Neuromuscular Junction Including

Pharmacology

Zekeriyya Alanoglu, MD, DESA

Ankara University School of Medicine,
Department of Anesthesiology and ICM

1
 Overview
• Final synapse in the motor pathway
– The motor neuron and muscle fiber
• Cellular structure
– Presynaptic terminal
– Synaptic cleft
– Postsynaptic membrane
• Cellular function
– Ion channels
• Role of key molecules and NMBAs
– Acethylcholine (ACh)
– Acethycholineesterase (AChE)
– Neuromuscular blocking drugs
– Reversal agents

8 Zekeriyya Alanoglu, MD, DESA

 Structure and Function of The NMJ

Steinbach, Wu. Neuromuscular function in Anesthetic

9 Ed. Evers, Maze, Kharasch
Pharmacology 2nd Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ

Steinbach, Wu. Neuromuscular function in Anesthetic

Pharmacology10
2nd Ed. Evers, Maze, Kharasch Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ

Steinbach, Wu. Neuromuscular function in Anesthetic

Pharmacology11
2nd Ed. Evers, Maze, Kharasch Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ

12 64 (Suppl. 1), pages 1–9

Anaesthesia, 2009, Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ
• Reliable and rapid excitation
• Minimal synaptic delay
• Presynaptic action potential
– Activates voltage-dependent Ca2+ channels
– Fusion of synaptic vesicles
– Release of ACh into the cleft

13 Zekeriyya Alanoglu, MD, DESA

 Structure and Function of The NMJ
• Postsynaptic depolarization
– ACh binds to postsynaptic AChR
– Receptor channel opens
– A net influx of cations
– Postsynaptic depolarization
• Activation of voltage dependent Na+ channels
– Action potential
– Propagates along the muscle fiber
– Ca2+ release from sarcoplasmic reticulum
– Muscle contraction
14 Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ

Steinbach, Wu. Neuromuscular function in Anesthetic

Pharmacology15
2nd Ed. Evers, Maze, Kharasch Zekeriyya Alanoglu, MD, DESA
Steinbach, Wu. Neuromuscular function in Anesthetic
Pharmacology16
2nd Ed. Evers, Maze, Kharasch Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ
• Cholinergic receptors
– Muscarinic
– Nicotinic
• Three types of nAChR at NMJ
• Two postsynaptic on the skeletal muscle
• Junctional and Extrajunctional
• Presynaptic
– Two alfa (α)
– One beta (β)
– One epsilon (ε)
– One delta (δ)
– Up-regulation or Down-regulation
17 Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ

Morgan, Mikhail, Murray. Neuromuscular blocking agents. In

18
Clinical Anesthesiology 4th Ed. Page 205-227 Zekeriyya Alanoglu, MD, DESA
 Na+ Channel and nAChR

Continuing Education in Anaesthesia, Critical Care & Pain

19 4 Number 1 2004
Volume Zekeriyya Alanoglu, MD, DESA
 Structure and Function of The NMJ
• Extrajunctional nAChRs
– Trauma
– Skeletal muscle denervation
• Rapid proliferation
• Appear over the entire postjunc. membrane
• Highly responsive to agonists
• Unpredictive response to NMBA
Stoelting and Hillier, Neuromuscular Blocking Drugs. In
Pharmacology & Physiology
20 in Anesthetic Practice. 4th Ed.
Page 208-250
Zekeriyya Alanoglu, MD, DESA
 Acetylcholine Synthesis and Degradation
Pyruvate Dehydrogenase
Pyruvate Acetyl-CoA + choline

Choline acetyltransferase
Reuptake
Acetylcholine

Acetylcholinesterase (AChE)

Acetate + choline
 Mechanisms of action of NMBA
• Non Competitive block
– Succinylcholine
– Partial agonist
– Occupies α subunit of nAChRs
– Continuous depolarization
– Voltage gated sodium channels
– Initial fasciculation
– Net effect relaxation

