Neuromuskuläre Blockade

Currently, the main aims of using neuromuscular blocking agents during general anaesthesia are the improvement of surgical and intubation conditions. Neuromuscular blocking agents themselves are neither analgesic nor anaesthetic. All agents interact with the acetylcholinergic receptor at the neuromuscular junction and induce a blockade either through a continuous activation imitating the effect of acetylcholine or through a competitive antagonism against acetylcholine. Succinylcholine is the only depolarizing muscle relaxant that is in clinical use. Non-depolarizing neuromuscular blockers may be grouped by their chemical structure into benzylisoquinolines or aminosteroids, and cover the complete range from short and intermediate, to long acting agents. Possible adverse drug reactions to the single agents are also related to their mechanism of action. Moreover, pharmacokinetic properties and effects such as histamine liberation could play an important role when choosing a myorelaxant. The depth of a neuromuscular block and recovery from paralysis can be monitored using qualitative and quantitative techniques. Therefore, the monitoring of neuromuscular recovery plays an important role in the prevention of postoperative complications due to residual paralysis. In case of residual paralysis, cholinesterase inhibitors are suitable for reversal.

Age-related changes in tolerance to the marine algal excitotoxin domoic acid

During an incident of toxic mussel poisoning, the epileptogenic excitotoxin domoic acid (DOM) was associated with lasting neurological deficits mainly in older patients (), suggesting supersensitivity to excitotoxins is a feature of brain aging. Here, hippocampal slices from young (3 months) and aged (26-29 months) Sprague Dawley rats were assessed by CA1 field potential analysis before and after preconditioning with DOM. In naïve slices from young animals, DOM produced initial hyperexcitability followed by significant dose-dependent reductions in population spike amplitude during prolonged application. Following toxin washout, only small changes in neuronal activity were evident during a second application of DOM, suggesting that a resistance to the effects of DOM occurs in hippocampal slices which have undergone prior exposure to DOM. This inducible tolerance was not antagonized by the NMDA receptor blockers APV or MK-801, nor was it diminished by the group I, II or III mGluR blockers AIDA, CPPG and EGLU. Likewise, neither the AMPA/KA blocker CNQX nor the VSCC blocker nifedipine were effective in blocking tolerance induction in young slices. Field potential analysis revealed significant age-related reductions in CA1 EPSP strength, population spike amplitude and paired-pulse inhibition, but aged slices did not differ in sensitivity to DOM relative to young. However, aged CA1 failed to exhibit any tolerance to DOM following preconditioning, suggesting that a loss of inducible neuroprotective mechanisms may account for increased sensitivity to excitotoxins during aging.

Skeletal muscle relaxants: pharmacodynamics and pharmacokinetics in different patient groups

Muscle relaxants can be safely administered during anaesthesia, providing the basic pharmacodynamic and pharmacokinetic characteristics of the compounds together with the physiological status of the patient are known. In this review the pharmacodynamics and pharmacokinetics of the neuromuscular blocking agents are discussed and related to the physical health or disease state of groups of patients.

The effects of antagonizing residual neuromuscular blockade by neostigmine and glycopyrrolate on nausea and vomiting after ambulatory surgery

