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127 Cards in this Set
- Front
- Back
List the following in order of paralysis:diaphragm, eyelids, chest, extremities, abdominal muscles
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1. eyelids
2. extremities 3. chest 4. abdominal 6. diaphragm ** opposite is order of recovery |
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With TOF monitoring, what % block exists with 4 equal twitches without fade?
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Less than 70%
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IF monitoring TOF you find you have 4 twitches WITH fade-what % block do you have?
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70-75%
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Another name for Phase 1 block?
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depolarizing ( sux)
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Another name for phase 2 block?
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Nondepolarizing block
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Why does sux work top down?
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Cardiac output delivers drug to head areas first
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Which kind of block has:
*fasciculations prior to NMB *no fade to tetanic stim *no posttetanic stimulation |
Phase 1 block
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Which kind of block has:
* no muscle fasciculation *tetanic fade TOF and DBS fade |
Phase 2 block
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Which kind of NMB can be potentiated by anticholinesterase drugs?
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depolarizers ( sux)
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Which kind of NMB can be reversed by anticholinesterase drugs?
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nondepolarizers
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Can sux ever produce a phase 2 block?
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Yes-rare, but overdose >6 mg/kg
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Which is considered the gold standard for NMB recovery?
A. vital capacity B. NIF C. Head lift D. sustained tetanus |
C
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How is succinylchoine metabolized?
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pseudocholinesterase
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Renal failure is a contraindication to the use of sux. T or F?
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False-if pt is dialyzed and has nl K, it is OK- it is the K level that is the contraindication
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Which of the following are contraindications to the use of sux?
A. MH B. hyperkalemia C. muscle trauma D. Burns E. muscular dystrophy |
All are correct
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What are the 2 chemical classes of nondepolarizing NMBs?
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1. benzylisoquinolines
2. Steroidal |
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The major disadvantage of atracurium?
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Histamine release
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Why do all nondepolarizing NMBs have no CNS effects?
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they are quaternary ammonium compounds-they are always ionized, so they cant cross BBB (or placenta)
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Why are nondepolarizing NMBs given IV only?
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100% ionized all the time, so they can't be absorbed from GI
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Which nondepolarizer should you not give to a pt with renal disease?
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Pavulon (Pancuronium) -excreted by kidney (85%) & 15% by the liver
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Which nondepolarizer can you not give to pt. with liver disease?
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Roc (>70%), Vec (30-40%)-excreted by the liver
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Which muscle relaxant should you not give to pt with atypical cholinesterase?
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Sux
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What are the two chemical classes of nondepolarizing NMBs?
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benzylisoquinolones
steroidal |
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What are the 2 general classes of NMB's?
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depolarizing
nondepolarizing |
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Single twitch is?
strength of current? |
single supramaximal stimulus
.1-1.0 Hz |
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Which nerve stim test, test for a series of 4 twitches at 2Hz, every 1/2 sec for 2 sec.?
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TOF
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tetanus stim test is at what strength for how long?
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30, 50 or 100 Hz for 5 sec. (use sparingly-very painful)
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which nerve stim test is easier to detect fade?
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DBS
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Which nerve stim test is 2 short bursts of 50 Hz separated by .75 sec?
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DBS
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Onset time is defined as?
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time from admin of drug to when it hits maximum effect
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Clinical duration is defined as?
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time from admin to 25%recovery of twitch response
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What % paralyzed is the pt when 25% of recovery of twitch response is present?
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75%
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Recovery index is defined as?
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time from 25%-75% recovery of twitch response
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TOF ratio is what?
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Comparison of 4th twitch of TOF with the 1st twitch
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What is an indicator of recovery with the TOF test?
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when TOF ratio is .9 ( in other words, 4th twitch is 90% of the first)
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Which muscle is most sensitive to test for onset of NMB?
A. adductor pollicis B. orbicularis oculi C. facial nerve |
B
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Which muscle is most sensitive to test for recovery of NMB?
