Non-depolarizing Neuromuscular Blocking Agents

Transcription

1 Nn-deplarizing Neurmuscular Blcking Agents Based n Ottawa mngraphs (2009) * differences/similarities amng the nn-deplarizing neurmuscular blcking agents: Indicatin: All have same indicatins f facilitatin f endtracheal intubatin and skeletal muscle relaxatin during surgery r mechanical ventilatin Rcurnium als includes facilitatin f rapid sequence endtracheal intubatin Adistratin: IV direct: MD trained in anesthesilgy; RN can give reinfrcing dses. Ventilatr supprt, cardiac mnitring. Atracurium adister undiluted ver secnds Cisatracurium - adister undiluted ver 5-10 secnd Pancurnium - adister undiluted ver at least 60 secnds Rcurnium - adister undiluted r diluted in SWFI ver 5-15 secnds Vecurnium Recnstitute each 10 mg vial with 10 ml bacteristatic WFI, NS, D5W r SWFI t btain 1 mg/ml slutin undiluted ver secnds Infusin: Ventilatr supprt, cardiac mnitring. Atracurium (chamber) dilute t final f 0.2 mg/ml r 0.5 mg/ml. DO NOT GIVE IM Cisatracurium - dilute t final f 0.1 mg/ml r 0.4 mg/ml in D5W r NS Pancurnium (chamber) dilute in cmpatible slutin; titrate rate t patient respnse Rcurnium - dilute in cmpatible slutin t 0.5 mg/ml r 2 mg/ml Vecurnium further dilute in D5W, NS, RL r D5W-NS t mg/ml Ptential Adistratin Hazards CV bradycardia (A, C) tachycardia(a, P,R) hyptensin (A,C) transient rise in BP (P) arrhythmias (P-transient, R ) Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)

2 abnrmal ECG (R ) mild change in HR (V) change in systemic vascular resistance (V) change in cardiac index (V) change in BP (V) Skin reactins flushing (A,C) erythema(a) hives (A) rash (C, P,R) Salivatin if n antichlinergic premedicatin (P) Pulmnary wheezing (A) brnchspasm (A, C) Injectin site Pain(P) edema (R ) Antidte: antichlinesterase agents such as nestige, edrphnium r pyridstige, in cnjunctin with an antichlinergic agent such as atrpine r glycpyrrlate (A,C, P) Histae release unlikely fllwing usual dses (R,V) Dsage See specific mngraphs fr dses Mentins: Atracurium different dses if patient has been adistered isflurane/enflurane/sevflurane/desflurane cmpared t halthane/fllwing succinylchline/ patients with CV disease/ patients with allergies (histae release) Pancurnium Dse fr endtracheal intubatin included Rcurnium Dse fr endtracheal intubatin included Dse fr rapid sequence intubatin included Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)

3 Miscellaneus Atracurium prduces max N M blckade within 3-5 utes and lasts abut utes Cisatracurium prduct is hyptnic d nt adister int line f bld transfusin. Pancurnium nset 3 utes; duratin utes -increased duratin and intensity f effect when used with sme inhalatin anesthetics -cautin in patients with myasthenia gravis, debilitated states, renal impairment and hepatic insufficiency -effect ptentiated by hypkalemia and hypermagnesemia -safe fr use in malignant hyperthermia Rcurnium nset 1 ute; duratin 30 utes (t 25% recvery) after 0.6 mg/kg dse Vecurnium nset utes; duratin utes *Bedard M, Massictte A, Prasad S, editrs. The Ottawa Hspital Parenteral Drug Therapy Manual. 13 th ed. Ottawa; Infrmatin cllated by Carmen Bell, SDIS Drug Infrmatin Cnsultant, May 24, 2012 Select Tables Table 30-9 Nndeplarizing Neurmuscular Paralytic Agents Agent Rcurnium (intermediate/lng) Adult Intubating IV Dse 1 milligram/kg 1 3 Onset Duratin Cmments Tachycardia. Lnger duratin f actin makes it a secnd chice t succinylchline. Use if succinylchline cntraindicated. 15 Vecurnium (intermediate/lng) Atracurium (intermediate) milligram/kg milligram/kg (highdse prtcl) milligram/kg Prlnged recvery time in bese r elderly, r if there is hepatrenal dysfunctin. Hyptensin. Histae release. Brnchspasm. Vissers RJ, Danzl DF. Chapter 30. Tracheal Intubatin and Mechanical Ventilatin. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Tintinalli's Emergency Medicine: A Cmprehensive Study Guide. 7th ed. New Yrk: McGraw- Hill; Accessed March 25, Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)

