Module 2 Section 4 (Neuromuscular Blocking Drugs and Anesthetics)

Question 1

What is the peripheral nervous system composed of?

Answer 1

The peripheral nervous system is composed of the autonomic nervous system and the somatic nervous system.

Question 2

What do the autonomic and somatic nervous systems innervate?

Answer 2

The autonomic nervous system innervates smooth and cardiac muscle

The somatic nervous system innervates skeletal muscle, which is under voluntary control and consists primarily of the muscles of posture and movement.

Question 3

How many neurons are required for the somatic nervous system to reach the target skeletal muscle?

Answer 3

Unlike the autonomic nervous system, which consists of two neurons to reach the target organ, the somatic nervous system requires just one neuron to reach the target skeletal muscle.

Question 4

True or false: in the somatic nervous system, the voluntary motor nerves extend from the CNS all the way to the skeletal muscle.

Answer 4

True

Question 5

Describe the structure of the neurons in the somatic nervous sustem and what they release.

Answer 5

Some neurons in the somatic nervous system can be very long.

At the skeletal muscle, the neuron releases acetylcholine, which binds to nicotinic receptors on skeletal muscle.
- Receptor activation on the skeletal muscle causes contraction of the muscle

Question 6

What is the neuromuscular junction?

Answer 6

The synapse between a motor neuron and skeletal muscle.

Question 7

What occurs when the NN receptors on the skeletal muscle are activated?

Answer 7

When the NM receptors on the skeletal muscle are activated, they cause the muscle to contract.

In order for a muscle to contract, multiple NM (N= nicotinic; M = muscle) receptors on the muscle fibre have to be activated at once, causing depolarization of the skeletal muscle membrane followed by muscle fibre contraction.

Full muscle contraction is achieved when many NM receptors on many muscle fibers are activated simultaneously.

Question 8

Drugs that target skeletal muscle act by interfering with neurotransmission within the neuromuscular junction. These drugs are called neuromuscular blocking drugs. What are the 2 types of neuromuscular blocking drugs?

Answer 8

Non-depolarizing neuromuscular blockers: these drugs act like competitive antagonists, blocking the NM receptors, thereby inhibiting the binding of acetylcholine to the receptors.
- Since less NM receptors are available for acetylcholine to bind to, the muscle is unable to depolarize and muscle contraction is inhibited.

Depolarizing neuromuscular blockers: these drugs function like agonists, activating the NM receptors, thereby initially causing muscle contraction.
- However, these drugs are resistant to acetylcholinesterase breakdown and therefore cause continual activation of the NM receptors without allowing time for the muscle to repolarize, leading to muscle paralysis.

Question 9

What is the different between non-depolarizing and depolarizing neuromuscular blockers?

Answer 9

Ex: compare stopping a car by using the brakes to not being able to start a car because of a flooded engine.

A non-depolarizing neuromuscular blocker is similar to using the breaks to stop your car. It inhibits the acetylcholine (i.e. gas) from activating the receptors (i.e. engine), thereby stopping muscle contraction (i.e. the car).

A depolarizing neuromuscular blocker is similar to flooding the engine, since too much acetylcholine is in the neuromuscular junction activating the receptors (i.e. too much gas is in the engine), which results in a desensitization of the receptors (i.e. engine will not start), and therefore the muscle becomes paralyzed (i.e. the car cannot run).

Question 10

Provide an example of non-depolarizing neuromuscular blockers.

Answer 10

The majority of clinically relevant neuromuscular blockers are non-depolarizing blocking agents.

The prototypical example drug in this class is tubocurarine.

• Onset of action of tubocurarine = four minutes
• Pharmacological effect = 45-60 minutes.

Clinically, tubocurarine is no longer commonly used, as it has been predominantly replaced by related drugs that have better safety profiles.
- However, the agents currently used clinically act in the same manner as tubocurarine.

Question 11

How can the effect of non-depolarizing blocking agents be overcome?