The effects of neostigmine on the incidence of postoperative nausea and vomiting (PONV) are controversial. In this study, we evaluated the effects of neostigmine and glycopyrrolate on the incidence of PONV and the need for antiemetics in patients undergoing ambulatory surgery. One hundred healthy patients undergoing outpatient surgical procedures were included in the study. A standardized anesthetic technique was used for all patients. Patients were randomized to receive either mivacurium (n = 50) or rocuronium (n = 50) to achieve muscle paralysis. Bolus doses of mivacurium 2-4 mg or rocuronium 5-10 mg were administered to maintain one or two twitches of the train-of-four stimulation of the ulnar nerve at the wrist. After surgery, residual neuromuscular blockade was reversed with neostigmine 2.5 mg i.v. and glycopyrrolate 0.5 mg i.v. only if clinically deemed necessary (i.e., fade on train-of-four stimulation, inadequate tidal volume, reduced hand grip, or inability to maintain head lift). The incidence of PONV and the need for antiemetics were recorded in the post-anesthesia care unit (PACU), in the phase II unit, and 24 h after surgery. We compared patients who received neostigmine (n = 40) for reversal of residual neuromuscular blockade with those who did not (n = 60). More patients receiving rocuronium required reversal drugs than those receiving mivacurium (68% vs 10%). There were no differences in the incidence of nausea (18% vs 15%), vomiting (8% vs 12%), and the need for antiemetics (13% in both the groups) in the PACU between patients who received neostigmine and those who did not. In addition, the duration of PACU stay and the time to home-readiness were also similar between the groups. We conclude that, compared with rocuronium, the use of mivacurium decreases the need for reversal drugs. In addition, reversal of residual neuromuscular blockade with neostigmine does not increase the incidence of PONV or the need for antiemetic medications in patients undergoing ambulatory surgery.

IMPLICATIONS

In this study, we showed that the incidence of postoperative nausea and vomiting and the need for antiemetics do not increase with the use of neostigmine and glycopyrrolate for reversal of residual muscle paralysis.

The effect of mivacurium pretreatment on intra-ocular pressure changes induced by suxamethonium

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied in a double-blind, randomised, placebo-controlled study evaluating the efficacy of mivacurium pretreatment in attenuating the rise in intra-ocular pressure in response to suxamethonium administration, laryngoscopy and intubation. The patients were randomly allocated to receive either mivacurium 0.02 mg.kg-1 or normal saline as pretreatment 3 min before a rapid sequence induction technique using alfentanil, propofol and suxamethonium. Suxamethonium induced a significant increase in intra-ocular pressure in the control group but not in the mivacurium pretreatment group (mean (SEM) increase = 3.5 (1.2) mmHg vs. 0.4 (0.8) mmHg, p < 0.05). There was a decrease in intra-ocular pressure in both groups after laryngoscopy and intubation with no significant difference between the two groups. These results show that mivacurium pretreatment is effective in preventing the increase in intra-ocular pressure after suxamethonium administration.

A comparison of edrophonium and neostigmine for the reversal of mivacurium-induced neuromuscular blockade in sheep

The rate of reversal of neuromuscular block was compared in 36 sheep receiving either edrophonium (500 microg kg(-1)) and atropine (80 microg kg(-1)), neostigmine (50 microg kg(-1)) and atropine (80 microg kg(-1)) or saline (10 ml), using the train of four count (TO4C) recorded at n. facialis-m. levator nasolabialis. Neuromuscular block was produced with mivacurium (200 microg kg(-1)) followed later by a single incremental dose of 70 microg kg(-1). Antagonists or saline were given when spontaneous recovery from the incremental dose (TO4C = 1) had begun. The TO4C increased from 1 to 4 in all animals, in all treatment groups within 10 minutes of reversal. The TO4C was 4 in all animals five minutes after edrophonium, and seven minutes after neostigmine; differences were not statistically significant. The TO4C was significantly higher with edrophonium two and three minutes after antagonism compared with saline. The data show that spontaneous recovery from mivacurium is rapid in sheep, although reversal is accelerated by anticholinesterase drugs.

Antagonism of suxamethonium-induced jaw muscle contracture in rats

Masseter muscle rigidity (MMR) induced during general anaesthesia by suxamethonium is a clinical problem that may interfere with tracheal intubation. We have investigated the relation between twitch tension and contracture response to suxamethonium in rats. Rats were anaesthetized with 1% halothane (1.35 MAC). Jaw muscle temperature was maintained at either 37 or 41 degrees C while rectal temperature was kept at 37 degrees C by radiant heat. Twitch tension was produced by nerve stimulation at 0.2 Hz. Rats were pretreated with either a low dose of vecuronium (0.03 mg kg-1) or dantrolene (0.8 mg kg-1). Thereafter suxamethonium 750 micrograms kg-1 was administrated i.v. Low-dose vecuronium pretreatment significantly (90%) decreased suxamethonium-induced jaw muscle contracture (JMC) with minimal (3%) twitch block during local hyperthermia. Low-dose dantrolene pretreatment also reduced JMC (81% at 37 degrees C and 82% at 41 degrees C) while decreasing twitch by 30% at 37 degrees C and 31% at 41 degrees C. Both vecuronium and dantrolene at doses that minimally depressed the twitch response antagonized suxamethonium-induced JMC. We speculate that pretreatment with low-dose vecuronium decreases suxamethonium-induced MMR clinically.