4 Table 4-4. Selected Pharmaclgic Prperties f the Neurmuscular Relaxants Agent Intubatin dse (mg/kg) Average intubating time () Clinical duratin () Cmments Succinylchline Agent used fr rapid sequence intubatin. 1,2 Assciated with side effects such as exaggerated hyperkalemia in susceptible patients (> 24 hurs aftermajr burns and trauma, crush injury, denervatin, prlnged immbilizatin, paraplegia, hemiplegia, muscular dystrphy) and malignant hyperthermia. Elevates intracular, intracranial, and intragastric pressures. Rcurnium An alternative t succinylchline prvided there is n anticipated difficulty in intubatin. 4 Mivacurium Degraded by plasma chlinesterase. Releases histae. Vecurnium Cardivascular effects unlikely. Alternative t succinylchline. Cisatracurium Stereismer f atracurium. N cardivascular effects. Organ-independent eliatin. Atracurium Eliatin independent f liver and kidney. Releases histae. Pancurnium Tachycardia and sympathetic nervus system activatin. Inductin. In: Reichman EF, Simn RR, eds. Emergency Medicine Prcedures. New Yrk: McGraw-Hill; Accessed March 25, Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)

5 Table 5-2. Rapid Sequence Inductin Medicatins fr Specific Patient Prfiles Patient type Premedicatin* Inductin and paralysis "Nrmal adult" Vecurnium (0.01 mg/kg) Etmidate (0.3 mg/kg) r prpfl (1 2.5 mg/kg) r thipental (3 mg/kg) and succinylchline "Nrmal child" Vecurnium (0.01 mg/kg) and atrpine (0.02 mg/kg, dse 0.1 mg) Thipental (5 mg/kg) and succinylchline Asthma, adult Lidcaine (1.5 mg/kg) and atrpine (0.5 mg) Ketae (1 2 mg/kg) and succinylchline Asthma, child Lidcaine (1.5 mg/kg) and atrpine (0.02 mg, 0.1 mg) Ketae (1 2 mg/kg) and succinylchline Head injury, adult Vecurnium (0.01 mg/kg) and lidcaine (1.5 mg/kg) and fentanyl (3 5 g/kg) Etmidate (0.3 mg/kg) and succinylchline Head injury, child Vecurnium (0.01 mg/kg) and atrpine (0.02 mg/kg, 0.1 mg) and lidcaine (1.5 mg/kg) and fentanyl (3 5 g/kg) Thipental (5 mg/kg) and succinylchline Head injury, adult, hyptensive Vecurnium (0.01 mg/kg) and fentanyl (3 g/kg) and lidcaine (1.5 mg/kg) Etmidate (0.2 mg/kg) and succinylchline (1.5 mg/kg) Head injury, child, hyptensive Vecurnium (0.01 mg/kg) and atrpine (0.02 mg/kg, 0.1 mg) and lidcaine (1.5 mg/kg) and fentanyl (2 3 g/kg) Midazlam (0.15 mg/kg) r etmidate (0.3 mg/kg) and succinylchline Hyperkalemia r renal failure, adult Nne Etmidate (0.3 mg/kg) r prpfl ( mg/kg) r thipental (3 mg/kg) and rcurnium (0.6 mg/kg) r vecurnium (0.01 mg/kg) Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)

6 Table 5-2. Rapid Sequence Inductin Medicatins fr Specific Patient Prfiles Patient type Premedicatin* Inductin and paralysis Hyperkalemia r renal failure, child Nne Thipental (5 mg/kg) and rcurnium (0.6 mg/kg) r vecurnium (0.01 mg/kg) Status epilepticus, adult Nne Thipental (3 mg/kg) and succinylchline Status epilepticus, child Nne Thipental (5 mg/kg) and succinylchline Pregnancy Atrpine (0.5 mg) Ketae (1 2 mg/kg) and rcurnium (0.6 mg/kg) r vecurnium (0.01 mg/kg) Mrcc M, Reichman EF. Chapter 5. Ortracheal Intubatin. In: Reichman EF, Simn RR, eds. Emergency Medicine Prcedures. New Yrk: McGraw-Hill; Accessed March 25, Tables cllated by Carmen Bell, Drug Infrmatin Cnsultant; March 28, 2012 Saskatchewan Drug Infrmatin Service T: (SK); (Saskatn)