A. Adductor pollicis B. orbicularis Oculi C. Facial nerve |
A
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Which electrode should be placed over the nerve: positive or negative?
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negative (it is a negative experience to be shocked)
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List the following in order of paralysis:
diaphragm, chest, eyelids, extremities, abdominal muscles |
1. eyelids
2. extremities 3. Chest 4. abd. muscles 5. diaphragm |
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List the following in order of recovery from NMB: diaphragm, eyelids, extremities, chest, adbominal muscles
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1. diaphragm
2. abd. muscles 3. chest 4. extremities 5. eyelids |
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0 twitch response means you are what % blocked?
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100%
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1 twitch response means what % blocked?
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90-95%
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2 twitch responses mean what % blockade?
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80-85%
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3 twitch responses means what % blockade?
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75-80%
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4 twitches means what % is blocked if TOFR is < 90%
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70-75%
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4 twitches with TOFR of 90% or greater means how much % blocked?
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70% or less
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Which kind of NMB produces a Phase 1 block?
A. nondepolarizer B. depolarizer |
B
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Which type of NMB normally produces phase 2 block?
A. nondepolarizer B. depolarizer |
A
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Which of the following are signs of Phase 1 block?
A. fasciculations B. TOF or DBS fade C. lack of DBS or TOF fade D. potentiation by anticholinesterase drugs |
A, C, D
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Which of the following is characteristic of Phase 2 block?
A. fasciculations B. TOF or DBS fade C. reversal with anticholinesterase drugs D. sustained response to tetanic stim |
B, C
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How is sux metabolized?
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pseudocholinesterase
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What is the name of the test used to dx atypical PseudoCholinesterase?
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Dibucaine number test or dibucaine challenge test
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What is a normal Dibucaine number?
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80
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What two things does a Dibucaine test report?
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1. dibucaine #
2. what is the % of enzyme activity |
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A low Dibucaine number and normal activity will result in?
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atypical enzyme/prolonged apnea
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A normal Dibucaine # and low % activity will result in?
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normal enzyme with low levels/prolonged apnea
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A low Dibucaine # + low activity will result in?
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atypical enzyme/prolonged apnea
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A normal Dibucaine # and normal activity will result in?
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normal enzyme and mat.( In other words, there is some other reason your pt is not breathing....)
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HOw much can sux elevate K+ levels?
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.5 meq
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Which of the following are side effects of sux?
A. masseter spasm B. MH C. decreased ICP D. myalgias E. elevated intragastric pressure F. ST depression |
A, B, D, E
(it also causes increased ICP and peaked T waves) |
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Masseter spasm is important why?
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precursor to MH
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Which of the following pts should not receive sux?
A. reanl failure pt who skipped dialysis B. pt with family hx of MH C. Pt with 3rd deg burn on 50% of body D. pt with CHI being emergently intubated |
None of them should!
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Matching: (drug to metabolism)
(pseudocholinesterase or non-specific esterases) a. Succ b. Neostigmine c. Edrophonium d. Atracurium e. Cisatracurium |
succ = pseudocholinesterase
Neostig = pseudocholin.... Edrophonium = pseudocholin.. Atracurium = non-specific est. Cisatracurium = non-specific.. |
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What two NMBs are metabolized by Hofmann elimination and nonspecific ester hydrolysis
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Atracurium and cisatracurium
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This NMB is metabolized predominately by non-specific ester hydrolysis and to a lesser extent hofmann elimination.
a. cisatracurium b. atracurium |
atracurium
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This NMB is metabolized predominately by hoffman elimination and to a lesser extent non-specific ester hydrolyis
a. cisatracurium b. atracurium |
cisatracurium
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how is rocuronium eliminated.
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> 70% liver
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What is the cardiovascular side effect (s) of Atracurium.
