AIL ine given options are associated with the risk of hyperkalemia from succinyicholine except myasthenta gravis. Myseinenia gravis: resistant to depolarizing muscle relaxants (SCh) and hypersensitive to non depolarizing Pearl #217: Conditions causing susceptibility to succinylcholine-induced hyperkalemia + Surn injury > Spinal cord injury + Encepnaitis, 2 Guitain-earre eynarame: Tetanus Prolonged total poay Immepiization Ruptured cerebral aneurysm Polyneuropathy Closed head injury Hemermnagie shock with metabolic actaosts Myapainies (eg, Ducnenne's dystrophy) Succinycnotine Is not contrainaicated in iver failure. tn liver rallure, the amount of butyry! cholinesterase wi decrease (10 20% of normaly, leading to prolonged neuromuscular blockade, It Is still not a major concern, Succiny! chotine Is contranaicated In head injury (transient rise In ICP), burns patient, ang muscle Gystropnies like Duchenne muscular dystrophy due te the risk of dangerous hyperkalemia Burn injury Spinal cord injury, Encepnatitis Guillain-Barre syndrome Prolonged total Boay immenuization Rupturea cerepral aneurysm Polyneuropathy Closed Nead injury Homormagic shock with motapolte acidosis: Myopatnies (eg, Duchenne's aystrapny) Reduced butyryl cholinesterase activity Is seen in Liver disease. Pregnancy Malnutrition Old age Drugs like - oral contraceptives, monoamine oxidase inhibitors, echothlophate, cytotoxic arugs, neoplastic disease, anticnolinesterase drugs and metoclopramide. Butyryichotinesterase is the enzyme which degrades succinyl chollne. It Is synthesized in the iver ang round nthe plasma. Decreased bulyryicholinesterase Is not a major concem in clinical practice because even in a large decrease in the enzyme activity will produce an only slight increase in duration of neuromuscular blockade. Dibucaine number indicates the genetic makeup of an Individual with respect to butyryicholinesterase. Dibucaine is a local anesthetic which measures pseudecholinesterase function but not the amount of ‘enzyme. Dibucaine number refers to the percentage of inhibition of pseudocholinesterase activity. It inhibits normal pseudocnolinesterase activity by 80% but innipits atypical enzyme activity by only 20%. A patient with normal pseudocholinesterase has a dibucaine number of 80; whereas a homozygote fer an atypical enzyme will nave a dipucaine number of 20.Neostigmine, oral contraceptive pills, and metoclopramide potentiate tne paralysis produced by succinylcholine by decreasing pseudocholinesterase/ butyrylcholinesterase. Neostigmine being an anticholinesterase leads to inhibition of acetyleholinesterase. This results in a higher ACh concentration at the nerve terminal, which intensifies depolarization. Dibucaine Is a local anesthetic which measures pseudocholinesterase function but not the amount of enzyme. It inhibits normal pseudocholinesterase activity by 80% but inhibits atypical enzyme activity by only 20%. Dibucaine number refers to the percentage of inhibition of pseudocholinesterase activity. A patient with normal pseudocnolinesterase has a dibucaine number of 80; a homozygote will have a dibucaine number of 20. ‘Therefore, adequacy of pseudocholinesterase can be determined + Quantitatively in units per liter - in the laboratory += Quaittatively by aibucaine number ‘The first ine of management in this child would be to increase the dose of succinylcholine, High incicence of muscle spasm without any symptoms ang signs of malignant hyperthermia trequently results from an inadequate dosage of succinylenoline. Succinyicholine dosage for intubation: 1-2m@/Ke. Conaitions to be ruled out in isolated masseterie spasm: + Inadequate dose of succinylenoline (less than tne recommended dose of 1 ma/ka) + Inadequate time for the onset of suecinylcholine action + Duchenne muscular dystropny, myotonia congensta, and other muscle disorders, + Temporomaneibular joint aistocation + Aithough an increase in tone of the masseter muscle Is considered to be an early indicator oF malignant hyperthermia, this finding is not consistently associated with that syndrome. + The massetene spasm occurs as a reault of an exaggerated contractlie respanse at the neuromuscular junction and cannot be used to establish a diagnosis of malignant hyperthermia + At present, in cases of isolated muscle spasm, there is no indication to change to a -non-triggering ‘The best answer to the above case scenario is phase Il blockade produced by succinylenotine. Phase Il Block is clinically seen wan tne dose >5 mg/kg. Mechanism of action of succinylenoline: + Phase | block: continuous endplate depolarization and subsequent muscle relaxation. + Phase Il block: seen witn alarge single dose, repeated doses, or a continuous intusion whien can lead to desensitization of the receptors resulting in prolonged neuromuscular blockade. ‘Causes of prolonged apnea include: + Atypicapseudochotinesterase Geticiency - can result in apnea even witn a normal dose of succinyicnotine: + Altered response of enapiate to depolarizing relaxant (myasthenia gravis) + Accumulation of succinyicnoline leading to phase 1! blockade though options B. C and D can lead to prolonged apnea. in ihe above case scenario. the patient nas received ~9 mg/kg of succinylcholine. Hence, the most probable diagnosis is phase Il blockade leading to prolonged apnea Rocuronium is the drug of choice during routine intubation in pediatric patients due to