Neuromuscular blockade

Neuromuscular blockade

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Pharmacodynamics
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Neuromuscular blockade involves the use of neuromuscular blocking agents (NMBAs) (i.e. paralytics) to facilitate endotracheal intubation and/or surgical procedures.

Drugs used

Non-depolarizing agents bind to and INHIBIT acetylcholine receptors at the end plate of the neuromuscular junction. Common examples below include:

Steroidal non-depolarizing agents (hepatic and/or renal excreted):

• Rocuronium
• Vecuronium

Benzylisoquinolinium non-depolarizing agents (broken down by Hoffman Elimination):

• Cisatrocurium (the cis-enantiomer of atrocurium)

Depolarizing agents on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

• Succinylcholine

Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.

Monitoring

Train of Four

In order to assess the level of paralysis during an anesthesia event, train of four monitoring (either quantitative or qualitative) is typically used throughout the duration of the procedure (e.g. during routine assessments) and prior to extubation. Quantitative train of four monitoring is the most accurate assessment of neuromuscular blockade and is preferred as it mitigates the risk of residual paralysis and subsequent post-op pulmonary complications. Equipment that can be used includes:

• Electromyography (EMG)
• Acceleromyography (AMG)
• Kinemyography (KMG)