NMBA08 - Neuromuscular Relaxants + Reversal Agents Charles...

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Neuromuscular Relaxants + Reversal Agents Charles E. Smith, MD Professor, Case Western Reserve University Director, Cardiothoracic Anesthesia MetroHealth Medical Center Cleveland, Ohio
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Objectives Mechanism of action Monitoring Pharmacology non-depolarizers depolarizers Reversal
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Historical 1942: dTC, long-acting, histamine 1952: sux 1954: 6 fold in mortality with dTC 1967: panc, long acting, CV stimulation 1986: interm acting relaxants: vec: no CV effects atrac: Hoffman elimination, histamine 1990 to present: newer agents to fill specific niche roc, cis, miv, pip, dox; rap: withdrawn from market
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Classical Mechanism of Action Non-depolarizers : bind to AchR, post junctional nicotinic receptor competitively prevent binding of Ach to receptor ion channel closed, no current can flow Depolarizers - succinylcholine: mimic action of Ach excitation of muscle contraction followed by blockade of neuromuscular transmission
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Taylor: Anesthesiology 1985;63:1-3 Postjunctional Nicotinic AchR
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Standaert FG: 1984
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Margin of Safety Wide margin of safety of neuromuscular transmission 70% receptor occupancy before twitch depression
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Smith CE, Peerless JR: ITACCS Monograph 1996 Clinical Use Anesthesia: facilitate tracheal intubation paralysis for surgery + mechanical ventilation ICU: VO 2 tetanus status epilepticus ICP shivering
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Viby-Mogensen, 1984 TOF Monitoring TOF: 4 supramaximal stimuli at 2 Hz, every 0.5 sec observe ratio of 4rth twitch to first Loss of all 4 twitches: profound block Return of 1-2 twitches: sufficient for most surgeries Return of all 4 twitches: easily “reversible”
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A-Nondepolarizing. B- Sux. Viby-Mogensen: BJA 1982;54:209 Onset + Recovery of NM Block
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Concept of “Effective Dose” ED 90 : dose that produces 90% block (+ SD) in average patient, derived from dose-response studies Clinical practice: – 3 x ED 90 at start of case smaller “repeat” doses during case lighten up NM block at end of case titrate opioids to respiratory rate “reverse” after dressing applied
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NMBA08 - Neuromuscular Relaxants + Reversal Agents Charles...

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