Categories
Dr. Rosenblum reviews the CDC's recommendations for prescribing opiates
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For more information, CME credit and Primary Anesthesiology Board Prep,
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For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
I was recently connected to the founder of Clinic Marketers (www.ClinicMarketers.com), Anthony Sarandrea.
After our first conversation, I was extremely impressed with their track record of growing pain practices in the healthcare space. I was also impressed how they are regularly quoted by Forbes and Inc. magazine regarding upcoming marketing trends in the healthcare industry: https://www.inc.com/
I was so impressed that I decided to hire them to perform an audit on our company’s marketing efforts.
They uncovered that we were wasting over 30% of our marketing dollars!
I asked Anthony if he would be open to recording an interview to share his insights for other doctors to take advantage of. He agreed and you can find the full recording here:
https://soundcloud.com/clinic-marketers/painexam-podcast
Listen to the interview if you’re interested in learning how to trim the fat and scale your practice profitably.
He and his team offered to perform their deep dive analysis and audits that they charge $2500 for, FREE of charge for the first 7 of you who read this email and reach out to him at: anthony@clinicmarketers.com or fill out a form on www.ClinicMarketers.com
Enjoy!
-David
NMDA receptor for the boards (ketamine, allodynia, etc)
Reference
The Role of N-Methyl-d-Aspartate (NMDA) Receptors in Pain: A Review
Petrenko, Andrei B. MD; Yamakura, Tomohiro MD, PhD; Baba, Hiroshi MD, PhD; Shimoji, Koki MD, PhD, FRCA
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Dr. Rosenblum discusses a challenging case of cancer invasion into the chest, neck and pain related to lymphedema in a patient with metastatic breast cancer.
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
This is a review for those who practice Anesthesia and may participate in resuscitation. Information was valid as of february 2017, per ACLS.net
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Dr. Rosenblum, reviews the latest guidelines (as of 2017 for ACLS)
Discussed in this podcast are new revelations bout lidocaine, vasopressin, etc.
References
ACLS.net
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Raj, PP. Radiographic imaging for regional anesthesia and Pain Management. 2005. p302-311
Pain Unit
Breast Pain and Intrathecal Pump
References
Raj, PP. Radiographic imaging for regional anesthesia and Pain Management. 2005. p302-311
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
A review of tarsal tunnel syndrome
Free version does not contain patellofemoral syndrome
Reference
https://en.wikipedia.org/wiki/Tarsal_tunnel_syndrome
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Patellofemoral pain syndrome and tarsal tunnel syndrome
an in depth review
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Lower Extremity nerve block review for the Anesthesia Boards
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Amniotic fluid and membrane injections to treat inflammatory and degenerative conditions
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Reference
Blue Cross Blue Shield Policy
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 100
Dr. Rosenblum discusses the evaluation and management of Cervical Spondylotic Myelopathy
Be sure to Check out our partner Boston Biolife
The next Hands on Boston Biolife Workshops is on July 16-17, and features:
-Stem Cell Therapies
-Biologics
Focusing on Regenerative Applications in Pain Medicine
Hands-On Overview:
- Each participant will attend a variety of diverse educational workstations.
- Each station will be structured to a particular technology and offer a comprehensive review of the principles and their applications.
- In addition to the clinical workstations the attendee will participate in other informative, small group sessions that relate to practice management and professional development surrounding regenerative medicine.
CME Presentation Topics:
- Clinical Applications & Research Landscape of Stem Cell Therapy
- Cellular Anatomy of Regenerative Medicine
- Fundamentals of Implementing Regenerative Medicine in your Pain Practice
- Musculoskeletal (MSK) Regenerative Medicine Research & Historical Perspective
- Adipose Derived Regenerative Medicine
- Computerized Radiographic Measurement Analysis (CRMA)
- Biochemistry of Alpha2 Macroglobulin (A2M)
- Comprehensive Approach to Regeneration of Injured Skeletal Muscles via Delivery of Growth Factors & Progenitor Cells
- 3D Targeting Analytics for BMAC Harvesting
Day 1 Agenda*
- 7:00 - 8:00 am Registration/Breakfast
- 8:00 - 1:00 pm CME Lecture Series
- 2:30 - 6:30 pm CME Break-out Stations
Day 2 Agenda*
- 7:00 - 8:00 am Registration/Breakfast
- 8:00 - 11:45 am CME Lecture Series
- 11:45 - 4:45 pm CME Break-out Stations
*Lunch & breaks are included on both days - Times / agenda subject to change
For all travel plans: Please plan on course completion at 4:45 on Day 2
Hands-On Stations:
(Completed Over 2-Days) You will participate in 4 workstations on day 1 AND 4 workstations on day 2 (all workstations will remain the same on both days). There will be time during and after for questions and answers.
