13. Neuromuscular blocking agents. Classifications. Mechanism of action. Therapeutic uses.

Adverse effect. Reversal of neuromuscular blockade

Neuromuscular-blocking drugs(NMBs) are important for producing complete skeletal muscle relaxation in surgery.They
increase the safety of anesthesia.
Classification:
Non depolarizing1)Long Acting -d- Tubocuvarine
Metocurine
Gallamine
Alcuronium
Pancuronium
Doxacurium
Pipecuronium
2) Intermediate acting- Vecuronium, Atracurium, Recuronium
3)short acting- Mivacurium
Depolarizing(partial agonist) agents:- Decomethonium
Succinylcholine(suxamethonium)
Mixed action Benzoquinonium.
Mechanism of action.
1)Non depolarizing- They combine with nicotinic receptor + prevent binding of ACH and prevent depolarization of the
musclke cell membrane and inhibit muscle contraction.
Sequence of paralysis- 1) small, rapidly contracting muscles of eye, face, limbs and
Pharynx
2)Fingers
3)Neck and trunk muscles
4) Intercostal muscles
5)Diaphragmatic muscles
Recovery in reverse order.
2) Depolarizing :- Attach to the nicotinic receptor and act like ACHto repolarize the junction. Unlike ACH which is
instantly destroyed by acetylcholinesterase. The depolarizing agents persist of high concentrations in the synaptic cell.
They remain attracted to the receptor for a longer time, providing constant stimulationwhich cause the Na channel
associated receptors to open. Which result in depolarization of receptor (phase 1). This cause Transient switching of
muscles. The continous binding renders the receptor uncapable of transmitting further impulses. With time the continuous
depolarization gives way to gradual repolarization. Na channels closes or blocked. This cause paralysis(phase 2)-chest and
abdomen.
Therapeutic uses.
1)Adjuvants in general anesthesia
2) Facillitation of endotracheal incubation, laryngoscopy, bronchoscopy and oesophagoscopy
3) Prevention of trauma and convulsion in electroshock therapy of psychiatric disorders.
4) for ocular surgery(competative blockers are preferred
5)severe cases of teanus and status epilepticus
Adverse Effects.
1) Dizziness
2) Muscle weakness
3) Hypotension
4) Bronchospasm
5) Prolonged opnea
6) Cardiovascular collapse
7) Depolarization- post operative muscle pain, Bradycardia, C release, increased IOP, Prolonged paralysis, malignant
hyperthermia.
Reversal of neuromuscular blockade.
Anticholinesterase( endrophonium, neostigmine) can overcome the action of non depolarizing neuromuscular blockers by
increasing the concentration of Ach at the motor end plate.