Week 5 - Neuromuscular Junction, Relaxants & Antagonists Flashcards
How does an action potential stimulate the distal motor nerve?
- Ca++ diffuses in terminal and voltage gated C++ channels open
- Synaptic vesicles fuse to the presynaptic membrane
- ACh is released into the cleft (10,000 molecules per vesicle)
- Presynaptic nicotinic receptor responds to the presence of ACh by synthesizing more and mobilizing ACh vesicles (+ feedback)
- ACh binds to the nicotinic ACh receptors on the surface of the post-junctional membrane —Contraction occurs
How is the Ca++ channel activated at the NMJ?
- During nerve action potential
- Na+ flows into the cell and depolarizes the voltage gated Ca++ channels
- Ca++ influx triggers the release of ACh
- ACh combines with postsynaptic nicotinic receptors
- BOTH alpha subunits must be occupied to open the ion channel (Na & Ca diffuse IN; K diffuses OUT)
- Ca++ influx continues until depolarization and the channels inactivate
How is ACh hydrolyzed?
by ACh esterase (AChE) to Choline and Acetic Acid
-Choline is taken up by presynaptic terminal for resynthesis of ACh
ACh depolarizes the NMJ and is rapidly metabolized by AChE
What is the release of neurotransmitters dependent upon?
The entry of Ca++
Hypocalcemia decreases release
Hypercalcemia increases release
How does hypo- and hypermagnesemia affect neurotransmitter release?
Hypomagnesemia increases release
Hypermagnesemia decreases release
What is the structure of the nicotinic ACh receptor?
a five subunit complex with 2 alpha, 1 beta, 1 delta, and 1 gamma
What occurs in up-regulated ACh receptors?
- ACh receptor agonists see increased sensitivity
- ACH receptor antagonists see decreased sensitivity (ie NDMRs)
- These patients require increased dosages or shorter redosing intervals of the NMDRs
*Occurs in denervation injuries – burns
What occurs in down-regulated ACh receptors?
Occurs in Myasthenia Gravis
- ACh receptor agonists see decreased sensitivity and require higher doses (Sux)
- ACh receptor antagonists see increased sensitivity and require lower dosages of NDMR and longer intervals between redosing
What is the mechanism of action of depolarizing muscle relaxants
depolarize the nicotinic ACh receptor — NOT competitive
-action similar to ACh
Where does SUX attach to the nicotinic receptor?
SUX attaches to the 2 alpha subunits and causes depolarization
How is SUX metabolized?
By Butyryl-cholinesterase (BCH-esterase)
-NOT present in the NMJ but found in the plasma
- After depolarization, SUX remains in the synaptic cleft until plasma level lowers and creates a concentration gradient out of the cleft
- When it moves out of the cleft, circulating BCH-esterase metabolizes the remaining SUX
- About 80-90% of a SUX dose is metabolized in the blood on the way to the NMJ
What is the mechanism of action of Non-Depolarizing muscle relaxants?
Competitive block – compete for ACh binding sites on the nicotinic receptor
- When NDMRs bind to the nAChr it prevents the ion channel from opening preventing depolarization of the membrane
- NDMRs completely BLOCK ACh from binding to the receptor and the post-synaptic membrane remains polarized (non-depolarized block)
What are characteristics of a non-depolarized block?
- it is from competitive inhibition of nAChr
- Shows FADE on TOF monitor (4 twitches can be different strengths)
- Can see post-tetanic facilitation (increase in TOF after tetanic stimulation)
- Can be antagonized (reversed) by AChE
- Do NOT see fasciculations (no depolarization)
What are the benefits of muscle relaxation?
Improve surgical conditions
Facilitate endotracheal intubation
What are the risks associated with muscle relaxation?
No analgesic or anesthetic properties whatsoever by themselves
What’s the difference between neuronal nAChr and fetal nAChr?
Neuronal (mature): presynaptic nerve ending – has a shorter burst duration and higher conductance of Na, K, and Ca than fetal
Fetal - post-synaptic; during development and denervation, and in immobilization and burn injury
When is the nicotinic ACh receptor closed and open?
Closed during resting states
Opens when ACh binds to the 2-alpha subunits and a conformational change occurs
What does the ED50 of a muscle relaxant mean?
the dose at which a muscle relaxant produces a 50% depression of twitch tension in the nicotinic ACh receptor
What does a depolarizing neuromuscular blocker do?
1) Desensitizes the nACh receptor
2) Inactivates the voltage gated sodium channel and the NMJ
3) Increases potassium permeability in the surrounding membrane
*Due to these no action potential can be generated and ACh blockade occurs
What is the sensitivity of fetal nACHr to NDMRs and Succinylcholine?
Resistant to NDMRs
More sensitive to Succinylcholine
*Fetal nACHr are low-conductance channels, thus ACh release causes brief activation and reduced probability of channel opeing
Neuromuscular blockade develops faster, is less profound (deep), and wears off (recovers) sooner in ______ located muscles?
centrally located muscles – i.e. larynx and diaphragm
What percent of nAChr need to be blocked for twitch to be completely eliminated?
