1. Non -depolarizing muscle relaxant
Done by : lina abdullah

2. objectives Mechanism of action.
Factors affecting duration of non-depolarizing muscle relaxant.
Atracurium and cis-atracurium.
Rocuronium bromide.
Pancuronium bromide.
Vecuronium bromide.

3. Mechanism of action:
Nondepolarizing agents are competitive antagonist that means competitively block ACh at the nicotinic receptors They compete with ACh at the receptor without stimulating it. These drugs prevent depolarization of the muscle cell membrane and inhibit muscular contraction. Their competitive action can be overcome by administration of cholinesterase inhibitors, such as neostigmine and edrophonium, which increase the concentration of ACh in the neuromuscular junction. this strategy empoly to shorten the duration of the neuromuscular blockade.

5. Factors affecting duration of non-depolarizing muscle relaxant:
A. temperature: Hypothermia prolongs blockade by decreasing metabolism (e.g atracurium) and delaying excretion(e.g pancuronium )
B. Acid–Base Balance: Respiratory acidosis potentiates the blockade of most no depolarizing relaxants . This could prevent complete neuromuscular recovery in a hypoventilating postoperative patient.
C. Electrolyte Abnormalities: Hypokalemia and hypocalcemia augment a nondepolarizing block
D. Age: Neonates have an increased sensitivity to nondepolarizing relaxants because of their immature neuromuscular junctions but Older patients have prolonged effect.

6. The ED95 is (The ED95 of any drug is the effective dose of a drug in 95% of individuals.) For neuromuscular blockers one often specifies the dose that produces 95% twitch depression in 50% of individuals .
Muscle groups vary in their sensitivity to muscle relaxants. In general, the diaphragm, jaw, larynx, and facial muscles (orbicularis oculi) respond to and recover from muscle relaxation sooner than the thumb
For example, the laryngeal muscle recover from blockade more quickly than the adductor pollicis

8. Atracurium
Structure: it is aquaternary group {like all muscle relaxants}.benzylisoquinoline structure {responsible for its unique method of degradation }. *Atracurium is so extensively metabolized that its pharmacokinetics are independent of renal and hepatic function, and less than 10% is excreted unchanged by renal and biliary routes.
Two separate processes are responsible for metabolism:
A. Ester Hydrolysis This action is catalyzed by nonspecific esterases, not by acetylcholinesterase or pseudocholinesterase.
B. Hofmann Elimination (also known as exhaustive methylation) A spontaneous non enzymatic chemical breakdown occurs at physiological pH and temperature.

9. Atracurium triggers dose-dependent histamine release that becomes significant at doses above 0.5 mg/kg
Dosage:
Intubation dose: 0.5 mg/kg
Maintance dose: mg/kg
Side effects:
A. Hypotension and Tachycardia
Cardiovascular side effects are unusual unless doses in excess of 0.5 mg/kg are administered
B. Bronchospasm
should be avoided in asthmatic patients
c. Allergic Reactions
d. Laudanosine toxicity : it is a tertiary amine, is a product of atracurium’s Hofmann elimination and has been associated with central nervous system excitation, precipitation of seizures

10. CISATRACURIUM Metabolism & Excretion Dosage No histamine release
a stereoisomer of atracurium that is four times more potent
Metabolism & Excretion
Like atracurium, cisatracurium undergoes degradation in plasma at physiological pH and temperature by organ-independent Hofmann elimination.
Dosage
Intubation dose: 0.1 to 0.15 mg/kg within 2 min .
The typical maintenance infusion rate ranges from 1.0 to 2.0 mcg/kg/min.
. Side Effects & Clinical Considerations
No histamine release
Cv stability

11. PANCURONIUM
Metabolism & Excretion:Excretion is primarily renal (40%), although some of the drug is cleared by the bile (10%).
Dosage
A dose of 0.08 to 0.12 mg/kg of pancuronium provides adequate relaxation for intubation in 2 to 3 min.
Side Effects
A. Hypertension and Tachycardia : caused by the combination of vagal blockade
and sympathetic stimulation.
B. Arrhythmias
C. Allergic Reactions; in Patients who are hypersensitive to bromides

12. VECURONIUM
Vecuronium is pancuronium minus a quaternary methyl group (a monoquaternary relaxant). This minor structural change beneficially alters side effects without affecting potency.
Metabolism & Excretion
It depends primarily on biliary excretion and secondarily (25%) on renal excretion
After long-term administration of vecuronium to patients in ICU prolonged neuromuscular blockade (up to several days) may
be present after drug discontinuation, possibly from accumulation of its active 3-hydroxy metabolite, changing drug clearance, and in some patients, leading to the development of a polyneuropathy. Risk factors seem to include female gender, kidney failure, long-term or high-dose corticosteroid therapy, and sepsis.
Dosage
Vecuronium is equipotent with pancuronium, and the intubating dose is 0.08 to 0.12 mg/kg.
Side Effects
A. Cardiovascular
Even at doses of 0.28 mg/kg, vecuronium is devoid of significant cardiovascular effects.
B. Liver Failure

13. ROCURONIUM Side effects: Metabolism & Excretion Dosage
*This monoquaternary steroid analogue of vecuronium was designed to provide a rapid onset of action
Metabolism & Excretion
Rocuronium undergoes no metabolism and is eliminated primarily by the liver and slightly by the kidneys. Its duration of action is not significantly affected by renal disease, but it is modestly prolonged by severe liver failure and pregnancy
Dosage
Rocuronium is less potent than most other steroidal muscle relaxants It requires 0.45 to 0.9 mg/kg intravenously for intubation
Side effects:
No histamine release
Slight vagolytic effect

15. Other drugs: short- acting: - Mivacurium -Alcuronium Long –acting :
-Tubocuratine

17. Thank you