Nurs614 - Exam 1 Nmba

Front 1

Non-Depolarizing
Antagonists

Back 1

Aminosteroids (Pancuronium, Vecuronium & Rocuronium);
Benzylisoquinolines (Doxacurium, Atracurium, Cis-Atracurium & Mivacurium)

Front 2

Factors contributing to prolonged effects of Succinylcholine

Back 2

Hypothermia,
Low Pseudocholinesterase
Pregnancy (causes dilutional effect),
Liver disease (it is made in liver),
Renal disease
Certain drugs
Genetic defect (Homozygous - prolongs block 4-8hrs & Heterozygous - about 55mins)

Front 3

Genetic prevalence of pseudocholinesterse defect

Back 3

Heterozygous - 1 in 50 people
Homozygous 1 in 3000

Front 4

CV Effects of Succinycholine

Back 4

Children:
Sinus Bradycardia
Junctional Rhythm
Sinus Arrest
Adults:
Tachycardia
Hypertension
Hyperkalemia

Front 5

Adverse effects of succinycholine

Back 5

Myalgia;
Increased ICP/IOP/IGP
Trismus
Malignant Hyperthermia
Histamine Release
Hyperkalemia

Front 6

Treatment of Hyperkalemia

Back 6

Calcium Chloride / Gluconate (gluconate has 3x as much as Ca chloride);
Insulin & Glucose; Hyperventilation;
Sodium Bicarbonate;
Beta 2 Agonist (Albuterol); Lasix;
Sodium Polystyrene Sulfonate (Kayexalate)

Front 7

Succinylcholine Contraindications

Back 7

Renal Disease, SCI, CVA, Immobility, Hyperkalemia,
Burns, Crush Injuries, Sepsis,
Acidosis,
Atypical Pseudocholinesterase,
MH, Children **** (ASA recommendation), icreased ICP/IOP.

Front 8

Characteristics of Non-Depolarizers?

Back 8

Quaternary Ammonium Groups;
Highly Ionized;
Water Soluble Compounds at Physiological pH;
Limited Lipid Solubility;
Do not Cross Lipid Membrane (BBB, Renal Tubular Epithelium, GI Epithelium,
Placenta);
No CNS Effects.

Front 9

Characteristics of Aminosteroids

Back 9

Vagolytic - (Pancuronium > Rocuronium > Vecuronium
No Histamine Release
Organ Dependent Elimination ( Kidneys & Liver)

Front 10

Characteristics of
Benzylisoquinolines

Back 10

Absence of Vagolytic Effect;
Histamine Release:
dTc (curare)> Atracurium > Mivacurium > Cisatracurium
Generally Organ-independent Elimination;
Non-cumulative;

Front 11

Characteristics of Non Depolarizing Muscle Relaxants

Back 11

Nicotinic Antagonist;
Muscle Relaxation Occurs When Receptors are 80-90% Blocked;

Front 12

Long Acting (> 60 Minutes)
NDMR

Back 12

Pancuronium, Doxacurium & d-Tubocurarine

Front 13

Intermediate Acting (30 – 45 Minutes) NDMR

Back 13

Atracurium, Cisatracurium, Rocuronium & Vecuronium

Front 14

Short Acting (12 – 20 Minutes) NDMR

Back 14

Mivacurium

Front 15

General Pharmacological Characteristics of NDMR

Back 15

Hypothermia (decreases metabolism by decreasing enzymes activity in the liver);
pH
Hypokalemia / Hypocalcemia / Hypermagnesemia - augments the block;
Age;
Drugs (IA, dantrolene, myacins potentiate)
Dilatin causes resistance to ND blocking action);
Diseases;
Up & Down Regulation

Front 16

Pancuronium (Pavulon)- characteristics

Back 16

Long Acting Aminosteroid;
Dose:
Intubating = .12 mg / kg
2-3 mins for intubating conditions;
Maintenance dose -0.01 - 0.04 mg / kg (may use infusion).
Metabolism / Excretion -
Liver / Renal to Active Metabolite = Muscle Relaxation
Increase HR, BP & CO;
Vagal Blockade / Sympathetic Stimulation.

Front 17

Vecuronium (Norcuron)- characteristics

Back 17

Intermediate Acting Aminosteroid;
Dose:
Intubating: 0.12 mg /kg
Maintenance: 0.01 to 0.04 mg / kg (may use infusion or give bolus based on twitches and duration time).
Metabolism / Excretion -
Liver / Biliary & Renal.
Will accumulate with infusion b/c of active metabolite which will augment block.
Devoid of CV Effects.

