update on neuromuscular relaxants charles e. smith, md professor of anesthesia case western reserve...
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Update on Neuromuscular Relaxants
Charles E. Smith, MD
Professor of Anesthesia
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– roc, cis, miv, pip, dox; rap: withdrawn from market
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Drachman, NEJM
Classical Mechanism of Action
• Non-depolarizers:
– competitive block
– prevent binding of Ach to receptor
• Depolarizers-
– mimic action of Ach
– excitation followed by block
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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
• Receptor alterations – burns, MG, quadra-
+hemiplegia
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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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Terminology
• Efficacy: ability of drug to produce a desired effect
• Potency: quantity of drug to produce maximum effect
• Biologic variability: individual variation in response to identical dose of drug
• DRC: – measure efficacy and potency
– compare drugs, disease states
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Concept of “Effective Dose”
• ED90: dose that produces 90% block (+ SD) in average patient at standard muscle group
• Usually adductor pollicis- ulnar nerve• Derived from dose-response studies
• Intubating dose: 2- 3 x ED90
• Repeat doses: < ED90
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DRC- show differences in potency, slope, efficacy + individual responses. Stoelting + Miller, 2000
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Donati F: Semin Anesth 2002;21:120; Donati F: Anesthesiology 1986;65:1
Altered Dose-Response• Some muscle groups more resistant-
DRC shifted to right: – diaphragm, larynx, eye, abdominal
• Some muscle groups more sensitive- DRC shifted to left: – pharyngeal muscles, upper airway– muscles of the thumb
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Meistelman: CJA 1992;39:665-9
Rocuronium: Larynx v. Thumb
Muscles of the larynx, diaph, + eye are more resistant to non-depolarizers v. thumb
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Elimination
• Most NMBA: 2 compartment models: redistribution, then elimination– a) NM junction non-effector site tissue
– b) elimination from plasma
• Exceptions: sux, miv, atrac, cistrac
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Stanski 1982. Drug Disposition in Anesthesia
Two Compartment Model
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Stanski, 1982. Drug Disposition in Anesthesia
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Volume of Distribution
• Calculated number, [conc] = dose / Vd
• Inject known amount of drug
• Measure plasma concentration
• Does not refer to anatomic volumes– reflects volume of compartments that drug is
distributed in– influenced by: protein binding, degree of
ionization + water solubility
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Altered Vd Vd: [conc] for any given dose
– neonates– burns – hepatic failure– cardiopulmonary bypass
Vd: [conc] for any given dose – elderly– shock– CHF
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Vecuronium
• ED90: 0.04 mg/kg– intubating dose: 0.1-0.2 mg/kg– onset: 2-4 min, clinical duration: 30-60 min
• Maintenance dose: 0.01-0.02 mg/kg, duration: 15-30 min• Metabolized by liver, 75-80%• Excreted by kidney, 20-25%• ½ life : 60 minutes• Prolonged duration in elderly + liver disease• No CV effects, no histamine release, no vagolysis• May precipitate after thiopental
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Concerning rocuronium, which are true?
1. Onset delayed compared with vec (equipotent doses)
2. Onset faster at the diaphragm compared with muscles of the thumb
3. Duration is longer than that of equipotent doses of vecuronium
4. Duration is shorter in elderly patients compared with young adults
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Rocuronium
• ED90: 0.3 mg/kg– intubating dose: 0.6-1.0 mg/kg– onset: 1-1.5 minutes, clinical duration: 30-60 min
• Maintenance dose: 0.1-0.15 mg/kg, duration: 15-30 min• Metabolized by liver, 75-80%• Excreted by kidney, 20-25%• ½ life : ~ 60 minutes• Mild CV effects- vagolysis, no histamine release, • Prolonged duration in elderly + liver disease• Only non-depolarizer approved for RSI
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Prielipp et al: Anesth Analg 1995;81:3-12
Cisatracurium
• ED90: 0.05 mg/kg– intubating dose: 0.2 mg/kg
– onset: 2-4 minutes, clinical duration: 60 min
• Hofmann elimination: not dependent on liver or kidney for elimination
• Predictable spontaneous recovery regardless of dose
• ½ life : ~ 60 minutes
• No histamine release
• CV stability
• Agent of choice for infusion in ICU
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Succinylcholine
• ED90: 0.3 mg/kg– intubating dose: 1.0-1.5 mg/kg– onset: 30-45 sec, clinical duration: 5-10 min– can be given IM or sublingual– dose to relieve laryngospasm: 0.3 mg/kg
• Maintenance dose: no longer used • Metabolized by pseudocholinesterase
– prolonged duration if abnormal pc (dibucaine # 20)• Prolonged effect if given after neostigmine dose requirement for non-depolarizers after sux
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Concerning sux, which are true?
