muscle relaxant dr najwa mansor 2013. muscle relaxant relaxant depolarizingnon-depolarizing...
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Muscle RelaxantMuscle Relaxant
DR NAJWA MANSORDR NAJWA MANSOR20132013
Muscle Muscle relaxant
Depolarizing Non-depolarizing
Aminosteroid“-uronium”
Benzyl isoquinoline“-urium”
Short: mivacurium
Intermediate: Atracurium
cisatracurium
Long:Curare, metocurine
doxacurium
Short: rapicuronium
Intermediate:Vecuroniumrocuronium
Long:Pancuroniumpipecuronium
reversalreversal
Factors
General considerations in General considerations in the use of muscle relaxantsthe use of muscle relaxants
Always be certain that you will able to maintain Always be certain that you will able to maintain airway before paralyzing them. airway before paralyzing them.
allow time for relaxation to develop before attempting allow time for relaxation to develop before attempting intubation. intubation.
The supplemental dose should be about 25% of the The supplemental dose should be about 25% of the initial dose.initial dose.
Never attempt to reverse the relaxation until at least Never attempt to reverse the relaxation until at least 15-20 minutes after the last dose of relaxant was 15-20 minutes after the last dose of relaxant was given. given.
Never extubate a patient until you are certain that the Never extubate a patient until you are certain that the paralysis has been reversed and they have adequate paralysis has been reversed and they have adequate muscle strength to protect their airway and breathe. muscle strength to protect their airway and breathe.
ensure that the depth of anaesthesia is adequateensure that the depth of anaesthesia is adequate
Thank you Thank you
PYSIOLOGY OF NEUROMUSCULAR
TRANSMISSION
NMJ
• Transmission of neural impulse at the nerve terminal translated into skeletal muscle contraction at motor end plate
Junction between the terminal of a motor neuron and a muscle fiber.
One kind of synapse. Also called myoneural
junction.
NEUROMUSCULAR NEUROMUSCULAR JUNCTIONJUNCTION
• When 2 Ach molecules bind simultaneously to 2 subunits – a channel opens thru the
center. • Allowing Na+ & Ca2+ tp
move into the muscle & K+ to move out.
AcethylcholinesteraseAcethylcholinesterase
• Synthesis in the muscle, under the end plate• Secreted from the muscle but remains attached
to it via thin stalk of collagen fastened to the basement membrane
• Destroy Ach that do not react immediately with receptor & that are released from binding sites.
• Ach is destroyed in < 1 ms after it is released.
Prevent sustained depolarization
Prevent tetany
• Most efficient enzyme known.– A single molecule has the capacity to
hydrolyze an estimated 300 000 molecules of Ach per minute.
INTRODUCTIONINTRODUCTION
BRIEF HISTORY PRINCIPLES OF
NEUROMUSCULAR TRANSMISSION
MUSCLE RELAXANT Ideal properties Indications & Contraindication Mechanism of action Side effect
Before neuromuscular blocking introduce: High concentration of inhalational anesthetic
agent Regional anesthesia
1942 curare (tubocurarine) introduce Less anesthetic administered
block neuromuscular transmission paralysis
presynaptically via the inhibition of acetylcholine (ACh) synthesis or release
postsynaptically at the acetylcholine receptor. adjunct to anesthesia to induce paralysis
not fully selective for the nicotinic ® and hence may have effects on muscarinic ®
Histamine release hypotension, flushing, and tachycardia.
! Important to realize that relaxant does not ensure unconsciousness, amnesia or analgesiaunconsciousness, amnesia or analgesia
BRIEF HISTORY OF BRIEF HISTORY OF NMBAsNMBAs •Curare- arrow poison by South American
Indian.