- Platelet Rich Plasma (PRP)
• Anatomy • Composition • Processing - Bone Marrow Acquisition Techniques with Cadaver
• Anatomy • Composition • Harvesting Techniques - Stem Cell Basics
• Biochemical Composition, Amniotic Fluid • Stem Cells
• Growth Factors & Cytokines - Lipo Aspiration Techniques with Cadaver
• Clinical Techniques • Acquisition & Processing • Equipment - Flouroscopic Interventional Biologics for Pain Management with Cadaver
• Joints • Discs • Fibrin & Other Biologics - Bone Marrow Aspiration Imaging Technologies
• Imaging • Targeting • Bone Marrow Acquisitions - Live Patient MSK Joint Imaging & Anatomy Using Ultrasonography
• Shoulders, Knees, Elbows, Ankles - Laboratory Fundamentals for Regenerative Medicine
• Protocol Development • Sample Preparation • GMP
CME
- 18 CME Credits Offered for this course (complies with ACCME standards)
For more information Call: 978 569-8080
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 1
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 54
AnesthesiaExam Podcast- Subscription Premium Episodes Now Available
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Paianful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 53
Does Regional anaesthesia improve outcome after total hip arthroplasty? A systematic review
Br. J.anaesth. (2009)103 (3) 335-345
A Brief Review of Neuromuscular Blocking Agents
For the Premium Version, Subscribe here
AnesthesiaExam Podcast
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
- Basic and Advanced Anesthesia Exam Review, Go to ABAStagedExams.com
- For CRNA Board Prep, go to CRNABoardPrep.com
- For the Pediatric Anesthesiology Board Review, Go to PedsAE
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Skeletal Muscle relaxants
Classification
- Peripherally acting (Neuromuscular blockers)
- Pre synaptic neuromuscular blocker
- Inhibit Ach synthesis: triethylacholine – hemicholinium
- Inhibit Ach release: Mg, aminoglycosides, botulinum toxin
- Post synaptic neuromuscular blocker
- Competitive (non depolarizing blockers):
- d- tubocurarine
- Gallamine
- Atracurium
- Pancuronium
- Vecuronium
- Depolarizing blockers: succinylcholine (suxamethonium)
- Competitive (non depolarizing blockers):
- Pre synaptic neuromuscular blocker
- Centrally acting skeletal muscle relaxants
- Baclofen – Diazepam
- Direct acting skeletal muscle relaxants
- Dantrolene
Mechanism of action
- Non depolarizing relaxant drugs
- All neuromuscular blocking agents used in USA except succinylcholine are classifies as non depolarizing agents
- When small doses of nondepolarizing muscle relaxants are administered, they act predominantly at nicotinic receptor site by competing with acetylcholine
- The least potent relaxant (eg. Rocuronium) have the fastest onset and the shortest duration of action
- In large doses, nondepolarizing drugs enter the pore of ion channel to produce a more intense motor blockade. This action further weakens neuromuscular transmission and diminishes the ability of the cholinesterase inhibitor (eg. Neostigmine, edrophonium, pyridostigmine) to antagonize the effect of non depolarizing muscle relaxants.
- They also block prejunctional sodium channels. As a result of this action, muscle relaxants interfere with the metabolization of acetylcholine at the nerve ending.
- Both halothane and succinylcholine increase the intensity and duration of action of pancuronium. (1)
- Depolarizing relaxant drugs
- Phase I block (depolarizing)
- Succinylcholine is the only available depolarizing neuromuscular blocking drug. (2)
- It produces a longer effect at the myoneural junction
- It reacts with the nicotinic receptor to open the channel and cause depolarization of the motor end plate, and this in turn spreads to the adjacent membranes, causing contractions of muscle motor units.
