Neuromuscular blockers
(PH 1.15)
Dr Mahesh Kumar D
Associate Professor
A 30-year-old male patient was posted for
appendicectomy operation and was given
halothane and succinyl choline prior to surgery.
After surgery, the patient developed sudden bouts
of apnea ( cessation of breathing ).
CLINICAL DIAGNOSIS AND MANAGEMENT???
WHAT ARE NEUROMUSCULAR
BLOCKERS?
Peripherally acting Skeletal Muscle Relaxants (SMRs)
Acts on the NeuroMuscular Junction
Which are the other groups of SMRs?
CLASSIFICATION
Neuromuscular
blockers
I) Non II) Depolarizing
depolarizing blockers
(Competitive) Succinylcholine
blockers Decamethonium
I) Non depolarizing/
Competitive blockers
Long acting Intermediate
acting Short acting
d-tubocurarine Mivacurium
Atracurium
Pancuronium
Cisatracurium
Vecuronium
Rocuronium
I) Non depolarizing/
Competitive blockers
Lesser
Histamine
release and
ganglionic
blockade
Steroid derivatives Non steroid derivatives
Pancuronium d-tubocurarine
Vecuronium Atracurium
Rocuronium Mivacurium
NEUROMUCULAR JUNCTION
(NMJ)
Tubocurarine
named because
Source: Strychnos toxifera of packing in
hollow bamboo
tubes
MECHANISM OF ACTION OF COMPETITIVE/
NON-DEPOLARIZING BLOCKERS
MECHANISM OF ACTION OF
DEPOLARIZING BLOCKERS
PHARMACOLOGICAL ACTIONS OF
NEUROMUSCULAR BLOCKERS
• Skeletal muscle
• Ganglion
• Histamine release
• CVS
• GIT
COMPARATIVE PROPERTIES OF
NEUROMUSCULAR BLOCKERS
PHARMACOKINETIC PROPERTIES
• Polar compounds
• Administered parenterally
• Low volume of distribution
• Longer acting agents have renal elimination
• Atracurium and cis atracurium: Hofmann’s elimination
• Succinyl choline and Mivacurium: Pseudocholinesterase
• In conjunction with
General anaesthesia
When do – To facilitate
we require Tracheal intubation
skeletal – Facilitate mechanical
ventilation
muscle – Optimize surgical
relaxation working conditions
• Spastic disorders
• Tetanus and ECT
ADVERSE EFFECTS OF
SUCCINYLCHOLINE
• Hyperkalemia and cardiac arrhythmia
• Muscle pain and soreness
• Bradycardia as well as tachycardia!
• Increases all pressures! (IOP, ICT, BP)
• Bronchospasm and itching due to histamine release
• Pharmacogenetic importance??
A 30-year-old male patient was posted for
appendicectomy operation and was given
halothane and succinyl choline prior to surgery.
After surgery, the patient developed sudden bouts
of apnea ( cessation of breathing ).
CLINICAL DIAGNOSIS AND MANAGEMENT???
CLINICAL CASE:
A 30-year-old male patient was posted for
appendicectomy operation and was given
halothane and succinyl choline prior to surgery.
After surgery, the patient developed sudden bouts
of apnea ( cessation of breathing ).
CLINICAL DIAGNOSIS:
Succinyl choline apnea due to
pseudocholinesterase deficiency
TREATMENT:
Mechanical ventilation
Fresh frozen plasma
Recombinant pseudocholinesterase?
Neostigmine is not used
Dibucaine number related to succinyl choline apnoea
Sugammadex (SRBA)
All are non depolarizing blockers
EXCEPT:
d-tubocurarine
Cisatracurium
Suxamethonium
Vecuronium)
All are non depolarizing blockers
EXCEPT:
d-tubocurarine
Cisatracurium
Suxamethonium (Succinylcholine)
Vecuronium)
Shortest acting neuromuscular blocker is:
Atracurium
Mivacurium
Rocuronium
Succinylcholine
Shortest acting neuromuscular blocker is:
Atracurium
Mivacurium
Rocuronium
Succinylcholine (Lasts 5-8 minutes)
Muscle relaxant of choice in a patient with high
Q)
bilirubin and creatinine levels is:
Atracurium
Vecuronium
Mivacurium
Pancuronium
Muscle relaxant of choice in a patient with high
Q)
bilirubin and creatinine levels is:
Atracurium (Hofmann eleimination)
Vecuronium
Mivacurium
Pancuronium
Q) Advantages of Cis atracurium over Atracurium
includes ALL EXCEPT:
Lesser incidence of CNS toxicity
Unlikely to release histamine
Undergoes Hofmann elimination
Does not produce a toxic metabolite:
Laudanosine
Q) Advantages of Cis atracurium over Atracurium
includes ALL EXCEPT:
Lesser incidence of CNS toxicity
Unlikely to release histamine
Undergoes Hofmann elimination
Does not produce a toxic metabolite:
Laudanosine
Succinyl choline can cause ALL EXCEPT:
Q)
Apnea
Hypokalemia
Rhabdomyolysis
Nausea and Vomiting
Succinyl choline can cause ALL EXCEPT:
Q)
Apnea
Hypokalemia (causes hyperkalemia)
Rhabdomyolysis
Nausea and Vomiting
