|
|
What is the most reliable method for measuring the effects of NMBDs?
|
PNS (peripheral nerve stimulator)
|
|
|
What are the three things gauged by PNS?
|
onset, titration and reversal readiness
|
|
|
What is an alternative use of PNS?
|
locating/ verifying nerve blocks
|
|
|
What is the frequency, in hertz of PNS?
|
1 cycle/second
|
|
|
For abdominal surgery, maintain what TOF?
|
1 of 4
|
|
|
You must have at least how many twitches before reversal?
|
one twitch
|
|
|
The stimuli lines are longer when the response is what?
|
stronger
|
|
|
Whcih NMBD will elicit four of the same height twitches?
|
succinylcholine
|
|
|
100% Blockade will look like what (in regards to the patient)?
|
Flaccidity, no TOF, no repsonse at all
|
|
|
The twitches in TOF progressively do what as relaxation increases?
|
fade
|
|
|
A 75% blockade will result in __ of 4 twitches.
|
four
|
|
|
1 tiwtch of four on the TOF is about what percent blocked?
|
90%
|
|
|
Sustained contraction without fade indicates what?
|
adequate recovery from blockade
|
|
|
A tetanic stimulus will have how many stimulations per second?
|
50
|
|
|
A TOF stimulus applied after the tetanic stimulus produces:
|
a muscle response equal in intensity to the original
|
|
|
Tetanus means
|
a continuous stimulation
|
|
|
What type of block has no tetanic fade and no post-tetanic facilitation?
|
depolarizing block (suxx)
|
|
|
Non depolarizers result in what kind of reponse to tetanus?
|
poorly sustained
|
|
|
You will have positive post-tetanic facilitation with what type of block?
|
non-depolarizing
|
|
|
What are the four sites for PNS?
|
ulnar, facial, post-tibial,
mandibular. |
|
|
FARMS=
|
fentanyl (2-10mcg/kg)
alfentanyl (10-100mcg/kg) remifentanyl (1 mcg/kg) morphine (0.1-1mg/kg) sufentanyl (0.2-0.8 mcg/kg) |
|
|
VCRAMPS=
|
vecuronium (0.08-0.12 mg/kg)
cisatracurium (0.1-0.15mg/kg) rocuronium (0.6-1.2 mg/kg) atracurium (0.5 mg/kg) mivacurium (0.15-0.2 mg/kg) pancuronium (0.08-0.12 mg/kg) succinycholine (1-2 mg/kg) |