- Because succinylcholine is not metabolized at the synapse, the depolarized membranes remain depolarized and unresponsive to subsequent impulses
- This is called Phase I (depolarizing) block, not reversed by cholinesterase inhibitors
- Phase II block (desensitizing)
- With prolonged exposure to succinylcholine, initial end plate depolarization decreases and the membrane become repolarized
- Despite this repolarization, the membrane cannot be easily depolarized again because it is desensitized
- The channel block is more important than agonist action at the receptor in phase II of succinylcholine’s neuromuscular blocking action
- Later in phase II, the characteristics of the blockade are nearly identical to those of a non depolarizing block (ie, a nonsustained twitch response to a titanic stimulus) with possible reversal by acetylcholinesterase inhibitors
- Phase I block (depolarizing)
- Succinylcholine produce reversible contracture of intrafusal fibers of the muscle spindle and leads to acceleration of the afferent discharge. (3)
- Another study by Martin Jeevendra and Duriex Marcel E found that: (4)
1. Succinylcholine caused initial activation of the muscle AchR followed by desensitization
2. At clinically relevant concentrations, succinylcholine has no stimulatory or inhibitory interactions with α3β2 (presynaptic) or α3β4 (ganglionic) AchRs
3. High doses of succinylcholine caused inhibition of both α3β2 and α3β4 receptor.
Pharmacokinetics of neuromuscular blocking drugs
- Succinylcholine has the fastest onset of action among all the muscle relaxants. (5)
- The elimination of succinylcholine appears to follow first order kinetics with linear relationship between intensity of the effect and logarithm of the dose. The rate of recovery is independent of dose for each age group. The rate of recovery is faster in children than in infants; the rate of recovery is faster in infants than in adults. The elimination rate constant for infabts was similar to that of children, but is dissimilar from those of adults. (6)
| Drug | Elimination | Clearance (mL/kg/min) | Approximate duration of action (minutes) | Approximate potency relative to Tubocurarine |
| Atracurium | Spontaneous | 6.6 | 20-35 | 1.5 |
| Cisatracurium | Mostly spontaneous | 5-6 | 25-44 | 1.5 |
| Doxacurium | Kidney | 2.7 | > 35 | 6 |
| Metocurine | Kidney (40%) | 1.2 | > 35 | 4 |
| Mivacurium | Plasma ChE (Butyrylcholinesterase) | 70-95 | 10-20 | 4 |
| Tubocurarine | Kidney (40%) | 2.3-2.4 | > 50 | 1 |
| Pancuronium | Kidney (80%) | 1.7-1.8 | > 35 | 6 |
| Pipecuronium | Kidney (60%) and liver | 2.5-3.0 | > 35 | 6 |
| Rocuronium | Liver (75-90%) and kidney | 2.9 | 20-35 | 0.8 |
| Vecuronium | Liver (75-90%) and kidney | 3-5.3 | 20-35 | 6 |
| Succinylcholine | Plasma ChE (100%) (Butyrylcholinesterase) | >100 | < 8 | 0.4 |
Soutce: Bertram G. Katzung, Susan B. Masters and Anthony J. Trevor. Basic amd Clinical Pharmacology. 11th Edition. Chapter 27. Skeletal Muscle Rexants. Page 451-465.
Pharmacology of Neuromuscular blocking drugs
| Drug | ED95a (mg/kg) | Intubating dose (mg/kg) | Onset timeb (s) | Clinical durationc(min) | |
| Succinylcholine | 0.3 | 1.0d | 60 | 10 | |
| Benzylisoquinolone | Tubocurarine | 0.5 | 0.5-0.6 | 220 | 80+ |
| Atracurium | 0.23 | 0.5 | 110 | 43 | |
| Mivacurium | 0.08 | 0.15-0.2 | 170 | 16 | |
| Doxacurium | 0.025 | 0.05 | 250 | 83 | |
| Cisatracurium | 0.05 | 0.1 | 150 | 45 | |
| Aminosteroids | Pancuronium | 0.07 | 0.1 | 220 | 75 |
| Vecuronium | 0.05 | 0.1 | 180 | 33 | |
| Pipecuronium | 0.045 | 0.08 | 300 | 95 | |
| Rocuronium | 0.3 | 0.6 | 75 | 33 | |
| Rapacuronium | 1.2 | 1.5 | <75 | 15 | |
a: The dose that depresses the twitch height by 95%
b: time to 95% depression of first twitch of train-of-four
c: time to 25% recovery of first twitch of train-of-four
d: This is about three times the ED95
Source: Jonnas Appiah-Ankam, Jennifer M Hunter. Pharmacology of neuromuscular blocking drugs. Contin Educ Anaesth Crit Care Pain. 2004;4(1):2-7.
Side effects of succinylcholine: (2)
- Cardiovascular effects: bradycardia. It can cause arrhythmias when administered with halothane anesthesia
- Muscle pain: experienced the day after surgery and is worse in ambulatory patients. It is more common in the young and healthy with a large muscle mass. The pain is thought to be a result of the initial fasciculations and occurs in unusual sites, such as the diaphragm, intercostal muscles and between the scapulae.