Comparison of rocuronium and mivacurium to succinylcholine during outpatient laparoscopic surgery

Tracheal intubating conditions and neuromuscular effects of succinylcholine, rocuronium, and mivacurium were studied in 100 healthy women undergoing outpatient laparoscopic surgery. After a standardized fentanyl-thiopental induction, tracheal intubation was facilitated with succinylcholine 1 mg/kg in Groups I (n = 23) and II (n = 25), rocuronium 0.6 mg/kg in Group III (n = 27), or mivacurium 0.2 mg/kg in Group IV (n = 25). If clinically indicated, bolus doses of rocuronium 5-10 mg (Groups I and III) or mivacurium 2-4 mg (Groups II and IV) were administered during the maintenance period. Anesthesia was maintained with desflurane and nitrous oxide 60% in oxygen. At the end of the surgery, residual neuromuscular block was reversed with edrophonium 0.5 mg/kg and atropine 10 micrograms/kg, if needed. The neuromuscular function was assessed using electromyography with a train-of-four mode of stimulation every 10 s at the wrist. Intubating conditions 90 s after succinylcholine and rocuronium were significantly better than after mivacurium. The onset time (from the end of injection until 95% suppression of the first twitch [T1]) for succinylcholine (63 +/- 21 s and 62 +/- 17 s in Groups I and II, respectively) were significantly shorter than for rocuronium (158 +/- 76 s) or mivacurium (210 +/- 93 s). Moreover, the onset times for rocuronium were significantly shorter than mivacurium. The recovery times (of T1 to 25% of the control value) were significantly shorter with succinylcholine and mivacurium than rocuronium. Significantly fewer patients needed reversal of residual neuromuscular blockade after mivacurium compared to rocuronium. One patient in Group I and six patients in Group IV displayed erythema on the upper body. Postoperative myalgia were experienced by 16% of the patients in Groups I and II compared to none in Groups III and IV. There was on difference in the incidence of postoperative nausea and vomiting among the four groups. In conclusion, rocuronium appears to be an acceptable alternative to succinylcholine for tracheal intubation. However, rocuronium's longer duration of action increases the need for reversal drugs. When rapid tracheal intubation is unnecessary, mivacurium is also an acceptable alternative to succinylcholine and is associated with a more rapid spontaneous recovery than rocuronium.

Effects of magnesium sulphate on suxamethonium-induced complications during rapid-sequence induction of anaesthesia

Twenty patients were studied in a double-blind manner to investigate whether magnesium sulphate, when given during a rapid-sequence induction of anaesthesia, lessens the side effects caused by suxamethonium. Patients were randomly allocated to two groups; equal volumes of either magnesium sulphate (40 mg.kg-1) or saline were given during rapid-sequence induction of anaesthesia, after thiopentone but before the administration of suxamethonium (1.5 mg.kg-1). The changes in the serum potassium concentration, the degree of muscle fasciculations and the presence of postoperative myalgia were recorded. The mean serum potassium concentration increased by 0.08 mmol.l-1 in the magnesium group and by 0.1 mmol.l-1 in the control group at 2 min after injection of suxamethonium; in neither group was there a significant increase from baseline values. The systolic blood pressure and heart rate increased in both groups after tracheal intubation. The incidence of fasciculations was significantly lower in the magnesium group. Magnesium did not clinically prolong muscle relaxation. There was no difference between the groups in the incidence of myalgia after surgery (one patient in each group). Since no significant increase in the serum potassium concentration was demonstrated, no assessment could be made of the effect of magnesium sulphate on the serum potassium concentration after administration of suxamethonium.

