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Toronto Notes 2019 Induction Table 11. Non-Depolarizing Muscle Relaxants (Competitive)
Anesthesia A19
Mechanism of Action
Classification
Intubating Dose (mg/kg)
Onset (min) Duration (min) Metabolism
Indications Side Effects
Histamine Release
Other Considerations
Competitive blockade of postsynaptic ACh receptors preventing depolarization
Short Intermediate
Long
Liver (minor)
Mivacuronium 0.2
2-3 15-25
Plasma cholinesterase
Rocuronium Vecuronium 0.6-1.0 0.1
1.5 2-3 30-45 45-60
Liver (major) Liver Renal (minor)
Cisatracurium Pancuronium 0.2 0.1
3 3-5 40-60 90-120
Hofmann Renal (major) Eliminations
Assist intubation, assist mechanical ventilation in some ICU patients, reduce fasciculations, and post-operative myalgias secondary to SCh
Yes
—
Increased duration of action in renal or liver failure
No No No No
— — —
Quick onset of rocuronium allows its use in rapid sequence induction
Cisatracurium is good for patients with renal or hepatic insufficiency
Tachycardia
Pancuronium if increased HR and BP desired
Reversing Agents
• sugammadexisaselectiverelaxantbindingagent
• neostigmine,pyridostigmine,edrophoniumareacetylcholinesteraseinhibitors
• administerreversalagentswhentherehasbeensomerecoveryofblockade(i.e.muscletwitch)
• canonlyreversetheeffectofnon-depolarizingmusclerelaxants
• anticholinergicagents(e.g.atropine,gylcopyrrolate)aresimultaneouslyadministeredtominimize
muscarinic effect of reversal agents (i.e. bradycardia, salivation, increased peristalsis, and bronchoconstriction)
Table 12. Reversal Agents for Non-Depolarizing Relaxants
Agent Pyridostigmine Neostigmine Edrophonium
Onset Slow Intermediate Intermediate
Sugammadex
Fast
Encapsulates and inactivates rocuronium and vecuronium → iamount of agent available to bind to receptors in NMJ
2-16 mg/kg NA
NA
Mechanism of Action
Dose
Recommended Anticholinergic Dose of Anticholinergic (per mg)
(acetylcholinesterase inhibitors) Inhibits enzymatic degradation of ACh, increases ACh at nicotinic and muscarinic receptors, displaces non-depolarizing muscle relaxants
Muscarinic effects of reversing agents include unwanted bradycardia, salivation, and increased bowel peristalsis*
0.1-0.4 mg/kg Glycopyrrolate 0.05 mg
0.04-0.08 mg/kg Glycopyrrolate 0.2 mg
0.5-1 mg/kg Atropine 0.014 mg
*Atropine and glycopyrrolate are anticholinergic agents administered to minimize muscarinic effects of reversal agents
Analgesia
• optionsincludeopioids(e.g.morphine,fentanyl,hydromorphone),NSAIDS,acetaminophen,ketamine, gabapentin, local, and regional anesthetic (see Table 15, A25)