Neuromuscular Blocking Agents - NMBAs Flashcards by Trenton Mobley

Pancuronium (Pavulon)

Chemical Classification
&
MOA

Chemical Classification
Aminosteroid - Non-depolarizing

MOA
Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization

Long Acting

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Pancuronium (Pavulon)

Dosing

IV: 0.1 mg/kg

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Pancuronium (Pavulon)

Onset
Duration

Onset
2-5 min

Duration
60-120 min

Aminosteroid - Long Acting

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Pancuronium (Pavulon)

Metabolism
&
Elimination

Metabolism
Hepatic: 50% metabolized

Elimination
50% secreted renally
80% eliminated unchanged in urine

↑ VD in liver disease
Need ↑ initial dose
↑ duration in liver & renal failure

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Pancuronium (Pavulon)

Side Effects
&
Considerations

No histamine release

Cardiovascular
↑ HR MAP & CO d/t
vagal blockade &
SNS activation;
↑presynaptic NE &
↓NE uptake
NO Δ in SVR or intropy

Interactions
VA; diuretics; corticosteroids; metoclopramide; LA; magnesium
can cause dose-dependent NMBA enhancement

Hypokalemia
↑ NMBD sensitivity
HYPERkalemia
↓ NMBD sensitivity (resistant to blockade)

Hypothermia can prolong duration

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Vecuronium (Nornuron)

Chemical Classification
&
MOA

Chemical Classification
Aminosteroid - Non-depolarizing

MOA
Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization

Intermediate Acting

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Vecuronium (Nornuron)

Dosing

IV: 0.1 mg/kg

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Vecuronium (Nornuron)

Onset
Duration

Onset
2-3 min

Duration
45-90 min

Aminosteroid - Intermediate Acting

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Vecuronium (Nornuron)

Metabolism
&
Elimination

Metabolism
Hepatic: 70%

Active metabolite is
50-80% potent

Elimination
Renal: 30%

Repeated dose & infusion have cumulative effects

E½ time prolonged in renal dysfunction

Better in liver failure only

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Vecuronium (Nornuron)

Side Effects
&
Considerations

No histamine release

VA; diuretics; corticosteroids; metoclopramide; LA; magnesium
can cause dose-dependent NMBA enhancement

If ACIDOSIS occurs BEFORE administration;
No NMB Δ in action
If ACIDOSIS occurs AFTER administration; WILL prolong NMBD blockade

Hypokalemia
↑ NMBD sensitivity
HYPERkalemia
↓ NMBD sensitivity (resistant to blockade)

Hypothermia can prolong duration

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Rocuronium (Zemuron)

Chemical Classification
&
MOA

Chemical Classification
Aminosteroid - Non-depolarizing

MOA
Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization

Intermediate Acting

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Rocuronium (Zemuron)

Dosing

IV: 0.6 mg/kg
RSI IV: 1.2 mg/kg

IBW

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Rocuronium (Zemuron)

Onset
Duration

Onset
2-5 min
RSI: 1-2 min

Duration
35-75 min
RSI: 40-70 min

Aminosteroid - Intermediate Acting

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Rocuronium (Zemuron)

Metabolism
&
Elimination

Metabolism
Hepatic: Remains unchanged in bile

Elimination
10-30% renal excretion

Greater hepatic involvement than Vecuronium

Good to use in renal failure

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Rocuronium (Zemuron)

Side Effects
&
Considerations

No histamine release

Minimal vagolytic activity

VA; diuretics; corticosteroids; metoclopramide; LA; magnesium can cause dose-dependent NMBA enhancement

Hypokalemia
↑ NMDB sensitivity
HYPERkalemia
↓ NMBD sensitivity (resistant to blockade)

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Cistatricurium (Nimbex)

Chemical Classification
&
MOA

Chemical Classification
Benzylisoquinolone - Non-depolarizing

MOA
Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization

Intermediate Acting

Cistatricurium (Nimbex)

Dosing

IV: 0.1 mg/kg

IBW in obese patients

Cisatricurium (Nimbex)