Discrimination by nimodipine, but not by nifedipine, between phasic and tonic contractions of guinea-pig taenia coli induced by K+ depolarization

Effects of Ca2+ channel blockers, such as nifedipine, nimodipine, gallopamil, verapamil, diltiazem, loperamide, Mn2+ and Ni2+, and papaverine, on contractile responses to K+ depolarization were evaluated in longitudinal muscles of taenia coli isolated from guinea-pig. Depolarization with high K+ solution (K+, 40 mM) produced a biphasic (phasic and tonic) contraction, which was inhibited by the above blockers in a concentration-dependent manner. Ratios of IC50 for the phasic contraction to IC50 for the tonic contraction of nimodipine, verapamil, gallopamil, nifedipine, loperamide, diltiazem, papaverine, Ni2+, and Mn2+ were 516.1, 73.7, 22.0, 6.4, 5.3, 4.9, 1.2, 0.7, and 0.1, respectively, indicating that nimodipine suppressed the tonic contraction more effectively than the phasic contraction. In a fluorescence study with fura 2, K+ depolarization elicited an increase in intracellular free Ca2+, [Ca2+]i, which was coupled with the phasic and tonic contraction. The increases in [Ca2+]i coupled with both types of the contraction were abolished by exposure to Ca(2+)-free solution. In addition, the increase of [Ca2+]i coupled with the phasic contraction was abolished by nifedipine, 10(-7) M, but not by nimodipine, 10(-7) M, whereas the increase with the tonic contraction was suppressed by both nifedipine and nimodipine. These findings suggest that the phasic and tonic contractions evoked by K+ depolarization are due to increases in [Ca2+]i via activation of respective nimodipine-resistant and nimodipine-sensitive Ca2+ channels in the longitudinal muscles of the taenia coli. Accordingly, nimodipine, but not nifedipine, appears to be a useful tool for distinguishing between the phasic and tonic contractions.

Antagonism by riluzole of entry of calcium evoked by NMDA and veratridine in rat cultured granule cells: evidence for a dual mechanism of action

1. Intracellular calcium levels were measured in cultured cerebellar granule cells of the rat by use of the fluorescent dye, indo-1/AM. 2. Intracellular calcium levels were increased by depolarizing stimuli such as N-methyl-D-aspartate (NMDA) (100 microM), glutamic acid (20 microM), and veratridine (10 microM). This increase was essentially due to entry of external calcium. 3. Riluzole (10 microM) blocked responses to all the depolarizing agents. 4. Riluzole could still block the increase in intracellular calcium evoked by NMDA or glutamic acid when sodium channels were blocked by tetrodotoxin, suggesting that this effect is not mediated by a direct action of riluzole on the voltage-dependent sodium channel. 5. Pretreatment of the cells with pertussis toxin (0.1 micrograms ml-1) did not modify the increases in intracellular calcium evoked by NMDA, glutamic acid or veratridine. 6. In pertussis toxin-treated cells, riluzole could no longer block responses to excitatory amino acids, but still blocked responses to veratridine. 7. It is concluded that riluzole has a dual action on cerebellar granule cells, both blocking voltage-dependent sodium channels and interfering with NMDA receptor-mediated responses via a pertussis toxin-sensitive mechanism. Furthermore, these two processes have been shown to be independent.

In vivo microdialysis of corticotropin releasing factor (CRF): calcium dependence of depolarization-induced neurosecretion of CRF

Corticotropin releasing factor (CRF) is a large neuropeptide which functions as a major neurotransmitter in physiological stress responses. We have developed a microdialysis method for detecting CRF release from the median eminence of anesthetized rats. Depolarizing concentrations of KCl increased release of CRF into the perfusion media; this effect was inhibited by 100 microM verapamil. Our characterization of the physiologic conditions of KCl-induced release of neuronal CRF using the microdialysis technique provides evidence that the CRF release system is Ca(2+)-dependent and maintains its integrity over many hours in anesthetized rats.