• 1932 – used in tetanus & spastic disorders (West)
• 1942 –1st used as muscle relaxant (Griffith & Johnson)
•Metocurine – few yrs later; 3x potency of dTC
•1949 - Sch independently described in
Italy, UK,USA
•1950 – Gallamine
•1961 – Alcuronium
•1967 – Pancuronium
•1972 – Fazadinium
•1980’s – Atracurium
– Vecuronium
•1938- Antagonism of curare by physostigmine (AChE). (Fetler et al) limited used d/t central effect
GallamineGallamine 1st synthetic NDMR after dTC. popularity d/t :
Mark CVS effect Potent vagal blockade Direct stimulating effect on ß1-receptor of
myocardium Both above lead to tachycardia + hypertension
Mainly excreated via kidney Contraindicated in ESRF & compromised renal f(x)
eg. Hypovolemia. Fat soluble++ Cross placenta
Contraindicated for LSCS
IDEAL PROPERTIES OF IDEAL PROPERTIES OF MUSCLE RELAXANT MUSCLE RELAXANT
Rapid onset (1 min)Rapid onset (1 min) To avoid hypoxia & aspiration of gastric contentTo avoid hypoxia & aspiration of gastric content
NondepolarizingNondepolarizing Predictable durationPredictable duration Easily antagonized, fully reversedEasily antagonized, fully reversed No drug interactionNo drug interaction Non-toxicNon-toxic Free of side effect eg. CVS, respiratoryFree of side effect eg. CVS, respiratory Stable pharmacokinetic and pharmacodynamic in Stable pharmacokinetic and pharmacodynamic in
the present of renal or hepatic diseasethe present of renal or hepatic disease No accumulationNo accumulation Safe in pregnancySafe in pregnancy
INDICATION OF NBAINDICATION OF NBA
To facilitate tracheal intubation Presence of residual
gastric content. Sch, rocuronium
To provide surgical relaxation To enable positive pressure
ventilation during & after
anesthesia Intensive care
unit
Sequence of Paralysis
orbicularis oculit
limbs Trunk Laryngeal muscle
IntercostalsDiaphragm
Recovery in Reverse
Thumb
DEPOLARIZING ACTION AT NMJ ( agonist )DEPOLARIZING ACTION AT NMJ ( agonist )
SuxamethoniumSuxamethonium
Suxamethonium chloride (also known as succinylcholine, or scoline) is a white crystalline substance, it is odourless and highly soluble in water. The compound consists of two acetylcholine molecules that are linked by their acetyl groups.
Administered IV, IM or SC agonists at nicotinic receptors activates prejunctional and endplate
receptors, resulting in depolarisation Causes muscle twitching and fasciculation,
which are followed by the onset of blockade Neuromuscular blockade is not complete until
~ 95% receptors occupied
Suxamethonium actionSuxamethonium action
2 succinylcholine molecules bind to the receptors in postsynaptic membrane
Depolarization- Fasciculation
Remains active at the endplate maintaining the depolarization
Preventing further muscle activity(paralysis)
Scoline –N ®
Sustained depolarization
depolarization
Opening of ion channel
hydrolyzed
paralysis
not
Dose 1 – 1.5 mg/kg
Onset 30 – 60 s
Duration
- 5 – 10 min
Half life 5 – 12 days
Metabolism
succinylcholine
plasma Pseudocholinesterases
succinylmonocholine + choline.
hydolyzed
succinic acid and choline
plasma Pseudocholinesterases Hydrolysis of scoline Rapid ate Extremely efficient
produce – liver Succinylcholine degraded in the serum but not in the
NMJ termination of action is then by dissociation &
diffusion, as there is no pseudocholinesterase at the endplate
Metabolism of SCh:
Elimination 10% is excreted unchanged in the urine. impaired renal function - prolonged apnoea
accumulation of succinylmonocholine
DNMB-SCh-duration of action
PLASMA CHOLINESTERASE ACTIVITY Elimination ½ life: 8-16 hours. Levels < 75% necessary for prolongation of Sch effect. Reduce/absent plasma cholinesterase in :
- Severe hepatic disease.- Drug induced – e.g: neostigmine, insecticides (anticholinesterase drugs), drugs for glaucoma and MG, nitrogen mustard & cyclophosphamide metoclopramide, high estrogen level.- Genetically determined.
Increase plasma cholinesterase in: - Obese pt. - Myasthenia Gravis (MG). - genetic inherited C5 isoenzyme - juvenile hyaline fibromatosis
SCh-duration of action
ATYPICAL PLASMA CHOLINESTERASE
Healthy patient who experiences prolonged NM blockade (1-3 hours) after conventional dose of SCh.
Dibucaine –related variant:
- Reflects quality of cholinesterase enzyme
- Patient with liver disease has normal dibucaine number.