its faster onset of action and its avallapilty for intramuscular injection. ‘Succinylenoline is avoided for routine, elective intubation in children due to its side effects. The only indication for inttavenous succinylcholine in children is rapid sequence induction with a ‘full’ stomach and laryngospasm. ‘The duration of action of vecuronium and pancurenium Is prolonged in children due to immature hepatic functionpseudoc! Wm Is short acting due to rapia hydrolysis by butyrytehé iinesterase), Inesterase (aka plasma cholinesterase or Patients witn atypical pseucocholinesterase will have prolonged duration of the block similar to succinyicholine administration. = Shonest acting muscle relaxant_Suceinylenotine + Shortest acting non-depolanzing muscle relaxant — Mivacurium (Gantacurium, If given in options, as itis ultra shart acting) Cis-atacurium does not depend on ine kidney for excretion. Cls-avacurium undeigoes Hofmann elimination, whien Ie spontaneous non-enzymatic degracation. So, renal failure cose not affect the clearance of cle atracurium. Hence, it Is the agent of choles in renal failure patients. Airacurium aiso undergoes Hofmann elimination and so Is an alternative to cls atracurium in renal Steroldal muscle relaxants are predominantly eliminated by ultranttration by the glomenili before urinary Doxacurium, pancuronium, and pipecuronium are partially excrated by the kidneys, 20 the euromuscular block Is proionged in pationts with renal Failure. Erythema, nusning, and nypotension are manifestations of histamine release. -tubeeurarine is the most potent histamine releaser Hence f ls mast likely to have caused It Pearl #247: Muscle Relaxant with Histamine release leading to Hypotension, Tachycardia, Flushing Least iKety: Atracurium (or cisatracurium) Is the kieal muscle relaxant for neonates. Neonates nave Immature hepatic ana renal functions. Atracurium and cisatracurium undergo Hormann Glimination, which Is spontaneous non-organ dependent hon-enzymatic degradation. Hence these drugs a. tupecurarine proauces maximum ganglionic blockade leading to nypetension Besides, -Tubocurarine is the most potent histamine releaser among muscle relaxants leading to bronchospasm, nypotension, wheals. Goth the effects of the ganglionic blockade and nistamine release can lead to severe hypotension. Hence, c.ubocurarine had been withdrawn from the market suceinylcnotne stmulates tne vagal ganglion, leading to braaycaraia, and stimulates the sympatneuc ganglion, causing hypertension and tachycardia Pancuronium Is vagolytie and produces sympathetic stimulation leading to tachycardia Rocuronium is the agent of choice for precurarization. Precurarization is the administration of a small dose (10% of £D95) of a non-depolarizing neuromuscular blocking agent a few minutes before Succinylcholine (Sch) to minimize the complications: of Sch use like tasciculaticns; postoperative myalgia; and rise in intragastric, introcular, and intracranial pressure. Rocuronium is ideal because it nas a rapid onset of action (80 seconds), whieh Is comparable wih ‘succinylcholine and is very effective in decreasing fasciculations and postoperative myalgiasVecuronium is devoid of significant cardiovascular effects and Is the most cardiovascular-staple muscle relaxant, which makes it the muscle relaxant of choice for cardiac patients. Drug type, Autonomic ganglia. CaFdiac muscarinic receptor Histamine release Depolarizing muscle relaxant Succinylenotine stimulates stimulates stigni Benzylisoquinotinium compounds Mivacurium None None stign: Aracurium None None stignt steroidal compounds Reeuronium None Blocks weakly None Pancuronium None Blocks moderately None Adductor pollicis is the last to recover from neuromuscular blockade, as it is the most sensitive to neuromuscular blockade among the given choices. Most sensitive to neuromuscular blockade: Abdominal muscles, peripheral muscles of the limbs, orbicularis ocull muscle. genichyoid, masseter, and upper airway muscles. COrbicularis ocull muscles recover from neuromuscular blockade sooner than the adductor pollicis. ‘The diaphragm Is much more resistant to NM blockade than adauctor pollicis ana also recovers earlier. ‘The confirmatory sign of recovery from neuromuscular blockade: Train of four ratie +09 ‘The TOF ratio must exceed 0.90 to exclude clinically Impertant residual neuromuscular Block. Clinical signs consistent with recovery are ‘Sustained leg lI for 5 seconas, Sustained nandgrip for 5 seconds. Sustained “tongue depressor test Manamum inspiratory pressure 40 1o 50 em H20- or greater Pearl #241: High Yield in Muscle Relaxants High Yield in Muscle Relaxants: + Shortest acting non-depolarizing muscle relaxant Gantacurium (Not FDA approved) 2 Mivacurium (12-20 minutes}/(FDA approved) snonest acting depolarizing muscle relaxant- SUcciny! choline (3-6 minutes) Muscle relaxant having the maximum duration of action -Dexacuntum (benzylisaquinoline)=Pancuromium (Aminosteroid) Muscie relaxant causing pain on Iv Injection site- Rocuronium, Muscle relaxant which crosses placenta - Gallamine. Muscle relaxant acting directly on Musele- Dantrolene. Muscle relaxants with central action- Benzodiazepine, mephenesin, baclofen, carisoprodot, metaxalone. Muscle relaxant significantly metabolized by liver. pancuronium, vecuronium, rapacurium, Muscle relaxant whose clearance depend mainly on biliary exeretion-vecuronium, rocuronium: