Neuromuscular Blockers and Reversal NRAN 80424 Spring 2024
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Questions and Answers

What is the recommended train-of-four ratio before extubation to reduce residual neuromuscular blockade?

  • 0.9 (correct)
  • 0.1
  • 0.5
  • 1.2
  • In which range of train-of-four ratio is Neostigmine considered a reasonable alternative for antagonism?

  • 0.4 to less than 0.9 (correct)
  • 0.9 to 1.2
  • 1.0 to 1.5
  • 0.1 to 0.3
  • What type of recovery in the train-of-four ratio indicates patients do not require pharmacological antagonism?

  • Exactly 1.0
  • Less than 0.4
  • Greater than or equal to 0.9 (correct)
  • Between 0.5 and 0.8
  • Where is quantitative neuromuscular monitoring recommended as per the guideline?

    <p>Adductor pollicis (D)</p> Signup and view all the answers

    Which type of neuromuscular block can Sugammadex be used for according to the guideline?

    <p>Deep, moderate, and shallow (B)</p> Signup and view all the answers

    Why is monitoring succinylcholine block unique compared to other neuromuscular blockers?

    <p>It does not demonstrate post-tetanic facilitation (A)</p> Signup and view all the answers

    Which neuromuscular blocker is a known trigger for malignant hyperthermia?

    <p>Succinylcholine (B)</p> Signup and view all the answers

    What may result from an increase in 'immature' forms of nicotinic acetylcholine receptors following administration of a depolarizing neuromuscular blocker?

    <p>Excessive potassium release (A)</p> Signup and view all the answers

    Why is the routine use of succinylcholine in otherwise healthy children contraindicated?

    <p>It is a trigger for malignant hyperthermia (A)</p> Signup and view all the answers

    Which patients are more likely to experience partial paralysis according to the text?

    <p>Patients with kidney failure (C)</p> Signup and view all the answers

    What is associated with the prolonged use of neuromuscular blockers in the ICU?

    <p>Critical Illness Polyneuropathy (CIP) (B)</p> Signup and view all the answers

    What should be used when neuromuscular blockade is necessary in the ICU?

    <p>Neuromuscular monitoring (B)</p> Signup and view all the answers

    Are adequate intubating conditions usually attainable without the use of neuromuscular blockers?

    <p>Yes, but not always (D)</p> Signup and view all the answers

    What does the presence of fade with repetitive stimulation indicate in monitoring non-depolarizing block?

    <p>Decreased potency (A)</p> Signup and view all the answers

    How do volatile anesthetics affect neuromuscular blockers?

    <p>Prolong the effect of blockers (A)</p> Signup and view all the answers

    Why is clinical assessment of recovery from neuromuscular blockade considered unreliable?

    <p>It predisposes to residual paralysis (B)</p> Signup and view all the answers

    What happens when an anticholinesterase is used to antagonize non-depolarizing neuromuscular blockers?

    <p>Increased levels of ACh at the NMJ (A)</p> Signup and view all the answers

    What is the purpose of pairing anticholinesterases with antimuscarinics for reversal of neuromuscular blockade?

    <p>To prevent unwanted muscarinic effects (A)</p> Signup and view all the answers

    Why does using a nerve stimulator alone increase the likelihood of residual paralysis?

    <p>It lacks objective measurement leading to underestimation (D)</p> Signup and view all the answers

    What is the primary mechanism of action of succinylcholine at the neuromuscular junction?

    <p>Stimulation of nACh receptors (C)</p> Signup and view all the answers

    Which type of blockade is most likely to occur with a large bolus dose of succinylcholine?

    <p>Phase II block (C)</p> Signup and view all the answers

    What is the primary factor contributing to the duration of action of succinylcholine?

    <p>Presence of pseudocholinesterase (D)</p> Signup and view all the answers

    In which type of muscle would one primarily find the expression of ε receptors?

    <p>Innervated muscle (B)</p> Signup and view all the answers

    Which condition is primarily associated with an increase in immature α7 nicotinic Ach receptors?

    <p>Sepsis (D)</p> Signup and view all the answers

    What is the primary effect of upregulation of immature receptor types on non-depolarizing neuromuscular blockers?

    <p>Increased sensitivity (C)</p> Signup and view all the answers

    Resistance to succinylcholine is primarily associated with which type of receptor regulation?

    <p>'Denervated' muscle (C)</p> Signup and view all the answers

    Which drug metabolism process occurs en route to and after diffusion away from the neuromuscular junction?

    <p>Metabolism by pseudocholinesterase (D)</p> Signup and view all the answers

    Study Notes

    Neuromuscular Blockers and Reversal

    • The 2023 ASA Practice Guidelines provide evidence-based recommendations for managing neuromuscular monitoring and antagonism of neuromuscular blocking agents.
    • The objective is to enhance patient safety by reducing residual neuromuscular blockade.

    Neuromuscular Blockers Classification

    • Neuromuscular blockers are classified based on onset and duration of action.
    • Depolarizing neuromuscular blockers (e.g., succinylcholine) act like acetylcholine, opening a channel that allows Na+ influx and K+ efflux, resulting in depolarization of the postsynaptic membrane.
    • Non-depolarizing neuromuscular blockers (e.g., aminosteroids, isoquinoliniums) act via competitive antagonism of ACh binding to the NAChR.

    Succinylcholine

    • Succinylcholine results in the fastest onset with the least variability and shortest duration of the NMBs.
    • Monitoring of succinylcholine block reveals no fade on train-of-four monitoring and no post-tetanic facilitation.
    • Succinylcholine is a trigger for malignant hyperthermia, which may occur due to a mutation in the ryanodine receptor, resulting in excessive calcium release.

    Neuromuscular Blockade Monitoring

    • Neuromuscular monitoring should be used in the ICU when neuromuscular blockade is necessary.
    • Periodic return of muscle function should be allowed to prevent prolonged use of neuromuscular blockers.
    • Clinical assessment of recovery from neuromuscular blockade is unreliable and predisposes the patient to residual postoperative neuromuscular blockade and morbidity.

    Reversal of Neuromuscular Blockade

    • Anticholinesterases (e.g., neostigmine) increase ACh levels at the NMJ to compete with the NMB drug for the alpha subunit of the NAChR.
    • The selective relaxant binding agent (SRBA) sugammadex encapsulates and renders ineffective the aminosteroidal NMBs, particularly rocuronium and vecuronium.
    • Sugammadex changes the way we think about a difficult airway scenario, CICO, and certain neuromuscular disorders, as recovery from neuromuscular block with rocuronium and sugammadex may be more rapid than spontaneous recovery from succinylcholine.

    Importance of Reversal

    • Inadequate reversal of muscle relaxant at the conclusion of surgery has significant consequences for patients.
    • Prolonged use of neuromuscular blockade in the ICU is associated with multiple concerns, including myopathy, polyneuropathy, and the potential for hyperkalemic arrest following the use of succinylcholine for emergent reintubation.

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    Description

    This quiz covers the practice guidelines for monitoring and antagonism of neuromuscular blockade agents, focusing on evidence-based recommendations to enhance patient safety by reducing residual neuromuscular blockade. The content is based on the 2023 ASA Practice Guidelines.

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