Dibucaine test : a local anesthetic with amide linkage - inhibit activation of normal plasma cholinesterase enzyme –
If 80% atypical enzyme is 20%
NM blockade after SCh 1mg/kg iv persist >3 Hrs or longer
Dibucaine no. Plasma
cholinesterase
Neuromuscular
recovery
Incidence
80% Normal Normal 96%
40-60% Heterozygous
atypical
Moderate increase
1:480
20% Homozygous
atypical
Prolonged by hours
1:3200
Cardiac dysrhythmias cholinomimetic actions, acting at,
a. parasympathetic & sympathetic autonomic ganglia b. M2 receptors of the heart
Stimulate cardiac post gangflionic M ® Sinus brady, junctional rhythm,ventricular arrythmia
effects are variable, a. adults premedication with antimuscarinic drugs
® tachycardia and increased BP b. children
bradycardia or sinus arrest,
sinus bradycardia or a junctional rhythm
>> after a second dose ( after 5 minute first dose )
Pretreatment Atropine Subparalyzing dose of NDM
Muscle Pains
Fasciculations transient, generalized, unsynchronized
muscle contraction Skeletal muscle damage and myalgias neck, shoulder girdle and chest Reduce the incidence with a “precurarization” Young muscular adult, minor procedure with
early ambulation
Hyperkalaemia
increase in serum [K+] ~ 0.5 mmol/l Hyperkalaemic response secondary to
proliferation of extrajunctional R More ion channels being open More site for pottasium leakage R remain open longer
No benefit of priming
a. denervation
b. burns -most common causes
c. major trauma
d. neurologic disease & trauma
e. severe sepsis
f. renal failure‡
g. cerebrovascular accidents
Extra Junctional Cholinergic ReceptorExtra Junctional Cholinergic Receptor Located throughout skeletal muscle membrane Normally not present in large number Synthesis is suppressed by neural activity Min. involvement in neural act-y proliferate rapidly
motor less active due to trauma ms denervation
Highly responsive to agonist – Ach/Sch
Within 24 h
it may persist for 2-3 months following burns up to 6 months following neurological lesions
renal failure- normokalaemic safely received scoline (lack of reliance on renal excretion)
Transient increase of IOP Contraction of extraocular muscle 2 – 4 min after admin. open eye inj
Increase in intragastric pressure Fasciculation of abdominal skeletal muscle Risk of aspiration
Transient increase ICP Masseter muscle spasm
Trismus ?? Malignant hyperthermia
Suxamethonium Apnoea prolonged apnoea may result from,
a. plasma cholinesterase deficiency
- acquired
- congenital
b. phase II block
c. drug interactions
Acquired Enzyme Deficiency
a. patients with acute or chronic liver diseases
b. malnutrition
c. pregnancy
d. collagen diseases
e. chronic anaemia
f. uraemia
g. myxedema
h. other chronic debilitating diseases
i. severe burns
j. chronic pesticide exposure & accidental poisoning
k. drugs
- chlorpromazine
- pancuronium, neostigmine
m.increased levels are found in obesity, type IV hyperlipoproteinaemia, nephrosis & toxic goitre
Malignant Hyperpyrexia
in genetically susceptible individuals ~ 70% elevated creatine phosphokinase
levels in the resting, fasted state determined by muscle biopsy studies masseter spasm occurs mainly in children
Malignant hyperthermia Presentation
Unexplained tachycardia
Tachypnoea in spont breathing pt
unresponsive to increased depth of anaesthesia
Ms rigidity Cardiac dysrhythmias ↓SpO2 and cyanosis end-tidal CO2 Labile blood pressure Metabolic acidosis
Immediate mx: Airway secured Hyperventilation with
100% oxygen All anaesthetic agents
stopped lowering of temperature sodium bicarbonate restoration of fluids,
adequate urinary output electrolyte balance IV Dantrolene Monitor vital signs Patient to be transfered
to ICU for continued monitoring
CONTRAINDICATION TO SUX
Drug interactions
2-Non depolarizing muscle relaxant Small doses of NDM antagonize DMR phase I block
by occupy some Ach R prevent depolarization by Succinylchol.
Except pancuronium,augment scoline block by inhibiting pseudocholenesterase.
NDM will potentiate phase II block Similarly succinylchol reduces NDM requirement for
at least 30 minutes
Bind to subunit in the same way that Ach does.
If bind to a pair of subunits stimulate an initial opening of ion channel producing a contraction known as fasciculation.
H/ever, this drugs are not broken down by acethylcholinesterase, they bind for longer period than Ach persistent depolarization of the end plate & neuromuscular block.
NDMRs compete with Ach to bind to subunit.
Attachment to subunit doesn’t open the ion channel so no current will flow thru the channel.
