Advertisement

Effect Sites of Neuromuscular Blocking Agents and the Monitoring of Clinical Muscle Relaxation

  • Claude Meistelman
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 523)

Abstract

The main goals of muscular relaxation during induction of anaesthesia are the paralysis of the vocal cords and jaw muscles to facilitate tracheal intubation and the relaxation of the respiratory muscles. Paralysis of the abdominal muscles and the diaphragm is often required intraoperatively, particularly during abdominal surgery. During recovery of neuromuscular blockade, restoration of complete skeletal muscular strength is essential to ensure adequate spontaneous ventilation and the permeability of the upper airway. For practical reasons, it is almost impossible to monitor the response of the respiratory or abdominal muscles during anaesthesia. Paton and Zaimis demonstrated in 1951 that respiratory muscles were more resistant to curare than other muscles.1 In humans, several studies have reported some discrepancies between the level of peripheral paralysis and respiratory depression or the intubating conditions.2,3 Therefore, both understanding and knowledge of the relationship between neuromuscular function at the monitored muscle and the other muscles are important in the interpretation of monitoring.

Keywords

Vocal Cord Respiratory Muscle Neuromuscular Blockade Neuromuscular Block Effect Compartment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    W. D. M. Paton and E. J. Zaimis, The action of d-tubocurarine and of decamethonium on respiratory and oher muscles in the cat. J Physiol 112, 311–331 (1951).PubMedGoogle Scholar
  2. 2.
    A. F. Bencini and D. E. Newton, Rate of onset of good intubating conditions, respiratory depression and hand muscle paralysis after vecuronium. Br J Anaesth 56, 959–965 (1984).PubMedCrossRefGoogle Scholar
  3. 3.
    J. C. Carnie, M. K. Street and B. Kumar, Emergency intubation of the trachea facilitated by suxamethonium. Br J Anaesth 58, 498–501 (1986).PubMedCrossRefGoogle Scholar
  4. 4.
    T. J. Gal and T. C. Smith, Partial paralysis with d-tubocurarine and the ventilatory response to C02: An example of respiratory sparing? Anesthesiology 45, 22–28 (1976).PubMedCrossRefGoogle Scholar
  5. 5.
    E. G. Pavlin, R. H. Holle and R. B. Schoene, Recovery of airway protection compared with ventilation in humans after paralysis with curare. Anesthesiology 70, 381–385 (1989).PubMedCrossRefGoogle Scholar
  6. 6.
    T. J. Gal and S. K. Goldberg, Diaphragmatic function in healthy subjects during partial curarization. J Appl Physiol 48, 921–926 (1980).PubMedGoogle Scholar
  7. 7.
    F. Donati, C. Antzaka and D. R. Bevan, Potency of pancuronium at the diaphragm and the adductor pollicis muscle in humans. Anesthesiology 65, 1–5 (1986).PubMedCrossRefGoogle Scholar
  8. 8.
    J. P. Cantineau, F. Porte, G. D’Honneur and P. Duvaldestin, Neuromuscular effects of rocuronium on the diaphragm and adductor pollicis in anesthetized patients. Anesthesiology 81, 585–590 (1994).PubMedCrossRefGoogle Scholar
  9. 9.
    C. E. Smith, F. Donati and D. R. Bevan, Potency of succinylcholine at the diaphragm and at the adductor pollicis muscle. Anesth Analg 67, 625–630 (1988).PubMedGoogle Scholar
  10. 10.
    B. E. Waud and D. R. Waud, The margin of safety of neuromuscular transmission in the muscle of the diaphragm. Anesthesiology 37, 417–422 (1972).PubMedCrossRefGoogle Scholar
  11. 11.
    R. Sterz, M. Pagala and K. Peper, Postjunctional characteristics of the endplates in mammalian fast and slow muscles. PflugersArch 398, 48–54 (1983).CrossRefGoogle Scholar
  12. 12.
    P. Bragg, D. M. Fisher, J. Shi, F. Donati, C. Meistelman, M. Lau and L. B. Sheiner, Comparison of twitch depression of the adductor pollicis and the respiratory muscles. Pharmacodynamic modeling without plasma concentrations. Anesthesiology 80, 310–319 (1994).PubMedCrossRefGoogle Scholar