Answer 11

The effect of non-depolarizing blocking agents can be overcome by using acetylcholinesterase inhibitor drugs (e.g. physostigmine). By inhibiting acetylcholinesterase, the buildup of acetylcholine is able to out compete the non-depolarizing blocking drug, resulting in muscle contraction.

Question 12

How do depolarizing blocking agents work?

Answer 12

Depolarizing blocking agents activate the NM receptors similar to acetylcholine, depolarizing the plasma membrane of the muscle fiber. However, the drugs are more resistant to the enzyme acetylcholinesterase.

Therefore, the drug is not broken down in the synapse and the muscle fibers are persistently depolarized. The result is paralysis of muscle fiber

Question 13

What depolarizing blocking agents are used clinically?

Answer 13

The only depolarizing blocking agent used clinically is succinylcholine.

• It has rapid onset (30 seconds) and a short duration of action (5-10 minutes).
• The short duration of action is due to the fact that succinylcholine is metabolised by cholinesterase in the plasma of the blood, which is why the duration of action is short compared to non-depolarizing blocking agents.

Question 14

Two phases exist to the depolarizing block. What are they?

Answer 14

1) Depolarizing phase: the muscle fibers depolarize in a disorganized manner, resulting in muscular fasciculation (i.e. twitching).
- Once the muscle fibers depolarize, they are unable to repolarize due to the continual presence of the drug activating the receptors, resulting in paralysis.

2) Desensitizing phase: this occurs after prolonged exposure to the depolarizing blocking agent.
- The muscle membrane eventually repolarizes, but it is now desensitized. Therefore, the muscle is no longer responsive to acetylcholine and full neuromuscular block has been achieved.
- The result is flaccid paralysis, a condition where your muscles are unable to contract.

Question 15

What occurs during the desensitization phase?

Answer 15

During the desensitization phase, once the NM receptors become desensitized to the depolarizing blocker, the NM receptors act as if an antagonist is binding instead of an agonist.

Consequently, binding of acetylcholine to the NM receptors also no longer activates them.

Because of this desensitization, the effect of depolarizing blocking agents is prolonged by the use of acetylcholinesterase inhibitor drugs, since neither acetylcholine nor the depolarizing blocking drug can activate the NM receptors.

Question 16

What are some adverse effects of depolarizing neuromuscular blockers?

Answer 16

Hyperkalemia: normal activation of NM receptors opens the receptor’s intrinsic Na K channel, causing Na to rush into the cell and K to trickle out of the cell.

• Usually, the channel is more permeable to Na than to K, however, during sustained depolarization, K can rush out of the cell and into the blood.
• Elevated levels of K in the blood can lead to cardiac arrest.
• Patients with burns, nerve damage, or neuromuscular disease are susceptible to this adverse effect, as NM receptors are often upregulated in these conditions.

Muscle pain: use of depolarizing blockers such as succinylcholine are associated with postop pain.
- This is more common for heavily muscled patients.

Malignant hyperthermia: this is an uncommon, genetically linked condition that can occur after exposure to succinylcholine and manifests as a rise in body temperature, tachycardia, and muscle rigidity.
- Symptoms usually develop within an hour of exposure.

Question 17

What are some clinical indications of neuromuscular blockers?

Answer 17

Not many drugs target skeletal muscle.

However, a few therapeutic indications for targeting skeletal muscle exist, such as during surgical procedures (e.g. to produce muscle paralysis as adjuncts to anesthetics) or to reduce spasticity (e.g. muscle relaxants for chronic back pain or fibromyalgia).

Surgery: the most common use of neuromuscular blockers is during surgical procedures.
- By using drugs to target skeletal muscle, it is possible to achieve adequate muscle relaxation for all types of surgical procedures, especially during intra-abdominal and intra-thoracic procedures, without the cardiorespiratory depressant effects of deep anesthesia.

Endotracheal intubation: relaxation of the tracheal and pharyngeal muscles, facilitating the insertion of the endotracheal tube, which maintains airways during surgery. - Succinylcholine is often used, as short-term paralysis is needed for endotracheal intubation.

