Workbook:

Neuromuscular Blockers

Copyright 2016 APEX Anesthesia Review

Neuromuscular Junction: Tell the Story
Extrajunctional Receptors
Succinylcholine and extrajunctional receptors:

Upregulation is caused by:

Nondepolarizers and extrajunctional receptors

Mechanism of Fade: Tell the Story
Phase 1 vs Phase 2 Block: Compare and Contrast Normal Phase I Phase II
TOF

Tetany

DBS

PTP
Assessment of Recovery
Recovery from neuromuscular blockade is believed to occur when the TOF ratio _______________.

_______________ of blockade is best measured at the _______________ muscle with the

_______________ nerve.

_______________ of blockade is best measured at the _______________ muscle with the

_______________ nerve.

How do we define recovery?

Normal Function Maximum % of Receptors Occupied

Tidal volume

Single twitch

Train-of-four

Vital capacity

Sustained tetanus

DBS

Inspiratory force

Head lift > 5 seconds

Handgrip same as at induction

Bite on tongue blade

Succinylcholine Side Effects: List them all!
Pseudocholinesterase and Acetylcholinesterase
Metabolizes Ach Metabolizes Succinylcholine Key Facts about Pseudocholinesterase:

List the factors that can impair the function of pseudocholinesterase.

Drugs Co-Existing Conditions What other drugs are metabolized by pseudocholinesterase?
Dibucaine Test PChE variant Genotype Incidence Dibucaine # Succ duration

Typical
What is dibucaine? homozygous

Heterozygous

How does it aid in the diagnosis of pseudocholinesterase deficiency? Atypical

homozygous

Describe a normal test. How would you treat the patient with pseudocholinesterase deficiency?

Describe an abnormal test.

Succinylcholine Black Box Warning
Why does succinylcholine have a black box warning?

Describe the pathophysiology of this condition and relate it to the mechanism of action of succinylcholine.

Does this condition increase the risk of MH?

Can you recall the conditions that are definitely linked to MH? (You’ll find the answers in the Musculoskeletal Tutorial)
Succinylcholine & Hyperkalemia
Label the diagram and discuss how K+ and Ca+2 affect the
action potential. Goal Treatment
1.

2.

How does hyperkalemia affect the EKG?

3.
Succinylcholine & Myalgia
Who is at risk?

Can the risk of myalgia be reduced?

How does the dose for succinylcholine change when a defasciculating dose is used?

When should you avoid a defasciculating dose?

Diseases with Altered Responses to NMBs
Succinylcholine Nondepolarizer Write a 1-2 sentence description of each disease
Amyotrophic lateral sclerosis

Charcot-Marie-Tooth

Duchenne’s muscular dystrophy

Guillain-Barre

Huntington chorea

Hyperkalemic periodic paralysis

Hypokalemic periodic paralysis

Malignant hyperthermia

Multiple sclerosis

Myasthenia gravis

Myotonic dystrophy

Up-regulation of AChRs
Potency
The ED95 is a measure of _______________ - They are _______________ related.

Discuss the utility of ED95 in the context of neuromuscular blockers.

ED95 (mg/kg) Intubation (mg/kg) T to max twitch depression T to return of 25% of control

Mivacurium

Cisatracurium

Vecuronium

Atracurium

Rocuronium

Pancuronium
Metabolism
Benzylisoquinolinium NMBs Aminosteroid NMBs
Factors that Potentiate Neuromuscular Blockade
Drugs Electrolytes

Other
Cardiovascular Effects of NMBs
Histamine Release Autonomic Ganglia Heart M2 Receptors

Succinylcholine

Pancuronium

Rocuronium

Vecuronium

Cisatracurium

Atracurium

Mivacurium

Discuss histamine release as it relates to NMBs

Discuss the effects of NMBs on heart rate.

Anaphylaxis
Discuss why NMBs can cause anaphylaxis.

Rank the NMBs in terms of their likelihood to cause an allergic reaction.

Discuss the controversy between succinylcholine and rocuronium in terms of their ability to cause an allergic response.