Membrane will not depolarize muscle become flaccid
DEPOLARIZING MUSCLE RELAXANTDEPOLARIZING MUSCLE RELAXANT NONDEPOLARIZING MUSCLE RELAXANT
Patterns of Neuromuscular Blockade
Depolarising Block
fasciculations preceding paralysis
absence of tetanic fade at slow and fast rates
no post-tetanic potentiation potentiation by anti-AChE
agents potentiation by depolarising
relaxants antagonism by
nondepolarising relaxants
Nondepolarising Block
no muscle fasciculation
tetanic fade, with train of four (0.5-2 Hz)
post-tetanic potentiation antagonism by anti-AChE
agents antagonism by depolarising
relaxants potentiation by
nondepolarising relaxants
Phase IMembrane depolarizes resulting in an initial discharge which produces transient fasciculations followed by flaccid paralysis
Phase II Membrane repolarizes
but receptor is desensitized
Phase II or Dual Block
phase II blockade occurs more commonly in patients either
a. given repeated doses of depolarising agents
b. with atypical plasma cholinesterase activity
c. with myasthenia gravis, or myasthenia-like syndromes
Muscle RelaxantsMuscle Relaxants
2 CLASSIFICATION
Steroidal CompoundsPancuroniumPipecuroniumVecuroniumRocuronium
Benzylisoquinolinium Compoundsd-TubocurarineMetocurineDoxacuriumAtracuriumMivacurium
Trisquaternary etherGallamine
duration of action
Long-acting–Pancuronium–Doxacurium –Pipecuronium
Intermediate-acting–Atracurium–Vecuronium–Rocuronium–Cisatracurium
Short-acting–Mivacurium
Rapid onset, short acting–Rapacuronium
By chemical structure
NON DEPOLARIZING NON DEPOLARIZING M. RELAXANTSM. RELAXANTS
- Do not cause depolarization
- Competes with Ach for postsynaptic receptors
- Competitively inhibit Ach stimulating the receptors at the motor end plate
- Block prejunctional Ach receptors: decrease Ach release
• Slower time of onset• Longer duration of action• Used- following Suxamethanium to maintain
relaxation during surgery- to facilitate tracheal intubation in non-
urgent situation• Onset decreased by
– Large dose– Priming principle
Non-depolarising m.relaxants generalNon-depolarising m.relaxants general
Priming principle
• Admin 10-20 % intubation dose of NDM 5 min before induction
• Not lead to clinically significant paralysis (safety margin for transmission and blockade is not
seen until > 70% receptor occupancy)– Some pt do
• Dyspnea or dysphagia
• Significant decrease resp fx ( FVC)– Desaturation---marginal pulmonary reserve
• Small dose binds a certain no. of spare ®
• Second larger dose----speed of onset
Generally not actively metabolized by the liver (although some of the steroidal muscle relaxants are an exception).
Reasons:
i. Water solubility of relaxants inhibits uptake into hepatocytes
ii. Cytochrome P-450 oxidative enzyme system in liver microsomes requires lipophilic substrates, generally excluding the relatively hydrophilic muscle relaxants.
All muscle relaxants are highly water soluble and hydrophilic.
Reason:i. +ve charges, which give muscle
relaxants the physicochemical properties of cations in watery media such as the plasma and urine
ii. Various oxygen-bearing groups Ester linkages of Sch &
atracurium Acetate groups of
pancuronium, vecuronium & rocuronium
Molecular Features & Molecular Features & Physicochemical Properties…Physicochemical Properties…
PHARMACOKINETICSPHARMACOKINETICSBecause of their quaternary ammonium groups, these agents:
almost completely ionized at physiological pH highly water soluble very low lipid soluble
They tend to be, poor GIT absorption
Oral absorption is not effective. resistant to hepatic metabolism (steroids excluded) low volumes of distribution
Similar to ECV ~ 200 mls/kg If Vd ↓, the same dose of drug produces a higher plasma [ ] &
apparent potensy of the drugs augmented. Dehydration Acute haemorrhage
poor BBB penetration (CNS) No CNS effects
Placenta – fetus not affected
Long actingTubocurarine (Curare, d-tubocurarine)
South American plant genus Strychnos
• 3-5 minutes to act • lasts for 30-40 minutes. • 0.3-0.6 mg/kg• hypotension - histamine
- blocking autonomic ganglia
• Bronchospasm
• Route of excretion in the urine.
LONG-ACTING NONDEPOLARIZING NMB
PANCURONIUM
INTRODUCTION• Bisquaternary aminosteroid.
• ED95: 0.07mg/kg.
• Onset: 3 – 5 min.• Duration: 60 – 90 min.
MOLECULAR STRUCTUREPANCURONIUM
PANCURONIUM –clearance
• 10 – 40% of dose of pancuronium undergoes hepatic diacetylation produce:i. 3 – desacetylpancuronium – 50% potent as pancuronium.ii. 17 – desacetylpancuronium.iii. 3,17 – desacetylpancuronium. minimal activity
• Pt with total biliary obstruction, hepatic obstruction : will have- Increase Vd ( Large initial dose required but prolonged action because of decrease plasma clearance)- Prolonged elimination ½ time of pancuronium.
Aging: in elderly, decreased in plasma clearance (reduce renal fn) – prolonged elimination half time of drug hence duration of neuromuscular blockade prolonged.
PANCURONIUM
CLEARANCE
• 80% of single dose of pancuronium is eliminated unchanged in urine.
• Renal failure: plasma clearance is decreased 33 – 55%. As a result-prolonged elimination half time
Normal hepatic fn
cirrhosis
Vol.of distribution (Vd)-ml/kg 279 416
Clearance –ml/kg/min 1.9 1.5
Elimination half time-min 114 208
Pharmacokinetic and hepatic dysfunction
PANCURONIUM
CVS EFFECTS• 10 – 15% increase in heart rate, cardiac o/put due to:
- Selective cardiac vagal blockade.- Activation of sympathetic nervous system.Mechanism:
i. Release of NE from adrenergic nerve endings.ii. Blockade of uptake of NE back into postganglionic nerve endings.
iii. Release of NE from muscarinic receptor inhibition • Increase plasma concentration of catecholamines.
PANCURONIUM –cvs effect
• increased in BP due to effect of increased heart rate on cardiac output.
• increase incidence of cardiac dysrhythmias - in pt with digitalis
• may increase MI incidence in patient with CAD.• No histamine release.• No autonomic ganglion blockade
Doxacurium
• a new benzylisoquinoline ester
• very potent, long lasting relaxant
• ~ 2x as potent as pancuronium
• no histamine release / CVS effects
• excreted - kidney & bile
Pipercuronium
• similar potency & duration to pancuronium
• excreted principally through the kidney & bile
• duration of action is similarly prolonged in renal and hepatic insufficiency, and in the elderly
• elimination half life, t½ ~ 100 min
• Intermediate-acting– Atracurium– Vecuronium– Rocuronium– Cisatracurium
• Minimal cumulative effects as infusion d2 rapid clearance
• Lack of CV effects• Higher cost
ATRACURIUM
INTRODUCTION• Bisquaternary benzylisoquinolones
• ED95 : 0.2 mg/kg
• Onset: 3 – 5 min
• Duration: 20 – 35 min
• 82 % bound to plasma proteins, presumably albumin
• Undergo spontaneous Hoffmann elimination at normal body temperature and pH
• Iodide salt besylate:
- Provides water solubility
- Adjust the pH of 3.25 – 3.65, minimizes the likelihood of
spontaneous degradation
Should not mixed with alkaline drugs (barbiturates)
INTERMEDIATE ACTING NONDEPOLARISING NMB
ATRACURIUM
CLEARANCE
• 2 processes:i. base-catalysed reaction: Hofmann elimination.ii. hydrolysis by non specific plasma esterases : ester hydrolisis
• Major metabolites of both pathways: - Laudanosine – not active at NMJ. - electrophilic acrylate – from Hoffman degradation• Routes of metabolism independent of:
- Hepatic function. - Renal function.- Plasma cholinesterase activity.
• Efficient clearance mechanism minimize cumulative effects.
METABOLISM OF ATRACURIUM
ATRACURIUM - clearance
LAUDANOSINE• Major metabolite. Each molecule of atracurium produce:
- Hofmann elimination: 2 molecules
- Ester hydrolysis: 1 molecule
• Peak plasma concentration: after 2 min
• Depends on liver for clearance, 70% excreted via bile
- Hepatic cirrhosis: clearance unaltered
- Biliary obstruction: impaired metabolite excretion
• CNS stimulant in animal studies (epileptiform)
ATRACURIUM -
ACID BASE CHANGES• pH alter rate of Hofmann elimination (accelerate by alkalosis, slowed
by acidosis)
• pH changes influence the rate of ester hydrolysis in a reduction opposite to the changes in the rate of Hofmann elimination.
CUMULATIVE EFFECT• Absence of significant cumulative drug is due to rapid clearance of
atracurium from plasma, that is independent of renal and hepatic function.
ATRACURIUM
CVS EFFECTS• 2X ED95: SBP and heart rate do not change.
3x ED95: Increase HR by 8.3%.
Reduce MAP by 21.5%
The effects is:
- Transient.
- Occuring 60 – 90 sec after administration.
- Disappear within 5 min.
Due to release of histamine.
Plasma histamine concentration must double before CVS changes
• Histamine release evoked by atracurium and mivacurium does not occur repeatedly because tissue histamine stores are not replenished for several days.
ATRACURIUM
PEDIATRIC PATIENT• Children (2 – 16 years old): ED95 as adult.
• Infants (1-6/12 old): One ½ dose given to older children.
• Recovery: infants is more rapid than adolescent.
ELDERLY PATIENT• Rate of recovery and duration of neuromuscular blockade is similar in
young adults and elderly.
• Changes in Vd that occur with aging will not influence clearance of atracurium from plasma.
INTERMEDIATE NONDEPOLARISING NMB
VECURONIUM
INTRODUCTION• Monoquaternary aminosteroid
• ED95: 0.05mg/kg
• Onset: 3 – 5 min
• Duration: 20 – 35 min
• Vecuronium = pancuronium w/out quaternary methyl group
• Absence of quaternary methyl group decreases the Ach-like character of pancuronium – reduce vagolytic property by 20 fold
• Increased lipid solubility due to monoquaternary structure
• Unstable in solution
MOLECULAR STRUCTURE
VECURONIUM
VECURONIUM
CLEARANCE• Hepatic metabolism and renal excretion.• Deacetylation (in liver) produce:
- 3-desacetylvecuronium: ½ potent as parent component.
- 17-desacetylvecuronium.