90%
What are clinical tests that can be used to monitor cessation of neuromuscular block and return of muscle function?
1) 5-second, unaided, maintained head lift - equivalent to a NIF of -55 cmH2O - can be done with TOF ratio as low as 50%
2) Lift legs off the OR table - NIF of -50 cmH2O
3) Strong handgrip from which you cannot remove your two fingers
4) Tidal volume - requires only return of diaphragmatic muscle tone (can still pull 5 mL/kg with 80% of nAChr still occupied by NDMR)
5) Head lift and hand grip may be only 38% and 43% of control strength when inspiratory/expiratory flow rates are 90% of baseline
6) Inspiratory force may be only 70% of baseline when vital capacity and expiratory flow rates are 90% of control values
What type of compounds are all neuromuscular blockers?
Quaternary Ammonium Compounds
- positive charges at these sites mimic the quaternary nitrogen atom of ACh and allow the blockers to attach to the nicotinic ACh receptor at the NMJ
- also affect other nACh receptor sites (autonomic ganglia, sympathetic/parasympathetic ANS, and prejunctional nicotinic/muscarinic receptors in the NMJ)
What is the mechanism of action of Succinylcholine?
Depolarizing muscle relaxant — agonist at the NMJ (may have action at both muscarinic and nicotinic receptors)
-Mimics the action of ACh by binding the alpha subunits of the cholinergic nicotinic receptor at the NMJ and also at nicotinic ganglionic muscarinic autonomic receptors in the autonomic ganglia
What is the duration of action, onset time, recovery time, and ED95 of SUX?
Duration of Action = Ultrashort (rapid onset/rapid offset)
Onset = 0.5 - 1.5 min (45-60 seconds at 1 mg/kg)
Duration to 90% recovery = 8-15 minutes (9-13 min) at 1 mg/kg dose
ED95 = 0.25 - 0.3 mg/kg
What is the dosing for SUX? How is it supplied?
Typical Dose = 0.3 - 1 mg/kg
Classic Dose = 1 mg/kg — (results in complete suppression of neuromuscular response in 60 seconds)
Newer Dose = 0.5-0.6 mg/kg
*provided in a concentration of 20 mg/mL in a 10mL vial (200mg/vial)
What diseases or drugs prolong the duration of action of SUX?
Liver Disease — Advanced Age — Malnutrition — Pregnancy — Burns — Oral Contraceptives — MAOIs — Ecothiophate — Cytotoxic Drugs — Neoplasms — Anticholinesterases — Tetrahydroaminacrine — Hexafluorenium — Metoclopramide
(All decrease BCH-esterase activity, thus less SUX metabolism and prolonged duration of action)
*longest duration related to these issues has been reported as 23 minutes
What is the Dibucaine number?
It communicates how inhibited the action of BCH-esterase is by Dibucaine (tests for atypical BCE genetic variant)
- Normal = 70-80 — will have a normal duration of action of succinylcholine
- Homozygous atypical BCE person = 20-30 — will have prolonged action of SUX up to 4-8 hours and possible 24 hrs
- Heterozygous atypical BCE person = 50-60 — will have 50-100% longer duration of action of SCX (~30 minutes)
*High # = normal action Low # = poor action
What are the CV side effects of SUX?
- At low doses: BOTH negative inotropic and chronotropic effects may occur (decreased contractility/HR)
- At higher doses: tachycardia may occur
- Cardiac dysrhythmias, sinus brady, junctional and ventricular dysrhythmias
- sinus brady especially in children (they have lots of vagal tone and SUX simulates cardiac muscarinic receptors in the SA node)
- ventricular dysrhythmias may occur due to the increase in catecholamines and potassium increase (33%) after SUX dose
Why does hyperkalemia occur with SUX administration?
Via depolarization of the NMJ, Na+ moves into cells and K+ moves out of cells
-causes temporary 0.5 mEq/L increase in K+ levels
- Usually tolerated well in healthy patients
- Significant increase in pt’s with hypovolemia and metabolic acidosis
- Increased risk in conditions that lead to an increase in extrajunctional receptors
How do you treat severe rapid onset of Hyperkalemia?
- Hyperventilation
- 1-2 mg Calcium Chloride IV
- 50 mL D50 IV + 10 units IV insulin (Adults) or 1 mL/kg D50 + 0.15 U/kg insulin (Peds)
- 1 mEq/kg Sodium Bicarb
What effect does SUX have on Intra-Ocular Pressure?
Results in increased Intraocular Pressure within 1 minute, peaks 2-4 min, and subsides in 6 min
-SUX is contraindicated in eye injuries that result in an open anterior chamber
What effect does SUX have on Intra-gastric pressure?
it increases intra-gastric pressure
- Normal pressure = 20 cmH2O
- Greater than 28 cmH2O to vomit
- SUX raises pressure to 30 cmH2O
*may be an issue in pt’s with gastroesophageal junction issues – May increase risk of aspiration