- Hyperkalemia: Administration of succinylcholine 1.0 mg kg−1 produces a small increase (∼0.5 mmol litre−1) in serum potassium concentration in patients undergoing halothane anaesthesia.
- Malignant hyperthermia: Succinylcholine is a recognized trigger factor for malignant hyperthermia and may also precipitate muscle contracture in patients with myotonic dystrophies.
- Hypersensitivity: Succinylcholine accounts for about 50% of hypersensitivity reactions to NMBDs. The incidence is estimated to be 1 in 4000 administrations.
- Increased intraocular pressure: The average increase in intra-ocular pressure after succinylcholine 1.0 mg kg−1 is 4–8 mm Hg. The increase occurs promptly after intravenous injection, peaking at 1–2 min and lasting as long as the neuromuscular block.
- Increased intragastric pressure:
- This complication is likely to occur in patients with delayed gastric emptying (those with diabetes), traumatic injury, esophageal dysfunction and morbid obesity.
- Prolonged paralysis: Reduced plasma cholinesterase activity, a result of inherited or acquired factors, may alter the duration of action of succinylcholine, leading to prolonged paralysis.
Effects of muscle relaxants:
- Vecuronium, pipecuronium, doxacurium, cisatracurium and rocuronium all have minimal cardiovascular effects
- Pancuronium, atracurium and mivacurium produce cardiovascular effects that are mediated by either autonomic or histamine receptors
- Tubocurarine and to lesser extent metocurine, mivacuronium and atracurium can produce hypotension as a result of histamine release
- With larger doses, ganglionic blockade may occur with tubocurarine and metocurine
- Pancuronium causes a moderate increase in heart rate and a smaller increase in cardiac output, with little or no change in systemic vascular resistance
- Pancuronium induced tachycardia is primarily due to vagolytic action, release of norepinephrine from adrenergic nerve endings and blockade of neuronal uptake of norepinephrine may be secondary mechanisms
| Drug | Effect on autonomic ganglia | Effect on cardiac muscarinic receptors | Tendency to cause histamine release |
| Atracurium | None | None | Slight |
| Cisatracurium | None | None | None |
| Doxacurium | None | None | None |
| Metocurine | Weak block | None | Slight |
| Mivacurium | None | None | Moderate |
| Tubocurarine | Weak block | None | Moderate |
| Pancuronium | None | Moderate block | None |
| Pipecuronium | None | None | None |
| Rocuronium | None | Slight | None |
| Vecuronium | None | None | None |
| Gallamine | None | Strong block | None |
| Succinylcholine | Stimulation | Stimulation | Slight |
Source: Bertram G. Katzung, Susan B. Masters and Anthony J. Trevor. Basic amd Clinical Pharmacology. 11th Edition. Chapter 27. Skeletal Muscle Rexants. Page 451-465.
Interactions with other drugs
- Anesthetics
- Inhaled anesthetic potentiate the neuromuscular blockade produced by non depolarizing muscle relaxants in dose dependent fashion
- Inhaled anesthetic augment the effect of muscle relaxants in the following order:
Isoflurane (most); sevoflurane, desflurane, enflurane and halothane; nitrous oxide (least)
- Rare interaction of succinylcholine with volatile anesthetics results in malignant hyperthermia
- Isobolographic and fractional analysis of the suxamethonium-mivacurium and suxamethonium-atracurium combinations demonstrated antagonistic interactions. (7)
- The recovery from the effects of one nondepolarizing muscle relaxant given after partial recovery from another, more resembles the recovery from the muscle relaxant given first. (8)
- Antibiotics
- Neuromuscular blockade is enhanced by antibiotics (eg. aminoglycosides)
- For patients treated with gentamycin and tobramycin, atracurium offers advantage over vecuronium when prolonged block is not desired. (9)
- Many antibiotics have shown to cause a depression of evoked release of acetylcholine similar to that caused by administering magnesium. The mechanism of this prejunctional effect appears to be blockade of specific P-type calcium channels in the motor nerve terminal
- Antiarrhythmic drugs and local anesthetics
- The antiarrhythmics lidocaine, procainamide, propanolol and diphenylhydantoin increase the intensity and duration of d-Tubocurarine neuromuscular blockade. (10)
- Higher concentrations of bupivacaine have been associated with cardiac arrhythmias independent of the muscle relaxant used.