Onset
Duration

Onset
2-5 min

Duration
40-75 min

Benzylisoquinoline - Intermediate Acting

Cistatricurium (Nimbex)

Metabolism
&
Elimination

Metabolism
Ester hydrolysis

Elimination
Hoffman elimination;
pH & temp dependent

DOC: Hepatic & renal failure

Cistatricurium (Nimbex)

Side Effects
&
Considerations

LEAST likely to have allergic reaction

VA; diuretics; corticosteroids; metoclopramide; LA; magnesium
can cause dose-dependent NMBA enhancement

Atracurium (Tracrium)

Chemical Classification
&
MOA

Chemical Classification
Benzylisoquinoline - Non-depolarizing

MOA
Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization

Intermediate Acting

Atracurium (Tracrium)

Dosing

IV: 0.5 mg/kg

Atracurium (Tracrium)

Onset
Duration

Onset
3-5 min

Duration
20-35 min

Benzylisoquinoline - Intermediate Acting

Atracurium (Tracrium)

Metabolism
&
Elimination

Metabolism
Ester hydrolysis

Elimination
Hoffman elimination;
pH & temp dependent

Metabolite
Laudonosine; 70% hepatic excretion
via bile; 30% in urine

**Atracurium (Tracrium)** Side Effects & Considerations

Most likely to cause bradycardia Greatest concern for histamine release VA; diuretics; corticosteroids; metoclopramide; LA; magnesium can cause dose-dependent NMBA enhancement

**Mivacurium (Mivacron)** Chemical Classification & MOA

**Chemical Classification** Benzylisoquinoline - Non-depolarizing **MOA** Blocks ACh from binding to nACh receptors on motor endplate inhibiting depolarization | Short Acting

**Mivacurium (Mivacron)** Dosing

IV: 0.15 mg/kg

**Mivacurium (Mivacron)** Onset Duration

**Onset** 2-3 min **Duration** 12-20 min | Benzylisoquinoline - Short Acting

**Mivacurium (Mivacron)** Metabolism & Elimination

**Metabolism/Elimination** Plasma cholinesterase

**Mivacurium (Mivacron)** Side Effects & Considerations

Histamine Release MAP ↓ > in pts w/ HTN; Possible bronchospasms VA; diuretics; corticosteroids; metoclopramide; LA; magnesium can cause dose-dependent NMBA enhancement

**Succinylcholine (Anectine)** Chemical Classification & MOA

**Chemical Classification** Depolarizing Neuromuscular Blocking Agent **MOA** Mimics Ach; produces sustained depolarization of motor endplate at NMJ

**Succinylcholine (Anectine)** Dosing

IV: 1-1.5 mg/kg* 1.5-2 mg/kg in myasthenia gravis *ABW

**Succinylcholine (Anectine)** Onset Duration

**Onset** 30-60 sec **Duration** 3-5 min

**Succinylcholine (Anectine)** Metabolism & Elimination

**Metabolism/Elimination** Hydrolyzed by butyrylcholinesterase (Pseudocholinesterase) **Metabolite** Succinylmonocholine; can cause seizures

**Succinylcholine (Anectine)** Side Effects & Considerations

**Histamine release ↑ K+ by 0.5 mEq/L** Dysrhythmias Myalgia Myoglobinuria Masseter spasm ↑ intragastric; intraocular; intracranial pressure MOST likely to have allergic reaction **Cardiovascular** Dysrhythmias: SB, JR, & sinus arrest Subsequent doses: 2nd ↑ risk of dysrhythmias ↑ HR & SBP (ANS response) HYPOkalemia ↓ SCh sensitivity (resistant to blockade) HYPERkalemia ↑ SCh sensitivity *Phase II block occurs w/ Sch dose 2-4 mg/kg* **Can cause MH** 20% less dose in Lambert-Eaton pts 1.5-2 mg/kg in myasthenia gravis C/I in pediatrics & Pseudocholinesterase deficiency(prolonged neuromuscular blockade)