Articles: neuromuscular-blocking-agents-adverse-effects.
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The incidence of immune-mediated anaphylaxis during anesthesia ranges from 1 in 10,000 to 1 in 20,000. Neuromuscular blocking agents are most frequently incriminated, followed by latex and antibiotics, although any drug or substance used may be a culprit. Diagnosis relies on tryptase measurements at the time of the reaction and skin tests, specific immunoglobulin E, or basophil activation assays. Treatment consists of rapid volume expansion and epinephrine administration titrated to symptom severity.
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Neuromuscular blocking drugs are designed to bind to the nicotinic receptor at the neuromuscular junction. However, they also interact with other acetylcholine receptors in the body. Binding to these receptors causes adverse effects that vary with the specificity for the cholinergic receptor in question. ⋯ At the end of anaesthesia, no residual effect of a neuromuscular blocking drug should be present. However, the huge variability in response to neuromuscular blocking drugs makes it impossible to predict which patient will suffer postoperative residual curarization. This article discusses the undesirable effects of the currently available neuromuscular blocking drugs including the definitions, diagnosis and causes of hypersensitivity reactions and postoperative residual curarisation.
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We Japanese anesthesiologists can now use rocuronium as well as vecuronium. Although the onset of rocuronium is more rapid, the non-depolarizing neuromuscular blocking (NMB) agent has similar characteristics of duration and recovery compared to vecuronium. Reversal of NMB is therefore essential to recover patients safely. ⋯ Sugammadex is a novel and unique compound designed as an antagonist of rocuronium and possibly other steroid NMB agents. Sugammadex exerts its effect by forming very tight water-soluble complexes at a 1 : 1 ratio with steroid NMB agents (rocuronium>vecuronium>pancuronium). PhaseIII trials in Japan as well as Europe and the US have just been finished, and it is expected to be used clinically in the near future.
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Neuromuscular blocking agents are used to facilitate tracheal intubation and surgical procedure in ambulatory anesthesia. However, the ideal neuromuscular blocking agents for ambulatory anesthesia are not yet available. The only depolarizing neuromuscular blocking agent, suxamethonium, is still widely used by its rapid onset and short duration of action producing excellent intubating conditions, in spite of its numerous adverse effects. ⋯ The use of neostigmine for reversal and the measurement of the TOF ratio during recovery are recommended after intermediate-acting neuromuscular blocking agents. Some studies have shown that tracheal intubation without neuromuscular agents may be associated with postoperative hoarseness and vocal cord injuries. Sugammadex will resolve many issues in using nondepolarizing neuromuscular agents in ambulatory anesthesia.
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In the intensive care unit (ICU), neuromuscular blocking agent (NMBA) is occasionally used with sedatives and/or analgesics, for the management of mechanically-ventilated critically ill patients. For its application in ICU, close attention should be paid on the side effects unlikely seen during operation because the basal conditions of ICU patients are more serious and its infusion period is likely to be long. There have been reports of the prolonged weakness after the long term use of NMBA. ⋯ Strategy should be focused on its prevention. For example, routine monitoring with peripheral nerve stimulation and titration to the minimum dose of requirement, are relevant and effective. The application of NMBA in ICU is reviewed and rocuronium recently placed on market is within the scope of this article.