1. Bradycardia + nodal rhythms unlikely after “2nd dose” sux
2. Hyperkalemia + cardiac arrest unlikely 1 week after major burns, or in children with Duchenne’s muscular dystrophy
3. Contraindicated in patients with head injury4. May cause malignant hyperthermia or masseter
spasm5. Duration unaffected by prior administration of
neostigmine
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Stoelting R, Miller RD: 2000
Succinylcholine + Arrhythmias
• Bradycardia, nodal rhythms, asystole
• Especially after 2nd dose: give atropine, 0.6 mg, IV prior
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Kovarik, Mayberg, Lam: Anesth Analg 1994;78:469-73
Head Injury + Sux
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Bevan DR: Semin Anesth 1995;14:63-70
Succinylcholine Adverse Effects
• Malignant hyperthermia, masseter spasm IOP, myalgias, intragastric pressure ICP: doubtful significance• Hyperkalemia + cardiac arrest in “at risk patients”
– Receptor alterations: denervation, burns– Myopathy rhabdomyoslysis
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Bevan DR, Bevan JC, Donati F: 1988
Sux + Hyperkalemia• Burns, Hemiplegia, Paraplegia, Quadraplegia:
extrajunctional receptors after burn or denervation
– Danger of hyperkalemia with sux: 48 hrs post injury until …?
• Muscular Dystrophies: • Others:
– severe infections, closed head injury, crush, rhabdo, wound botulism, necrotizing pancreatitis
• Tx of Hyperkalemia:
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Berg: Acta Anaesthesiol Scand 1997;41:1096. Eriksson: Anesthesiology 1993+1997
Residual NM Block
• 1979: 42% incidence with long acting drugs [Viby-Mogensen]
• 1988: incidence with vec + atrac [Bevan, Smith, Donati- Mtl]
• 1992: ventilatory response to hypoxia, TOF 0.6-0.7
• 1997: pharyngeal muscle coordination with TOF 0.6-0.8 • 1997: panc is risk factor for postop pulmonary
complications [v. vec + atrac; RCT n= 693 patients]
• 2003: 45% incidence with interm acting drugs w/o reversal, TOF 0.9 [Debaene, Plaud, Donati-
France]
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Time for conc to decrease by 1/2
Elimination Half-Life, t 1/2
# of half-lives % remaining % eliminated
0 100 0
1 50 50
2 25 75
3 12.5 87.5
4 6.25 93.75
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Viby-Mogensen, 2000
Double Burst
• TOF fade: difficult to detect clinically until < 0.2
• Use double burst:– 2 short bursts of
tetanic stimulation separated by 750 ms
– Easier to detect fade + residual block, 0.2-0.7
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Reversal of NM Block
• Clinical practice:– if no evidence block + 4 half-lives: omit reversal
– if still evidence block: give reversal
– if unsure: give reversal
• Rule of thumb:– if 2 twitches of TOF visible, block is usually reversible
– if no twitches visible, best to wait (check battery)
• Neostigmine 2.5 mg/Glycopyrolate 0.5 mg– do not omit anti-cholinergic!
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Org 25969: A safer way to reverse NMB?
• Gijsenbergh et al, Anesthesiology 2005;103;695-703. Belgium
• Modified cyclodextrin
• Encapsulates roc
• Promotes dissociation of roc from AchR
• Phase 1 study, n=29
• No recurarization
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Gijsenbergh et al. Anesthesiology 2005;103:695
+
=
Roc Org 25969
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Adductor pollicis acceleromyography- TOF watch
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Bevan DR: Can J Anaesth 1995;42:93. Quote from the internet 10/94
How Much Relaxation?
• Muscle relaxants do not make the hole bigger.• They do not relax bone• They do not decompress bowel• They do not give a surgeon judgement• They do not relax fat