  13. 13.
    M. Chauvin, C. Lebrault and P. Duvaldestin, The neuromuscular blocking effect of vecuronium on the human diaphragm. Anesth Analg 66,117–122 (1987).PubMedCrossRefGoogle Scholar
  14. 14.
    K. Kirov, C. Motamed and G. Dhonneur, Differential sensitivity of abdominal muscles and the diaphragm to mivacurium: an electromyographic study. Anesthesiology 95,1323–1328 (2001).PubMedCrossRefGoogle Scholar
  15. 15.
    J. M. Saddler, L. F. Marks and J. Norman, Comparison of atracurium-induced neuromuscular block in rectum abdominis and hand muscles of man. Br J Anaesth 69, 26–28 (1992).PubMedCrossRefGoogle Scholar
  16. 16.
    K. Kirov, C. Motamed, X. Combes, P. Duvaldestin and G. Dhonneur, [Sensitivity to atracurium in the lateral abdominal muscles]. Ann Fr Anesth Reanim 19, 734–738 (2000).PubMedCrossRefGoogle Scholar
  17. 17.
    F. Donati, C. Meistelman and B. Plaud, Vecuronium neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis. Anesthesiology 74, 833–837 (1991).PubMedCrossRefGoogle Scholar
  18. 18.
    C. Meistelman, B. Plaud and F. Donati, Rocuronium (ORG 9426) neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis in humans. Can J Anaesth 39, 665–669 (1992).PubMedCrossRefGoogle Scholar
  19. 19.
    B. Plaud, B. Debaene, F. Lequeau, C. Meistelman and F. Donati, Mivacurium neuromuscular block at the adductor muscles of the larynx and adductor pollicis in humans. Anesthesiology 85, 77–81 (1996).PubMedCrossRefGoogle Scholar
  20. 20.
    C. Meistelman, B. Plaud and F. Donati, Neuromuscular effects of succinylcholine on the vocal cords and adductor pollicis muscles. Anesth Analg 73,278–282 (1991).PubMedCrossRefGoogle Scholar
  21. 21.
    B. Plaud, J. H. Proost, J. M. Wierda, J. Barre, B. Debaene and C. Meistelman, Pharmacokinetics and pharmacodynamics of rocuronium at the vocal cords and the adductor pollicis in humans. Clin Pharmacol Ther 58, 185–191 (1995).PubMedCrossRefGoogle Scholar
  22. 22.
    D. M. Fisher, J. Szenohradszky, P. M. Wright, M. Lau, R. Brown and M. Sharma, Pharmacodynamic modeling of vecuronium-induced twitch depression. Rapid plasma-effect site equilibration explains faster onset at resistant laryngeal muscles than at the adductor pollicis. Anesthesiology 86, 558–566 (1997).PubMedCrossRefGoogle Scholar
  23. 23.
    S. Isono, T. Ide, T. Kochi, T. Mizuguchi and T. Nishino, Effects of partial paralysis on the swallowing reflex in conscious humans. Anesthesiology 75, 980–984 (1991).PubMedCrossRefGoogle Scholar
  24. 24.
    G. D’Honneur, O. Gall, A. Gerard, J. M. Rimaniol, Y. Lambert and P. Duvaldestin, Priming doses of atracurium and vecuronium depress swallowing in humans. Anesthesiology 77, 1070–1073 (1992).PubMedCrossRefGoogle Scholar
  25. 25.
    C. E. Smith, F. Donati and D. R. Bevan, Differential effects of pancuronium on masseter and adductor pollicis muscles in humans. Anesthesiology 71, 57–61 (1989).PubMedCrossRefGoogle Scholar
  26. 26.
    A. F. L. Van Der Spek, W. B. Fang, J. A. Ashton-Miller, C. S. Stohler, D. S. Carlson and M. A. Schork, The effects of succinylcholine on mouth opening. Anesthesiology 67,459–463 (1987).PubMedCrossRefGoogle Scholar
  27. 27.
    J. M. Saddler, Jaw stiffness-An ill understood condition. Br J Anaesth 67, 515–516 (1991).PubMedCrossRefGoogle Scholar
  28. 28.
    C. E. Smith, J. M. Saddler, J. C. Bevan, F. Donati and D. R. Bevan, Pretreatment with non-depolarizing neuromuscular blocking agents and suxamethonium-induced increases in resting jaw tension in children. Br J Anaesth 64, 577–581 (1990).PubMedCrossRefGoogle Scholar
  29. 29.
    L. I. Eriksson, E. Sundman, R. Olsson, L. Nilsson, H. Witt, O. Ekberg and R. Kuylenstierna, Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology 87, 1035–1043 (1997).PubMedCrossRefGoogle Scholar