- 3,17-desacetylvecuronium.• 40% of drug excreted unchanged in bile in 1st 24 hours.• 30% of administered dose appeared in urine as unchanged drugs and
metabolites in 1st 24 hours.
<1/10 potent
VECURONIUM -clearance
RENAL DYSFUNCTION• Prolonged elimination half time – decrease clearance.
• Increase plasma concentration of 3-desacetylvecuronium may contribute to persistent skeletal muscle paralysis after prolonged infusion.
HEPATIC DYSFUNCTION• Smaller dose (0.1mg/kg) – elimination ½ time have no difference due to:
- Renal clearance.
- Diffusion of drug into inactive tissue.
• 0.2mg/kg – prolonged duration of action.
VECURONIUM
ACID BASE CHANGES• Depends on the changes in blood pH precede or follow the administration of
vecuronium.
eg: Changes in PaCO2 - before administration: no effect.
- after administration: enhance vecuronium effect.
CUMULATIVE EFFECTS• Less than pancuronium and greater from atracurium.
• Occur in renal failure patient:
- Gradual saturation of peripheral storage site.
- Accumulation of 3-desacetylvecuronium especially after repeated
doses.
VECURONIUM
CVS EFFECTS• No circulatory effects even with rapid IV administration of doses that exceed
ED95 x 3 - lack of vagolitic effect/histamine release
• Modest vagotonic effect
• Other effects that has been described: sinus node exit block and cardiac arrest
PEDIATRIC PATIENT• Potency of vecuronium is similar in all age group
• Onset rapid in infants – increase COP
• Duration of action:
Longest in infant due to: - Immature enzyme system of liver
- Increase Vd.
- Age related changes in biliary clearance
VECURONIUM
ELDERLY PATIENT• Age related decreased in liver blood flow and microsomal enzyme activity.
Age related decreased in renal blood flow.
*decrease plasma clearance - prolonged duration of action
• Delayed rate of recovery
OBSTETRIC PATIENT• Insufficient amount cross the placenta to produce clinical significant effect in the
fetus eg : maternal to fetal ratio of vecuronium 0.11
• Clearance of vecuronium may accelerated during late pregnancy:
- Stimulation of hepatic microsomal enzymes by progesterone.
- CVS changes.
- Fluid shift.
INTERMEDIATE NONDEPOLARISING NMB
ROCURONIUM
INTRODUCTION• Monoquaternary aminosteroid
• ED95: 0.3 mg/kg
• Onset: 1 – 2 min• Duration: 20 – 35 min• Structurally resembles vecuronium except for the presence of a
hydroxyl group
• 3 – 4x ED95 resembles the onset of action of SCh 1mg/kg IV – alternative of SCh if contraindicated
Disadvantages:i. Large doses may resembles long acting NDNMB (pancuronium) action.ii. Laryngeal adductor muscle & diaphram are more resistant to
Rocuronium compared to adductor pollicis as with other NDNMB.- Onset will be delayed compared to SCh.- Risk of pulmonary aspiration if diaphragm & laryngeal
muscles are not fully relaxed.
MOLECULAR STRUCTURE
ROCURONIUM
ROCURONIUM
CLEARANCE• Largely excreted unchange in the bile (~50% in 2Hr)• No deacetylation• Renal excretion > 30% in 24 hours• Renal failure patient – modestly prolonged duration of action• Liver failure patient – increased Vd: longer duration of action especially
after repeated dose/infusion• Elderly:
- Similar speed of onset- Prolonged duration of action
CVS EFFECT• May produce slight vagolytic effect• Useful in surgery that associated with vagal stimulation• Absence of histamine release
Short-acting
Mivacurium
• Onset 3 - 5 min
• Duration 10 – 20 min
• hydrolysed by plasma cholinesterase– slightly slower than succinylcholine
• cardiovascular effects are minimal
• rapid bolus injection of larger doses results in histamine release with,
i. transient facial erythema
ii. a brief fall in mean arterial pressure
Rapid onset, short acting
Rapacuronium
• Rapid onset and offset• Being withdrawn by manufacture due to
several reports of serious bronchospasm including unexplained fatalities
Histamine Release & Anaphylaxis
• Generic side-effect of the benzoisoquinoline ester agentsa. dTCb. atracuriumc. mivacurium d. doxacurium
• NB: most drugs administered IV release small amounts of histamine, which are pharmacologically insignificant 1ng/ml
• increases of 5-10 fold are required for significant systemic effects
a. 2-3 ng/ml - no clinical significance
b. < 10 ng/ml - urticaria, flushing, tachycardia
c. > 10 ng/ml - ± life threatening bronchospasm, hypotension & arrest
Cardiac Vagus Effects
• Pancuronium & gallamine block M2-receptors and result in a tachycardia
• vagolytic activity is seen with all steroidal based agents
relaxant Met. excretion onset duration histamine Vagal blockade
cost
Tubocurarine Insignificant Renal + + + + + + + + 0 Low
Metocurine Insignificant Renal + + + + + + + 0 Mod
Atracurium + + + Insignificant + + + + + 0 High
Cisatracurium + + + Insignificant + + + + - 0 High
Mivacurium + + + Insignificant + + + 0 Mod
Pancuronium + Renal + + + + + - + + Low
Vecuronium + + Biliary + + + + - 0 High
Rocuronium Insignificant Biliary + + + + - + High
rapacuronium + Renal + + + 0 high
Summary of the pharmacology of NDMR
ASSESSEMENT OF NEUROMUSCULAR BLOCKADEASSESSEMENT OF NEUROMUSCULAR BLOCKADE
Mechanical Force
TransducerAcceleromete
r Intergrated EMG
Assessment of response
Monitoring of BlockadeMonitoring of Blockade
Observing or palpating
• Costly & complex
• Measure muscle tension
• Costly & complex
• Measure muscle tension
• Simplest method
• Inaccurate
• Simplest method
• Inaccurate
• The transducer consist of a piezo- electric ceramic wafer with electrodes on both sides
• Following changes in velocity, an electrical voltage proportional to acceleration is generated between the electrodes.