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cause histamine release therefore produce hypotension and tachycardia
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What is the cardiovascular side effect (s) of Pancuronium.
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is vagolytic and causes slight catecholamine release producing tachycardia
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What are the cardiovascular side effects of Succinylcholine
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sudden abrupt bradycardia may result from "repeat dosing" in adults and any dose in children.
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what drugs possibly interact with NMBs.
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antibiotics, steroids, dantrolene, magnesium and lithium....
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which reversal drug has the shortest onset of action?
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Edrophonium
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which reversal drug has the longest onset of action?
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Neostigmine
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How do the reversals work?
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blocks cholinesterase, therefore Ach can't be metabolized and it builds up and competes with the relaxant at the receptor.
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What drug do you mix neostigmine with?
What drug do you mix edrophonium with? |
neostigmine = robinul
edrophonium = atropine |
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What enzyme is responsible for the synthesis of Ach
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cholineacytelases
: cholineactelases makes Ach & cholinesterase breaks it down. |
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you have a patient that you are unable to reverse at the end of the case, what do you do?
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sedate, ventilate and let it wear off.
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time from drug administration to maximum effect
a. Clinical duration b. onset time c. total duration of action d. recovery index |
onset time
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time from drug administration to 25% recovery of the twitch response
a. onset time b. clinical duration c. total duration of action d. recovery index |
clinical duration
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time from drug administration to 90% recovery of twitch response
a. onset time b. clinical duration c. total duration of action d. recovery index |
total duration of action
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time from 25% to 75% recovery of the twitch response
a. onset time b. clinical duration c. total duration of action d. recovery index |
Recovery index
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Which of the following nondepolarizing NMBs are metabolized by Hoffman elimination?
A. Vec B. cisatracurium C. Roc D. atracurium |
B, D
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Which of the following has histamine release?
A. atracurium B. cisatracurium |
A
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Muscle relaxants have no CNS effects and do not cross the BBB. Why?
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They are quartenary ammonium compounds, they have a + charge all teh time, so they are always ionized.
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What NMB would you not choose to give a pt with renal disease?
A. Pavulon B. Sux C. Vec D. Roc |
A, , C
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Which NMB would you not choose to give a pt with liver disease?
A. Roc B. Vec C. Sux D. cisatracurium |
A, B
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Which NMB would you not give to a pt with atypical cholinesterase?
A. Vec B. Roc C. Sux D. cisatracurium |
C
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Pancuronium is:
A. sympatholytic B. vagolytic C. parasympathomimetic D. indirect sympathomimetic |
B, D(causes slight catecholamine release)
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Which of the following drug interact with NMBs?
A. steroids B. antibiotics C. volatile agents D. Dantrolene E. lithium F. Magnesium |
All are correct
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Which anticholinergic agent is typically mixed with edrophonium?
A. Atropine B. glycopyrrolate |
A
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Which anticholinergic agent is typically mixed with neostigmine?
A. atropine B. glycopyrrolate |
B
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Which anticholinergic has the fastest onset and shortest duration?
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Edrophonium
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Which anticholinergic has the slower onset?
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neostigmine
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Which of the following are clinical signs of NMB recovery?
A. head lift/leg lift B. cough C. resp smooth, unlabored with adequate TV and rate D. VC of 15 ml/kg E. NIF of 25-35 cm H20 |
All are
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What is the "MAX" dose of Neostigmine
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5 mg
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What is the "MAX" dose of Edrophonium
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1 mg/kg
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Match TOF count to minutes to recovery of reversal of intermediate relaxants:
a. Only 1 response b. 2-3 responses c. 4th response 1. within 5 minutes 2. as long as 30 minutes 3. 4-5 minutes |
A. 2
B. 3 C. 1 |
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The brief duration of Sux is due to?
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Rapid hydrolysis in plasma by cholinesterase enzyme to inactive metabolites
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Sux is broken down by plasma cholinesterase to form what?
