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