22 Zekeriyya Alanoglu, MD, DESA

 Mechanisms of action of NMBA
• Competitive block
– Non depolarizing NMBA
– No intrinsic agonistic activity
– No conformational change
– ACh and non depol. NMBA compete for receptor
– Binding depends on
• Concentration
• Affinity for the receptor

23 Zekeriyya Alanoglu, MD, DESA

 Mechanisms of action of NMBA
• Phase II block
– Complex phenomenon
– High single or cumulative doses of succinylcholine
– Lack of pseudocholinesterase
– Exact mechanism is underdebate
• Electrical imbalance at the junctional membrane
• Muscle membrane potential returns to normal
• Junction is still exposed to the drug
– Clinically
• Phase II block  Tetanic or TOF Fade
24 Zekeriyya Alanoglu, MD, DESA
 Mechanisms of action of NMBA
• Desensitization block
– nAChRs conformational changes
– Desensitized nAChRs  unable to open its channel
– Unphysiologicall high conc. of agonist
– Certain drugs such as
• Inhalational anesthetics
• Barbiturates
• Local anesthetics
– Decreased efficacy or margin of safety
– Susceptibility to antagonists
25 Zekeriyya Alanoglu, MD, DESA
 Mechanisms of action of NMBA
• Channel Block
– Direct channel blocking
– Conformation change in nAChRs
– Binding of ACh to α subunit is prevented
– Drugs
• Antibiotics
• Cocaine
• Quinidine
• Piperocaine etc…
26 Zekeriyya Alanoglu, MD, DESA
 Mechanisms of action of NMBA

27 Zekeriyya Alanoglu, MD, DESA

 Monitoring the Neuromuscular Function
• Train of Four
– Four twitches (2-Hz) 0.2 ms
• Tetany
– Sustained stimulus of 50-
100 Hz, 5 sec
• Twitch
– Single pulse 0.2 ms
• Double Burst Stm. (DBS3,2)
– Three short stm. (50Hz)
– 750 ms pause
– Two or Three additional
stm.
Morgan, Mikhail, Murray. Neuromuscular blocking agents. In
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Clinical Anesthesiology 4th Ed. Page 205-227 Zekeriyya Alanoglu, MD, DESA
Chemical Structure and Properties of NMBA
• Quarternary amine group
– α subunit binding
• Non depolarising NMBA
– Bisquarternary amine structure
• Postggl muscarinic AChRs
• Vagolytic effect
– Monoquarternary
• Less vagolytic effect
– Stereoisomers for histaminergic side effects
• Atracurium vs Cisatracurium
29 Zekeriyya Alanoglu, MD, DESA
30 Zekeriyya Alanoglu, MD, DESA
NMBA and Autonomic Nervous System, Histamine
Release
• Succinylcholine
– Bradycardia
– Arrhythmia
– Repetetive dosage

• ED50SE/ED95NM
B
• Higher the ratio
safer the drug
31 Zekeriyya Alanoglu, MD, DESA
 NMBA and Histamine Release
• Histamine release
– Antigen-Antibody rxn (IgE mediated)
– Complement system activation
– Direct action on mast cell surface
• Succinylcholine and Benzylisoquinolines
– Provoke histamine release from serosal mast cells
– Erythema, rash, tachycardia, hypotension etc…
– Subject to tachyphylaxis
– H1 receptor blockers
• Anaphylactic reactions  Rare
32 Zekeriyya Alanoglu, MD, DESA
NMBA and Effects on Bronchial Smooth Muscle
• Muscarinic type 2 (M2) enhance Ach release
• Muscarinic type 3 (M3)  contraction
• Net effect
– Depends on the affinty to M2 and M3
– Rapacuronium  Blocks M2, Activates M3
– Vecuronium  same as Rapacuronim but not in
clinical dosage
– Rocuronium, cisatracurium or mivacurium
• No effect
33 Zekeriyya Alanoglu, MD, DESA
 Mechanisms of action of NMBA
• Potency
– Effective dose (ED)
– ED95 or ED50
• Onset
– Max. neuromusc. block
• Clinical duration of
action
– dur25 or dur95
• Recovery Index 25-75%
• Total duration of action
34 Zekeriyya Alanoglu, MD, DESA
 Nondepolarizing NMBAs