Effects of different antagonists on depolarization of cultured chick myotubes by cobra venom cardiotoxins and Pyrularia thionin from the plant Pyrularia pubera

Cardiotoxins (3.12 and 3.12.1) purified from cobra venom (Naja naja siamensis) are basic single-chain polypeptides of about 60 residues. Although they depolarize nerve and muscle cells and have cytolytic effects, their mechanism of action is still unknown. Pyrularia thionin (P-thionin) isolated from nuts of the parasitic plant Pyrularia pubera is a strongly basic, single-chain polypeptide containing 47 residues. It is known to be haemolytic and cytotoxic, and to depolarize muscle cells, but its mechanism of action is unclear. The present studies explored the possible similarities between P-thionin and cobra venom cardiotoxins by comparing their effects on depolarization of cultured chick skeletal muscle cells in the presence and absence of possible antagonists. Cardiotoxins and P-thionin depolarized cultured chick skeletal muscle cells, but with P-thionin showing a steeper concentration-dependence. Ca2+ was more effective at reducing cardiotoxin action than P-thionin, while the Ca(2+)-channel blockers Ni2+ (100 microM) and verapamil (100 microM) had no blocking effects on the toxins. Ca2+ may block the binding of both toxins. Indomethacin (100 microM, an inhibitor of cyclooxygenase), quinacrine and dexamethasone (100 microM, inhibitors of phospholipase A2) did not block the effects of the toxins, implying that the actions on cultured chick skeletal muscle cells are not due to activation of endogenous phospholipase A2.

Suppression of domoic acid induced seizures by 8-(OH)-DPAT

Microinjections of the neuroexcitotoxin, domoic acid (DOM), in the ipsilateral rat hippocampal CA-3 region, induced generalized electrical seizure discharge activity, characterized by spikes and waves, followed by intermittent burst discharges. Computerized EEG analysis exhibited relative dominance of delta and theta and reductions in alpha and beta activities during domoic acid epileptogenesis. Seizure discharge activity was attenuated by the microinjection of the 5-HT1A agonist, 8-hydroxy-2-(di-N-propylamino)tetralin(8-(OH)-DPAT) and augmented by the specific 5-HT1A antagonist, spiroxatrine in the contralateral hippocampal CA-3 region. Neuronal recovery following 8-(OH)-DPAT was associated with significant reductions in the relative dominance of delta and theta and increases in the alpha and beta activities. The results suggest that activation of serotonergic 5-HT1A receptor in the hippocampus has a neuroprotective action.

Mivacurium: dose-response relationship and administration by repeated injection or infusion

The dose-response relationship and neuromuscular blockade after infusion or repeated injection of mivacurium were studied in 65 patients in nitrous oxide-narcotic anesthesia. The ED95 (twitch tension) was determined in 45 patients by intravenous injection of a single bolus of 30, 39, 47, 54, or 60 micrograms/kg (9 patients per dose). Another 20 patients received an initial bolus of 2 x ED95 followed either by an infusion started at 5% twitch recovery (i.e., 95% depression) and adjusted to sustain 95% twitch depression (n = 10) or by repeated injection of 0.6 x ED95 whenever twitch tension had recovered to 25% of control (n = 10). Five patients in each of these two groups received 7 micrograms/kg of neostigmine at 25% twitch recovery, and the others recovered twitch tension spontaneously. The mean ED95 was 73 micrograms/kg. A 2 x ED95 bolus was followed by complete twitch depression within 2.2 +/- 0.7 min. The mean infusion rate resulted in 6 +/- 2 micrograms.kg-1.min-1. The ensuing recovery index was 6 +/- 3 min. A 6 +/- 2 min recovery index was found after up to 10 repeat injections given every 9 +/- 3 min. There was no significant effect of neostigmine in both groups. In conclusion, the recovery indices after the infusion or repeat injection of near-equal doses of mivacurium were identical.