Front 18

Rocuronium (Zemuron)- characteristics

Back 18

Intermediate Acting Aminosteroid;
Dose:
Normal Intubation: 0.6 mg / kg;
RSI 1.2 mg / kg;
Maintenance: 0.15 mg /kg;
Infusions 5- 12 mcg/kg/min;
Duration with RSI dose 60-90mins.
Metabolism / Excretion - No Metabolism;
Excreted Unchanged via Bile / Urine / Feces.

Front 19

Doxacurium (Neuromax)

Back 19

Long Acting Benzylisoquinoline
Dose:
Intubating: 0.05-0.07 mg/kg (intubating conditions in 5mins);
Maintenance: 0.005 mg/kg
Metabolism / Excretion -
Slow Hydrolysis – Pseudocholinesterase.
Long duration of action -
Very Limited Clinical Use

Front 20

Atracurium (Tracrium)

Back 20

Intermediate Acting Benzylisoquinoline;
Dose:
Intubating: 0.5 mg/kg (Inject slowly to decrease histamine release – Intubate in 3-5 min.);
Maintenance: 0.1 - 0.25 mg / kg
Infusion: 5-10 mcg/kg/min. Good for infusion b/c of metabolism;
Metabolism / Excretion -
Ester Hydrolysis: Nonspecific Esterases & Hofmann Elimination - Nonenzymatic Chemical Breakdown That Occurs At physiological pH and Temperature.
Metabolite: Laudanosine
Histamine release --> Bronchospasm, increase SVR, HR & Allergic Reactions.

Front 21

Cisatracurium (Nimbex)

Back 21

Intermediate Acting Benzylisoquinoline;
Dose:Intubating:0.1-0.15 mg/kg (intubation conditions in 2 min).
Infusion: 1 – 2 mcg/kg/min (No Accumulation)
Metabolism / Excretion -
Hofmann Elimination.
Active Metabolite - Laudanosine

Front 22

Mivacurium (Mivacron)

Back 22

Short Acting Benzylisoquinoline
Dose: Intubating: .15 - .2 mg/kg (Intubating conditions in 2–3 mins);
Infusion: 4 – 10 mcg/kg/min(No Accumulation);
Metabolism / Excretion -
Pseudocholinesterase;
BOLO: For Pseudocholinesterase Deficiency.
Histamine release --> increased BP/hHR & Bronchospasm.

Front 23

Endogenous Esterases

Back 23

Acetylcholinesterase,
Pseudocholinesterase &
Nonspecific Plasma Esterases

Front 24

Action of AChEI at the NMJ

Back 24

Accelerate Reversal of NDMR activity by inhibiting AChE --> increase ACh concentration at NMJ

Front 25

Cholinesterase Inhibitors have Effects at All Cholinergic Receptors.
What are their CV effects?

Back 25

CV - Dec HR, causes dsrhythmias.

Front 26

Pulmonary effects of Cholinesterase Inhibitors

Back 26

Bronchospasm,
Increased Bronchial Secretions

Front 27

CNS effects of Cholinesterase Inhibitors

Back 27

Diffuse Excitation

Front 28

Action of Anticholinergics Anitmuscarinic

Back 28

Antagonism Of Cholinergic Stimuli At Muscarinic Receptors With Little To No Effect At Nicotinic Receptors.
Competitively Blocks Muscarinic Receptors

Front 29

Pharmacologic Characteristics of Anticholinergics Anitmuscarinic

Back 29

Tachycardia (atropine > glycopyrrolate > scopolamine);
Bronchdilation (moderate effects with atropine & glycopyrrolate, mild with scopolamine);
Sedation (high with scopolamine, slight with atropine, none with glycopyrrolate);
Antisialagogue (equally effective with glycopyrrolate & scopolamine. Moderate effects with atropine).

Front 30

NEOSTIGMINE - dose, onset, duration & recommended anticholinergic

Back 30

0.04 - 0.08 mg / kg;
5-10 minutes;
45-90 minutes;
Glycopyrrolate - 0.2 mg per 1 mg Neostigmine

Front 31

EDROPHONIUM - dose, onset, duration of action and recommended anticholinergic

Back 31

0.5-1.0 mg/Kg;
Within 5 Minutes;
30-60 Mins;
Atropine - 0.014 mg per 1 mg Edrophonium

Front 32

PYRIDOSTIGMINE - dose, onset, duration of action and recommended anticholinergic

Back 32

0.1-0.4 mg/kg;
10-20 minutes;
60-120 minutes;
Glycopyrrolate - 0.05 mg per 1 mg Pyridostigmine

Front 33

What test determines pseudocholinesterase abnormality?

Back 33

The Dibucaine test.
Dibucaine number of 80% = normal, 40-60%=heterozygous, 20%=homozygous.
Dibucaine number represents the quality of the Pseudocholinesterase NOT QUANTITY.