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Succinylmonocholine and Choline
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Sux is futher broken down from succinylmonocholine and choline to what? Still by plasma cholinesterase?
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Succinic Acid and choline
Yes, still by plasma cholinesterase |
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Suxs in the blood stream is broken down by?
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Plasma cholinesterase of pseudocholinesterase
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Sux is broken down in the neuromuscular synapse by what?
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Acetylcholinesterase
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What are the 2 types of cholinesterase in the body? Where are they found?
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Acetylcholinesterase- in synapse
Pseudocholinesterase - in plasma |
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Pseudocholinesterase is produced where?
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Liver - pts generally develop neuromuscular symptoms at about 60% of normal activity.
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What are the 4 esterase enzymes in the body.
Think "CRAP" |
Cholinesterase
RBC esterase Albumin esterase Paraoxonase |
|
HEALTH MODELS
The narrowest interpretation of health; people are physiologic systems; health is the absence of illness. |
Clinical model
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List ester local anesthetics that are broken down by pseudocholinesterase?
one "i" |
Cocaine
Procaine Chloroprocaine Tetracaine |
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Esmolol is an esterase dependant drug broken down by what esterase enzyme?
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RBC esterases
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Neostigmine and Edrophonium are broken down by what esterase enzyme?
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pseudocholinesterase
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True/False
Acetylcholinesterase and pseudocholinesterase are terms for ACh? The names just differentiate their location in the body? |
All true
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Esterase enzymes are metabolized by adding water, this process is referred to as?
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Hydrolysis
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True/False
Atypical cholinesterase enzyme is just considered a genetic difference in the cholinesterase enzyme? |
True, a pt with atypical enzyme is considered normal for their body, not a disease state. Counseling given once identified for future surgeries.
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Is it OK to give a patient with a severe burn sux in the first 24 hours?
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Yes, muscle damage in burn patients usually doesn't happen immediately. K+ doesn't rise for 24 hours.
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Fasciculations from sux cause what side effects?
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Myalgia, myoglobinemia, Increased intragastric pressure, ? increased ICP, increased intraocular pressure
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Can you give a patient with a muscle disorder a NDMB?
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Yes, increased sensitivity, consider decreasing dose, use nerve stimulator to evaluate response
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What are the 2 factors in Hoffman elimination that create the chemical reaction that causes molecule to break itself down?
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Change in pH and temperature
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According to Naglehout, what pH and temp does the body have to have to eliminate a drug by Hoffman elimination?
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Alive, regardless of the patient, will all break down the same.
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Prophylaxis against histamine release requires administration of both _____ and ______ receptor blockers?
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H1 (Benadryl) and H2 (Zantac, Pepcid)
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According to Naglehout, why don't you give more than 5mg of Neostigmine?
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5 mg provides 100% cholinesterase inhibition and you can't get more than 100%
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Neostigmine has an increased incidence of?
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PONV
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Glycopyrrolate may cause more or less initial tachycardia than atropine?
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less
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Why do we give Robinul with Neostigmine?
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Neostigmine builds up in the parasympathetic, causing vagal response, Robinul provides anti-muscarinic but still get nicotinic effects.
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What is the onset and duration time for Atracurium, Cisatracurium and Vecuronium?
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Onset 2-4 minutes
Duration 30-60 minutes |
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What is the onset and duration for Rocuronium?
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Onset 1-3 minutes
Duration 30-60 minutes |
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What is the onset and duration for succinylcholine?
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Onset 30-60 seconds
Duration 5-10 minutes |
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What are some factors that may prolong the action of the relaxants
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acid base and electrolyte status, temperature, age, drug interaction
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Potent drugs have a _______ onset and the less potent have a ______ onset secondary to the amount of drug used.
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potent = slower
less potent = quicker Higher numbers of drug molecules are able to attach to the neuromuscular junction quicker to create paralysis (have to give more of less potent so there is more available) |