• Force=mass x acceleration,thus the muscle tension response may be evaluated.
• The transducer consist of a piezo- electric ceramic wafer with electrodes on both sides
• Following changes in velocity, an electrical voltage proportional to acceleration is generated between the electrodes.
• Force=mass x acceleration,thus the muscle tension response may be evaluated.
• Register the EMG response via 2 surface/needle electrodes.
• Only monitors transmission across the NMJ.
• More specific than mech. assessment
• Register the EMG response via 2 surface/needle electrodes.
• Only monitors transmission across the NMJ.
• More specific than mech. assessment
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Single twitch response
Train Of Four
Tetanic Stimulation
Dual Burst Stimulation
Post Tetanic Stimulation
Post Tetanic Count
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Single twitch response
• A single pulse that is delivered from every second to every 10
second (1-0.1Hz)
• Increasing blockade results in decreased evoked response to
twitch stimulation
0.2 msec duration
Time
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Train of Four• 4 successive twitch in 2 seconds (2Hz)
• The twitches progressively fade as relaxation .• TOF ratio –between the 1st & 4th twitch – indicator for non dep. NMB
• Also by observation – disappearance of the 4th twitch – 75% block, the 3rd –
80% block & the 2nd – 90% block
0.2 msec
Time
500 msec
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Tetany• Continuous stimulation at 50 -100Hz
• Sensitive test for neuromuscular function
• Sustained contraction for 5 sec indicate adequate reversal from NMB
• Painful in conscious patient
0.2 msec
Time
20 msec
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Double-Burst Stimulation
• 2 variation of tetany DBS3,3 or DBS3,2
• 3 short (200 sec) high frequency burst at 50Hz followed 750msec
later by another 3/2 such burst
• Less painful & > sensitive than TOF for evaluation of fade
0.2 msec
Time
750 msec
Stimulation pattern
Monitoring of BlockadeMonitoring of Blockade
Post Tetanic Count• To assess intense blockade
• A single twitch 1 Hz for 1 minute than followed by 5 sec tetanus at 50Hz ,
and after 3 sec the no. of twitches at 1Hz is counted.
• A PTC of 2 suggest no twitch response for 20-30minutes, PTC of 5 10-15
minutes.
Fade
Monitoring of BlockadeMonitoring of Blockade
Indicative of Non dep. NMBA
Gradual decrease in strength of muscle contraction during
prolonged / repeated stimulation
Due to pre junctional effect of NMBA that reduce Ach in
the nerve terminal for release during stimulation.
Adequate clinical recovery absence of fade.
Post Tetanic potentiation
Monitoring of BlockadeMonitoring of Blockade
Indicative of Non dep. NMBA
Also indicative for dep.( MBA phase II)
The ability of tetanic stimulation to increase evoke
response to a subsequent twitch
Due to increase presynaptic mobilization & release of Ach
following tetanic stimulation
Stimulation patternMonitoring of BlockadeMonitoring of Blockade
EVOKED STIMEVOKED STIM DEPDEP NON DEPNON DEP
PH IPH I PH IIPH II
TOFTOF Constant &
amplitude
Fade Fade
TETANYTETANY Constant &
amplitude
fade fade
DBSDBS Constant &
amplitude
Fade Fade
PTFPTF Absent Present Present
MYASTHENIA GRAVIS (MG)
Myasthenia gravis (my: muscle, asthenia: weakness, gravis: severe)
Autoimmune disorder antibodies directed against acetylcholine
receptors.