Control of ventilation: for critically ill patients who have respiratory failure.
- By administering a neuromuscular blocker, chest wall resistance and ineffective spontaneous ventilation is eliminated, allowing the ventilator to maintain respiration.

Question 18

What are the neurotransmitters used in the parasympathetic, sympathetic, and somatic nervous system?

Answer 18

The parasympathetic nervous system releases acetylcholine from the presynaptic neurons and the postsynaptic neurons.

The sympathetic nervous system releases acetylcholine from the presynaptic neurons and norepinephrine from the postsynaptic neurons.

The somatic nervous system, a one-neuron system, releases acetylcholine from the motor neurons.

Question 19

What is anesthesia? What is the purpose?

Answer 19

Anesthesia is defined as a state of loss of sensation.

The purpose of anesthesia is to protect the patient from the pain of surgery, and secondarily to provide a still surgical field.

Question 20

What are the 5 physiological characteristics of general anesthesia?

Answer 20

• hypnosis (loss of consciousness)
• amnesia (loss of memory)
• analgesia (loss of response to pain)
• areflexia (loss of autonomic response)
• relaxation (skeletal muscle relaxati

Question 21

True or false: general anesthetics are often used in combination.

Answer 21

True

As you can probably guess, no single anesthetic agent is capable of achieving all of these desirable effects. Therefore, general anesthetics are often used in combination.

Question 22

How do anesthetics work?

Answer 22

In general, anesthetics work by globally depressing the CNS.

Specifically, anesthetics depress the reticular activating system (a bundle of nerve fibres near the brainstem that filters unnecessary information from reaching the brain, such as a crowd of talking people) in the brain.

Question 23

What are the potential theories by which neural depression occurs?

Answer 23

1) Facilitation of GABA-mediated inhibition at GABAA receptor chloride channel: strengthens the inhibitory function of GABA, increasing CNS depression.
2) Antagonism of glutamic acid excitation of NMDA channel receptor: decreases excitation in the CNS, enhancing CNS depression.

Question 24

What are the 2 categories that general anesthetics can be divided into?

Answer 24

1) Inhaled anesthetics

2) Intravenous anesthetics

Question 25

How do inhaled anesthetics work?

Answer 25

Once the drug reaches the alveoli of the lungs, it is transferred into the blood, where it travels to the brain.

Since the patient is breathing in the drug, increased pulmonary ventilation will increase the speed of anesthetic uptake.

Common inhaled anesthetics are nitrous oxide, halothane, and isoflurane.

Question 26

What is Minimum Alveolar Concentration (MAC). What does a high value mean?

Answer 26

It’s the concentration of inhaled anesthetic that is required to prevent 50% of patients from responding to a painful surgical stimulus with “gross purposeful movements.”

A high MAC corresponds to low potency of the inhaled anesthetic.

Question 27

What are the 2 main types of inhaled anesthetics?

Answer 27

1) Nitrous oxide (N2O): Nitrous oxide has a low potency and produces incomplete anesthesia.
- The onset and offset of nitrous oxide is rapid and it has prominent analgesic effects.
- Minimal hypotension and respiratory depression occur with the use of this inhaled anesthetic.

2) Volatile anesthetics (e.g. isoflurane, halothane): these anesthetics are liquid at room temperature, and are aerosolized for inhalation.
- They are potent drugs that produce unconsciousness and to lesser degrees analgesia and muscle relaxation.
- Adverse effects of volatile anesthetics are decreased blood pressure and decreased respiration. Bronchial dilation also occurs.

Question 28

How do intravenous anesthetics work?

Answer 28

Intravenous anesthetics are ones that are administered directly into the blood, and then travel to the brain to exert their effects.
- By traveling through the blood, the anesthetic travels to the vital organs (e.g. brain and heart), but also to muscle and fat.

The patient awakes after being given a bolus of drug because of redistribution of the drug from the brain to muscle and fat, not by elimination of the drug from the body.