35 Zekeriyya Alanoglu, MD, DESA

 Pharmacokinetics of NMBA
• Factors influencing pharmacokinetics
– Volume of distrubition (Vd)
– Plasma protein binding
– Pharmacologic potency
• High or Low ED95
– Speed of injection
– Perfusion
– Obesity
– Age
– Pregnancy
– Temperature
36 Zekeriyya Alanoglu, MD, DESA
Vd, Plasma Clearence and Elimination Half
Time of NMBAs

37 Zekeriyya Alanoglu, MD, DESA

 Elimination and Metabolism of NMBA
• Single dose of NMBA
– Redistribution of drug
– Junction and central compartment
– To Peripheral compartment
• Repeated doses or infusion
– Redistribution capacity will be saturated
– Recovery is dependent to elimination

38 Zekeriyya Alanoglu, MD, DESA

 Elimination and Metabolism of NMBA
• Renal elimination
– All NMBA can be eliminated through the kidney
– Decreased renal function
• Prolongs elimination half life of
• Pancuronium, Rocuronium
• Hepatic Elimination
– Steroidal NMBA
– Active metabolites
• Non enzymatic Hoffman elimination
– Spontaneous temperature
– pH dependent degradation
39 Zekeriyya Alanoglu, MD, DESA
 Elimination and Metabolism of NMBA
• Ester Hydrolysis
– Succinycholine and Mivacurium
– Plasma cholinesterase
• Atypical plasma cholinesterases
– Heterozygous 1:480 minimal effect
– Homozygous 1:3200 prolonged block up to several
hours
• Dibucaine test - Number
– Inhibits easily normal form of plasma cholinesterase
– The percentage of inhibition  Dibucaine Number
40 Zekeriyya Alanoglu, MD, DESA
 Dibucaine Number
Dibucaine Plasma Neuromuscular Incidence
Number Cholinesterase Recovery
˃ 70 Normal Normal -

35-65 Heterozygous Minimal 1:480

Atypical
˂ 30 Homozygous Prolonged by 1:3200
Atypical hours

41 Zekeriyya Alanoglu, MD, DESA

Elimination and Metabolism of NMBA

42 Zekeriyya Alanoglu, MD, DESA

 Clinical Pharmacology of NMBA
• Succinylcholine
– ED95 0.3 mg kg-1
– Intubating dose 1 mg kg-1
– Ideal dose is under debate
– Precurarization
• Signs of muscle weakness

43 Zekeriyya Alanoglu, MD, DESA

 Clinical Pharmacology of NMBA
Adverse effects of Succinylcholine

Stimulation of muscarinic AChRs of the Release of intracellular potassium

cardiac sinoatrial node

Bradycardia Myalgia

AV node rhythm Masseter Spasm

Ventricular arrhytmia Trigger for Malignant Hyperthermia

Depolarization of the endplate Allergic reactions

Increased intracranial, intraocular and

intragastric pressure

44 Zekeriyya Alanoglu, MD, DESA

 Clinical Pharmacology of NMBA
Contraindications to Succinylcholine

Neuromuscular disease Denervation (after 2 days)

Immobilization (after 3 days) Burns (after 2 days)

Chronic use of muscle relaxants Sepsis/Severe inflammation

(after 3 days) (after 3 days)