Characterised by weakness or exaggerated fatiguability on sustained effort.
Depolarizing muscle relaxant; Frequent phase II block even with single dose. Increase plasma [K+] concentration.
Non depolarizing muscle relaxant. Resistance, required higher dose for rapid sequence
intubation. Sensitivity and duration increased. Monitoring neuromuscular blocker is
necessary. Controlled factor which increase
neuromuscular block.
The Lambert-Eaton syndrome
Proximal fatiguability, which is relieved by exercise.
Association; Malignancy : pulmonary, gastric,
kidney or bowel tumours in (old patients)
Autoimmune diseases in (young patients).
Muscle relaxantMuscle relaxant Succinylcholine : normal response.Succinylcholine : normal response. NDMRs : increase sensitivity.NDMRs : increase sensitivity. NDMRs of intermediate duration of NDMRs of intermediate duration of
action action pyrido-stigmine is not effective.pyrido-stigmine is not effective.
TABLE 19-5. Comparison of Myasthenia Gravis and Myasthenic Syndrome
Myasthenia Gravis Myasthenic Syndrome
Manifestations Extraocular, bulbar, and facial muscle weakness Proximal limb weakness (legs > arms)
Fatigue with exercise Exercise improves strength
Muscle pain uncommon Muscle pain common
Reflexes normal or decreased Reflexes absent
Gender Female > male Male > female
Coexisting pathology
Thymoma Cancer (especially small cancer of the lung)
Response to muscle relaxants
Resistant to succinylcholine and sensitive to nondepolarizing muscle relaxants
Sensitive to succinylcholine and nondepolarizing muscle relaxants
ANTICHOLINESTERASE DRUGS AND CHOLINERGIC AGONIST
• Introduction.• Molecular structure.• Mechanism of action.• Classification.• Pharmacokinetic of anticholinesterases.• Pharmacologic effects of anticholinesterases.• Antagonist-assisted reversal of neuromuscular
blockade.
REVERSAL OF BLOCKADE REVERSAL OF BLOCKADE OF NDMRsOF NDMRs
SPONTANEOUS REVERSALSPONTANEOUS REVERSAL PHARMACOLOGIC REVERSALPHARMACOLOGIC REVERSAL
Gradual diffusionGradual diffusion RedistributionRedistribution MetabolismMetabolismMetabolismMetabolism ExcreationExcreationExcreationExcreation AnticholinesteraseAnticholinesterase
Indirectly increase the amount of Achavailable to compete with NDMRs
Reestablishing neuromuscular transmission
ANTICHOLINESTERASEANTICHOLINESTERASE
Drugs inhibit AChE (truecholinesterase) which responsible for hydrolysis of Ach. Prolong depolarizing blockade of Sch by possible
mechanism: Ach Inhibition of pseudocholinesterase activity.
glycopyrrolate + edrophonium = bradycardia "standard" reversal combination,
i. atropine 1.2 mg ~ 17 µg / kg x 70 ii. neostigmine 2.5 mg ~ 35 µg / kg x 70
atropine + neostigmine induce an initial tachycardia, followed by a late bradycardia
The choice & dose of cholinesterase inhibitor The choice & dose of cholinesterase inhibitor determine the choice & dose of anticholinergic.determine the choice & dose of anticholinergic.
Only the nicotinic effect of antiAChE Only the nicotinic effect of antiAChE are disiredare disired
the muscarinic effect must be block.the muscarinic effect must be block.
Reversal agent should be routinely given to a patients who have received NDMRs unless
Full reversal can be demonstratedPostoperative plan includes continued intubation & ventilation
Organ System Muscarinic Side Effect
Cardiovascular HR, dysrhythmias
PulmonaryBronchospasm,bronchial secreation
CerebralDiffuse excitation ( Physostigmine )
GITIntestinal spasm, salivation
G/urinary Bladder tone
Ophthalmologic Pupillary constriction
Cholinesterase Inhibitor
Usual Dose of Cholinesterase Inhibitor (mg/kg)
Recommended Anticholinergic
Usual Dose of Anticholinergic per mg of Cholinesterase Inhibitor
Neostigmine 0.04-0.08Glycopyrrolat
e0.2 mg
Pyridostigmine
0.1-0.4Glycopyrrolat
e0.05 mg
Edrophonium 0.5-1.0 Atropine 0.014 mg
Physostigmine
0.01-0.03Usually not necessary
NA
Sedation Antisiolagogue ↑ HR Relax smooth muscle
Atropine + + +++ ++
Scopolamine +++ +++ + +
Glycopyrrolate 0 ++ ++ ++
Mydriasis
cyloplegia
Prevent motion-induced nausea
↓ gastric H+
secretionAlter fetal
HR
Atropine + + + 0
Scopolamine +++ +++ + ?
Glycopyrrolate 0 0 + 0