Question 29

What are 2 common examples of IV anesthetics?

Answer 29

1) Propofol: It’s the most frequently administered drug for induction of anesthesia.
- Patients recover from propofol very rapidly despite prolonged infusions due to extensive metabolism in the liver and other organs. As such, propofol is the ideal ambulatory anesthetic.
- Low dose propofol can prevent nausea and vomiting.
- A common adverse effect is hypotension, however there is no change in heart rate.

2) Ketamine: It’s a common general anesthetic used in the hospital, and is often used in pediatric anesthesia.
- However, it is also sometimes used as a recreational street drug. In general, ketamine provides analgesia and is the anesthetic of choice for compromised blood flow.
- Ketamine does cause hypertension and tachycardia, but it does not usually cause apnea. It also causes high intracranial pressure, dysphoria (i.e. a state of unease), and a dissociative state (i.e. catalepsy and amnesia).

Question 30

How do local anesthetics work?

Answer 30

Local anesthesia refers to a loss of sensation that is confined to a discrete area of the body.
- Essentially, local anesthetics work by blocking sensory nerve conduction. The unionized local anesthetic enters the cell, where it becomes ionized and blocks the voltage-gated sodium channels, which inhibits nerve transmission.

Question 31

Other than blocking pain, what else do local anesthetics do?

Answer 31

Local anesthetics not only block pain, but can also block autonomic function, temperature sensation, light touch sensation, proprioception, and motor function.

Question 32

How are the therapeutic effects of local anesthetics terminated?

Answer 32

The therapeutic effect of local anesthetics can be terminated by systemic absorption, distribution, and elimination.

Recovery from local anesthesia is normally predictable, spontaneous, and complete, meaning that no residual effects of the local anesthetic remain after recovery. An example of acommonly used topical anesthetic is lidocaine

Question 33

What are local anesthetics used for?

Answer 33

1) Topical anesthesia: application of the anesthetic directly to the area involved (e.g. cornea of the eye).
2) Local infiltration anesthesia: local anesthesia produced by injection of the anesthetic solution in the area of terminal nerve endings.
3) Spinal anesthesia: anesthetic solution is injected into the spinal fluid.
4) Epidural anesthesia: anesthetic solution is injected into the epidural space.

Question 34

What are the adverse effects of local anesthetics?

Answer 34

Allergy (very rare): most “allergies” are not allergies to the anesthetic itself, but due to added preservatives to the anesthetic solution.
- Alternatively, sometimes the reaction is mistermed an allergy when it is in fact an additive physiologic effect due to other drugs the patient is taking.

Systemic toxicity: systemic toxicity occurs due to excessively high blood levels of the local anesthetic and is associated with drug overdose or accidental intravascular injection.
- Ex: all local anesthetics can produce sedation, light-headedness, visual and auditory disturbance, and restlessness when the blood levels of the anesthetic are too high.

Question 35

How do general and local anesthesia differ in terms of their administration and their effect?

Answer 35

General anesthesia leads to loss of consciousness, loss of memory, loss of response to pain, loss of autonomic function, and relaxation of skeletal muscle, and is administered intravenously or via inhalation.

In contrast, local anesthetics function by blocking voltage-gated sodium channels in the area applied, blocking nerve conduction and producing analgesia. They can be administered topically, via local infiltration, or via injection into the spinal column or epidural space

Question 36

The endogenous neurotransmitter at the motor nerve ending is:

a) Acetylcholine
b) Nicotine
c) Muscarine
d) Norepinephrin

Answer 36

a) Acetylcholine

Question 37

Which one of the statements regarding neuromuscular blockers is correct?

a) Succinylcholine is an example of a nondepolarizing blocker
b) Tubocurarine is an example of a depolarizing blocker
c) A non-depolarizing block occurs in two steps
d) Acetylcholinesterase inhibitors prolong depolarizing blockers

Answer 37

d) Acetylcholinesterase inhibitors prolong depolarizing blockers