  30. 30.
    E. Sundman, H. Witt, R. Olsson, O. Ekberg, R. Kuylenstierna and L. I. Eriksson, The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology 92, 977–984 (2000).PubMedCrossRefGoogle Scholar
  31. 31.
    L. I. Eriksson, M. Sato and J. W. Severinghaus, Effect of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. Anesthesiology 78, 693–699 (1993).PubMedCrossRefGoogle Scholar
  32. 32.
    L. I. Eriksson, Reduced hypoxic chemosensitivity in partially paralysed man. A new property of muscle relaxants? Acta Anaesthesiol Scand 40, 520–523 (1996).PubMedCrossRefGoogle Scholar
  33. 33.
    N. Wyon, L. I. Eriksson, Y. Yamamoto and S. G. Lindahl, Vecuronium-induced depression of phrenic nerve activity during hypoxia in the rabbit. Anesth Analg 82,1252–1256 (1996).PubMedGoogle Scholar
  34. 34.
    F. Donati, C. Meistelman and B. Plaud, Vecuronium neuromuscular blockade at the diaphragm, the orbicularis oculi, and adductor pollicis muscles. Anesthesiology 73, 870–875 (1990).PubMedCrossRefGoogle Scholar
  35. 35.
    B. Debaene, M. Beaussier, C. Meistelman, F. Donati and A. Lienhart, Monitoring the onset of neuromuscular block at the orbicularis oculi can predict good intubating conditions during atracurium-induced neuromuscular block. Anesth Analg 80, 360–363 (1995).PubMedGoogle Scholar
  36. 36.
    F. Le Corre, B. Plaud, E. Benhamou and B. Debaene, Visual estimation of onset time at the orbicularis oculi after five muscle relaxants: application to clinical monitoring of tracheal intubation. Anesth Analg 89, 1305–1310 (1999).PubMedCrossRefGoogle Scholar
  37. 37.
    B. Plaud, B. Debaene and F. Donati, The corrugator supercilii, not the orbicularis oculi, reflects rocuronium neuromuscular blockade at the laryngeal adductor muscles. Anesthesiology 95, 96–101 (2001).PubMedCrossRefGoogle Scholar
  38. 38.
    J. Viby-Mogensen, P. Howardy-Hensen, B. Chraemmer-Jorgensen, H. Ording, J. Engbaek and A. Nielsen, Posttetanic count (PTC): a new method of evaluating an intense non depolarizing neuromuscular blockade. Anesthesiology 55,458–461 (1981).PubMedCrossRefGoogle Scholar
  39. 39.
    D. R. Bevan, C. E. Smith and F. Donati, Postoperative neuromuscular blockade: a comparison between atracurium, vecuronium, and pancuronium. Anesthesiology 69, 272–276 (1988).PubMedCrossRefGoogle Scholar
  40. 40.
    C. Baillard, G. Gehan, J. Reboul-Marty, P. Larmignat, C. M. Samama and M. Cupa, Residual curarization in the recovery room after vecuronium. Br J Anaesth 84, 394–395 (2000).PubMedCrossRefGoogle Scholar
  41. 41.
    G. D’Honneur, V. Slavov, J. C. Merle, K. Kirov, J. M. Rimaniol, L. Sperry and P. Duvaldestin, Comparison of the effects of mivacurium on the diaphragm and geniohyoid muscles. Br J Anaesth 77,716–719 (1996).PubMedCrossRefGoogle Scholar
  42. 42.
    J. Y. Dupuis, R. Martin, J. M. Tessonnier and J. P. Tetrault, Clinical assessment of the muscular response to tetanic nerve stimulation. Can J Anaesth 37, 397–400 (1990).PubMedCrossRefGoogle Scholar
  43. 43.
    N. E. Drenck, N. Ueda, N. V. Olsen, J. Engbaek, E. Jensen, L. T. Skovgaard and J. Viby-Mogensen, Manual evaluation of residual curarization using double burst stimulation; a comparison with train-of-four. Anesthesiology 70, 578–581 (1989).PubMedCrossRefGoogle Scholar
  44. 44.
    K. Fruergaard, J. Viby-Mogensen, H. Berg and A. M. el Mahdy, Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis. Acta Anaesthesiol Scand 42, 1168–1174 (1998).PubMedCrossRefGoogle Scholar
  45. 45.
    A. F. Kopman, P. S. Yee and G. G. Neuman, Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology 86, 765–771 (1997).PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2003

Authors and Affiliations

  • Claude Meistelman
    • 1
  1. 1.Department of AnaesthesiologyNancyFrance

Personalised recommendations