Two pharmacological classes of quisqualate-induced electrical responses in rat retinal ganglion cells in vitro

The pharmacological properties of steady state responses elicited by the excitatory amino acid agonists quisqualate and alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) have been examined in isolated rat retinal ganglion cells with patch electrodes. Based upon testing retinal ganglion cells with both agonists at saturating concentrations (30 microM for quisqualate and 60 microM for AMPA), these neurons can be grouped into three different categories: (a) type I cells, in which AMPA steady state responses were larger than those induced by quisqualate; (b) type II cells, in which quisqualate steady state responses were larger than or equal to those produced by AMPA; and (c) type III cells, in which neither AMPA nor quisqualate elicited responses. Regardless of cell type (I or II), AMPA responses were substantially inhibited by the antagonists kynurenate (750 microM) and 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; 10 microM). In contrast, the effects of these antagonists on quisqualate responses varied depending on the cell type, with both kynurenate and CNQX being more effective in type II than in type I cells. Based upon further pharmacological manipulations, it is proposed that quisqualate-induced steady state responses in retinal ganglion cells are divisible into two pharmacological classes that exist in varying proportions in these cells in vitro.

The pharmacology of quisqualate and AMPA in the cerebral cortex of the rat in vitro

The depolarising population response to the excitatory amino acids, quisqualate and AMPA, in slices of cerebral cortex of the rat have been compared. Their respective dose-response curves had a similar maximum but the slope of the curve for AMPA was consistently steeper than that for quisqualate. The dose-response curves for AMPA had a mean log EC50 of -5.18 +/- 0.05, which was significantly different from -4.62 +/- 0.07 the mean log EC50 of the dose-response curves for quisqualate. Responses to both agonists were antagonised by kynurenic acid, barbiturates and gamma-DGT to a similar extent. The antagonism by kynurenate appeared to be competitive whilst the barbiturates were evidently noncompetitive antagonists. These results are in agreement with claims that quisqualate and AMPA act at a similar recognition site. The differences in the slopes of the dose-response curves for quisqualate and AMPA may be explained by the differences in the cellular uptake of the two agonists and/or by differences in efficacy.

Quinoxalinediones selectively block quisqualate and kainate receptors and synaptic events in rat neocortex and hippocampus and frog spinal cord in vitro

1. Two quinozalinediones, FG9041 and FG9065, which had previously been shown to displace binding to the quisqualate receptor, were tested on rat neocortex and frog spinal cord in vitro against depolarizations induced by quisqualate, kainate and N-methyl-D-aspartate (NMDA). In both preparations effects of quisqualate were reduced the most and those of NMDA the least. 2. The near unitary slopes of the Schild plots were consistent with a competitive type of interaction. pA2 values for FG9041 were estimated to be 6.6, 6.1 and 5.1 in frog cord and 5.9, 5.3 and and about 4 in the rat neocortex for quisqualate, kainate and NMDA antagonism, respectively. FG9065 gave equivalent pA2 values of 6.2, 5.6 and 4.5. 3. At concentrations, which were without effect on depolarizations induced by NMDA, FG9041 and FG9065 reduced or blocked synaptically-evoked field potentials in hippocampal and neocortical slices superfused with normal magnesium-containing medium. Since these synaptic components are also insensitive to NMDA antagonists, these results are consistent with their mediation by postsynaptic receptors of the quisqualate (or kainate) type. 4. By contrast, quinoxalinediones had only limited effects on spontaneous epileptiform activity seen in both neocortical and hippocampal preparations when superfused with magnesium-free medium. These burst discharges were, however, abolished by NMDA antagonists. 5. In the frog spinal cord the early component of the dorsal root to ventral root reflexes was selectively reduced by FG9041 whereas NMDA antagonists reduced the longer latency components. 6. Our results suggest that the quinoxalinediones are likely to be useful pharmacological probes for elucidating the role of non-NMDA receptors in the vertebrate central nervous system.