Disposition to malignant hyperthermia Allergy against succinylcholine

Homozygous for atypical plasma

cholinesterase

45 Zekeriyya Alanoglu, MD, DESA

 Clinical Pharmacology of NMBA
• Standart intubation
– ED95 x 2 dose
– Optimal time point for intubation ?
• Rapid sequence anesthesia induction
– Increased intubation dose (ED95 x 3 dose)
– Priming
– “Can`t ventilate Can`t intubate”
– Rocuronium vs Succinylcholine
46 Zekeriyya Alanoglu, MD, DESA
 The efficacy of Rocuronium-Remifentanil combination in rapid
sequence anesthesia induction
Alanoğlu Z, Yılmaz AA, Şahin N, Ateş Y, Tüzüner F
Anestezi Dergisi 2006; 14: 109-115
• n=80
• 6 mg.kg-1Thiopental
• Group I (n=20) Saline + 0.6 mg.kg-1 Roc.
• Group II (n=20) 1 µg.kg-1 Remi. + 0.6 mg.kg-1 Roc.
• Group III (n=20) Saline + 1.2 mg.kg-1 Roc.
• Group IV (n=20) 1 µg.kg-1Remi. + 1.2 mg.kg-1 Roc.
• Intubation conditions
• Hemodynamic changes

Zekeriyya Alanoglu, MD, DESA

 The efficacy of Rocuronium-Remifentanil combination in rapid
sequence anesthesia induction
Alanoğlu Z, Yılmaz AA, Şahin N, Ateş Y, Tüzüner F
Anestezi Dergisi 2006; 14: 109-115
• Total intubation score (max.14 points) median (25-75)
– Group I= 10.5 (9-13) points (p˂0.01) (SD vs other groups)
– Group II= 14 (13-14) points
– Group III= 13 (12-14) points (p˂0.01 ve p ˂0.05) (SD vs Remi
groups)

– Group IV= 14 (14-14) points

• Remifentanil and Rocuronium combination
provides superior intubation conditions
independent of the Rocuronium dose.
Zekeriyya Alanoglu, MD, DESA
• n= 120 hypertensive patients
• 5-7 mg.kg-1 Pentotal
• Group LS (n = 30) 1.5 mg.kg-1Lidocaine + 1 mg.kg-1Suc.
• Group LR (n = 30) 1.5 mg.kg-1Lidocaine + Roc.1 mg.kg-
1
• Group RS (n = 30) 1 µg.kg-1Remi. + 1 mg.kg-1Succ.
• Group RR (n = 30) 1 µg.kg-1 Remi. +1 mg.kg-1Roc.
• Intubation conditions
• Hemodynamic changes
Zekeriyya Alanoglu, MD, DESA
• Total Intubation Score (max.14 points) median (25-75)
– Group LS= 14 (12-14) points
– Group LR= 14 (13-14) points
– Group RS=NS
14 (14-14) points
– Group RR= 14 (13-14) points
• 12 points and higher points n,
– Group LS= 25, Group LR= 28
NS
– Group RS= 29, GroupZekeriyya
RR=Alanoglu,
29 MD, DESA
Factors Confounding The Clinical Pharmacology of
NMBAs
• Renal insufficiency
– Consider atracurium, cis atracurium or mivacurium
– Reduced activity of pl cholinesterase
– Prolonged effect of Succ. and Miv.
– Altered Vd
• Hepatic disease
– Increased Vd
– Higher doses needed and prolonged effect
– Reduced activity of pl cholinesterase
51 Zekeriyya Alanoglu, MD, DESA
 Factors Confounding The Clinical Pharmacology of
NMBAs
• Decreased number of nAChRs (down regulation)
– Myastenia Gravis
• Muscle weakness and fatigue
– Antibody against nAChRs (+) in 80% of cases
– Antibody against Muscle specific kinase (MuSK)
• Clustering and maturation of the receptor
– Decreased number of receptors
– Sensitivity to nondep. NMBAs
– Resistance to succs.
• Increased dose age is needed
• Concerns
54
for Phase II block
Zekeriyya Alanoglu, MD, DESA
Factors Confounding The Clinical Pharmacology of
NMBAs
• Eaton-Lambert syndrome
– Paraneoplastic syndrome assoc. with Small Cell Ca.
– Antibodies against PQ-Type voltage gated Ca++
channels
– A cross reaction
– Reduced pre-junctional transmitter release
– Increased sensitivity to both groups of NMBAs

