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INTRODUCTION

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HIGH ALERT

NEUROMUSCULAR BLOCKING AGENTS (nondepolarizing)

atracurium (a-tra-kyoor-ee-um)

Tracrium

cisatracurium (sis-a-tra-kyoor-ee-um)

Nimbex

doxacurium (dox-a-kyoor-ee-um)

Nuromax

gallamine (gal-a-meen)

Flaxedil

metocurine (me-toe-kyoor-een)

Metubine

mivacurium (miv-a-kyoor-ee-um)

Mivacron

pancuronium (pan-kyoor-oh-nee-um)

Pavulon

pipecuronium (pip-e-kyoor-oh-nee-um)

Arduan

rocuronium (roe-kyoor-own-ee-um)

Zemuron

tubocurarine (too-boh-kyoor-ar-een)

Tubarine

vecuronium (ve-kyoor-oh-nee-um)

Norcuron

Classification

Therapeutic: neuromuscular blocking agents—nondepolarizing

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Indications
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Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures. Facilitation of compliance during mechanical ventilation. Metocurine, tubocurarine: Adjunct to electroconvulsive therapy. Tubocurarine: Diagnostic agent for myasthenia gravis.

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Action
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Prevent neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Have no analgesic or anxiolytic properties. Therapeutic Effects: Skeletal muscle paralysis.

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Adverse Reactions/Side Effects
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Resp: bronchospasm. CV: tubocurarine: arrhythmias; atracurium, metocurine, tubocurarine: hypotension (↑ with tubocurarine); pancuronium, gallamine: hypertension (↑ with gallamine); atracurium, pancuronium, gallamine: tachycardia (↑ with gallamine). GI: pancuronium: excessive salivation. Derm: rash; atracurium: skin flushing. Misc: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS.

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PHYSICAL THERAPY IMPLICATIONS

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Examination and Evaluation
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  • Monitor signs of allergic reactions and anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

  • Be alert for residual skeletal muscle weakness that persists after the patient recovers from surgery. Report any strength deficits that might affect gait, balance, and other functional activities.

  • Assess blood pressure (BP) and compare to normal values (See Appendix F). Report changes in BP, either a problematic decrease in BP (hypotension) or a sustained increase in BP (hypertension).

  • Assess symptoms of bronchospasm (wheezing, coughing, tightness in chest) or decreased respiratory muscle function. Perform pulmonary function tests to quantify suspected changes in ventilation and respiration (See Appendix I).

  • Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report any rhythm disturbances or symptoms of increased arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

  • If used during mechanical ventilation, observe whether the chest wall is relaxed and compliant with ventilation. Notify physician or nursing staff if the patient is agitated or appears to be resisting mechanical ventilation.

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Patient/Client-Related Instruction
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  • Instruct patient to report other troublesome side effects such as excessive salivation or skin problems (rash, flushing).

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Pharmacokinetics
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Absorption: Following IV administration, absorption is essentially complete. Tubocurarine—Although well absorbed following IM administration, effect is delayed as compared with IV administration.

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Distribution: Atracurium, gallamine—Distribute into extracellular space; cross the placenta. Metocurine—Extensively distributed; crosses the placenta. Mivacurium—Tissue distribution is limited. Pancuronium—Rapidly distributes into extracellular fluid; small amounts cross the placenta. Tubocurarine—Extensively distributed and subsequently redistributed to various tissue compartments; saturation ...

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