American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
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Methods of monitoring and reversing neuromuscular blocking agents to avoid residual neuromuscular block are described. Studies have shown that if a long-acting neuromuscular blocking agent is used during anesthesia, the frequency of residual block, regardless of the method of neuromuscular monitoring, will be at least 20%. In the past 20-25 years, anesthesiologists have come to use some form of nerve stimulation to monitor the degree of residual neuromuscular block; there are various patterns of stimulation, including train-of-four (TOF) stimulation and double-burst stimulation (DBS). ⋯ Rapacuronium is a new investigational drug with similar onset characteristics to succinylcholine and, if reversed early, similar recovery characteristics. Postoperative residual neuromuscular block is frequent, dangerous, and difficult to recognize clinically. The action of neuromuscular blocking agents should always be reversed unless there is unequivocal evidence of adequate function.
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The clinical pharmacology of neuromuscular blocking agents is described. During neuromuscular blockade, succinylcholine attaches to receptors in the motor end plate and depolarizes the neuromuscular junction, making the end plate refractory to acetylcholine. The nondepolarizing relaxants have a structure similar to that of succinylcholine and bind to the same receptors. ⋯ Some nondepolarizing relaxants (atracurium, mivacurium, and pancuronium) are associated with histamine release, occasionally causing serious hypotension and tachycardia. Neuromuscular blocking agents are essential to anesthesia. Older compounds produce greater toxicity than newer compounds, and several of these older compounds therefore are no longer in clinical use.
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Am J Health Syst Pharm · Jun 1999
ReviewPharmacoeconomic issues related to selection of neuromuscular blocking agents.
Pharmacoeconomic issues related to the selection of neuromuscular blocking agents are described. Five models of economic analysis are commonly used in health care: cost-minimization, cost-benefit, cost-effectiveness, cost-utility, and cost-of-illness. The model used most commonly in anesthesiology is the cost-effectiveness model, in which outcomes are measured in nonmonetary terms that are then translated into units of success or failure. ⋯ Decreased length of stay in the PACU and the ICU can save hundreds of dollars per case because these areas have high personnel costs. If reversal drugs like neostigmine can be avoided, fewer patients may experience postoperative nausea and vomiting and the resulting complications. In searching for the best outcome at the most reasonable cost, practitioners should look for meaningful cost reductions, bearing in mind that the use of newer, shorter-acting drugs has led to improved perioperative efficiency in clinical practice.
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Factors driving the development of neuromuscular blocking agents are discussed. The goal of recent development of neuromuscular blocking agents is to develop agents with fewer adverse effects than succinylcholine and greater control. Greater control can be achieved through a short duration of action and a fast onset, similar to that found with succinylcholine. ⋯ Its short duration of action will make it potentially useful for short surgical procedures and procedures in which nerve integrity must be monitored. At the same time, its onset time approaches that of succinylcholine. Recent advances have made the administration of neuromuscular blocking agents much easier because the newer nondepolarizing relaxants offer faster onset and greater control.