55 Zekeriyya Alanoglu, MD, DESA

 Cholinesterase Inhibitors
• Reverse nondepolarising muscle blockade
• Commonly used inhibitors
– Neostigmine
– Edrophonium
– Pyridostigmine
• Organophosphates
– Irreversible bonds to the enzyme
– Not for OR use
56 Zekeriyya Alanoglu, MD, DESA
 Cholinesterase Inhibitors
Organ System Muscarinic Side Effects
Cardiovascular Decreased HR, Bradyarrhytmias

Pulmonary Bronchospasm, Increased Bronchial secretions

Cerebral Diffuse excitation (physostigmine)

Gastrointestinal Intestinal spasm, Increased salivation

Genitourinary Increased bladder tone

Ophthalmological Pupillary constriction

57 Zekeriyya Alanoglu, MD, DESA

 Cholinesterase Inhibitors
Cholinesterase Inhibitor Usual dose Recommended Anticholinergic

Neostigmine 0.04-0.08 mg. kg-1 Glycopyrrolate

Pyridostigmine 0.1-0.4 mg. kg-1 Glycopyrrolate

Edrophonium 0.5-1 mg. kg-1 Atropine

Physostigmine 0.01-0.03 mg. kg-1 Not necessary

(not for reversal of NMBAs)

58 Zekeriyya Alanoglu, MD, DESA

Does the new reversal agent brings more to our
practice?
• Rocuronium related prolonged block
• CV-CI scenario
• Sugammadex (Org 25969)
– Celation and encapsulation
– A selective effect for steroidal nondep. NMBAs
– Gama Siclodekstrin Anesthesiology 2005; 103: 695-703
• Combination with rocuronium
• Avoiding the side effects of Succinylcholine
• Effective and SAFE muscle relaxation??????
Anesthesiology 2006; 104: 667-74
BJA 2006; 96: 36-43
Anesthesiology 2007; 106: 283-8
Anest Analg 2007; 104: 569-74
Anest Analg 2007; 104: 555-62
Zekeriyya Alanoglu, MD, DESA
 • Cyclodextrins are cyclic
Sugammadex olygosaccharides.
• Cyclodextrins # of
gyclopiranozides:
- 6 unit – α
- 7 unit – β
- 8 unit - γ
α-CD β-CD • Cyclodextrins are :
- Hydrophilic exterior
- Hydrophobic cavity
γ-CD • Water soluble complex
Davis ME, et al. Cyclodekstrin-based pharmaceutics: Past, presemt and future. Nat Rev Drug Discov. 2004;12:1023-1035.
Hogg RM, Mirakhur RK. Sugammadex: a selective relaxant binding agent for reversal of neuromuscular block. Expert Rev Neurother. 2009;9(5):599-608.
Scene1

ACh

Cholinesterase
Scene 2

ACh

Cholinesterase

Rocuronium
 Scene 3

ACh

Cholinesterase

Rocuronium
Cholinesterase Inhibitor
Scene 4

ACh

Cholinesterase

Rocuronium

SUGAMMADEX
• n=115
• Propofol+opioid anesthesia
• 1.2 mg.kg-1 Rocuronium
• 1.0 mg.kg-1 Succinylcholine
• 12 mg.kg-1 Sugammadex
• Rocuronium-Sugammadex
combination provides rapid recovery
compared to spontanous recovery of
succinylcholine… Zekeriyya Alanoglu, MD, DESA
 Sugammadex
• Dose ???
• Related to the depth of the block
• TOF count of 2  2 mg.kg-1
• PTC 1-2  4 mg.kg-1
• Profound deep block  8-16 mg.kg-1
• More dosing studies needed

66 Zekeriyya Alanoglu, MD, DESA

 Conclusion
• Basic knowledge of
– Neuromuscular transmission
– Neurotransmitters
– Ion channels
– Types of NM block
– Agonists vs antagonists
– Pharmacokinetics and pharmacodynamics of drugs
– Myastenia Gravis
– Reversal agents
is a MUST…
67 Zekeriyya Alanoglu, MD, DESA