- In small doses, local anesthetics can depress posttetanic potentiation via a prejunctional neural effect.
- In large doses, local anesthetics can block neuromuscular transmission
- With higher doses, local anesthetics block acetylcholine- induced muscle contractions as a result of blockade of the nicotinic receptor ion channels
- Neuromuscular blocking agents potentiate the action of local anesthetics by acting on different sites of the neuromuscular junction. The block caused by combination of local anesthetic and neuromuscular blocking agent can be reversed by 4-aminopyridine. (11)
- Other neuromuscular blocking drugs
- The end plate depolarizing effect of succinylcholine can be antagonized by administering a small dose of non depolarizing blocker
- To prevent the fasciculation associated with succinylcholine administration, a small non paralyzing dose of a nondepolarizing drug can be given before succinylcholine (eg. d-tubourarine, 2 mg IV, or pancuronium, 0.5 mg iv)
- Lithium: Lithium enhances the myoneural blocking effects of suxamethonium, pancuronium and vecuronium. (12)
Reversal of nondepolarizing neuromuscular blockade
- The cholinesterase inhibitors effectively antagonize the neuromuscular blockade caused by nondepolarizing drugs
- Neostigmine and pyridostigmine antagonize the nondepolarizing neuromuscular blockade by increasing the availability of acetylcholine at the motor end plate, mainly by inhibition of acetylcholinesterase
- Edrophonium antagonized the neuromuscular blockade purely by inhibiting acetylcholinesterase activity. Edrophonium has a more rapid onset of action but may be less effective than neostigmine in reversing the effects of nondepolarizing blockers in the presence of a profound degree of neuromuscular blockade.
- A novel cyclodextrin reversal drug, sugammadex, has been submitted for FDA approval. It can rapidly inactivate steroidal neuromuscularblocking drugs by forming an inactive complex, which is excreted in the urine.
References:
- Katz Ronald L. Modification of the action of pancuronium by succinylcholine and halothane. Anesthesiology December 1971;35(6).
- Jonnas Appiah-Ankam, Jennifer M Hunter. Pharmacology of neuromuscular blocking drugs. Contin Educ Anaesth Crit Care Pain. 2004;4(1):2-7.
- Cedric M Smith, Earl Eldred. Mode of action of succinylcholine on sensory endings of mammalian muscle spindles. JPET February 1961;131(2):237-242.
- Martyn Jeevendra, Durieux Marcel E. Succinylcholine: New insights into mechanism of action of old drug. Anesthesiology April 2006;104(4):633-634.
- Sluga M, Ummenhofer W, Studer W, Seigemund M, Marsch SC. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: A prospective, randomized trial in emergent cases. Anesth Analg 2005;101:1356-61.
- Cook DR, Wingard LB, Taylor FH. Pharmacokinetics of succinylcholine in infants, children and adults. Clinical Pharmacology and Therapeutics. 1976;20(4):493-498.
- KS Kim, DJ Na, SU Chon. Interactions between suxamethonium and mivacurium or atracurium. British Journal of Anesthesia. 1996;77:612-616.
- Harrop-Griffiths AW, Hood JR. Interactions between non depolarizing muscle relaxants. Anesthesiology 1997;86(1):263.
- JY Dupuis, R Martin, JP Tetrault. Atracurium and vecuronium interaction with gentamycin and tobramycin. Can J Anaesth. 1989;36(4):407-11.
- Katzung BG, Walter M, Harrah Marvin D. The interactions of d-Tubocurarine with Antiarrhythmic drugs. Anesthesiology October 1970;33(4).
- Matsuo S, Rao DBS, Chaudry I, Foldes FF. Interaction of muscle relaxant and local anesthetics at the neuromuscular junction. Anesthesia & Analgesia. September/October 1978;57(5).
- Saarnivaara L, Ertama P. Interactions between lithium/rubidium and six muscle relaxants. A study on the rat phrenic nerve-hemidiaphragm preperation. Des Anaesthesist. 1992;41(12):760-764.
A Brief Review of Neuromuscular Blocking Agents
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AnesthesiaExam Podcast
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep
- Go to AnesthesiaExam.com
- For CRNA Board Prep, go to CRNABoardPrep.com
- For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medicaal Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
Skeletal Muscle relaxants
Classification
- Peripherally acting (Neuromuscular blockers)
- Pre synaptic neuromuscular blocker
- Inhibit Ach synthesis: triethylacholine – hemicholinium
- Inhibit Ach release: Mg, aminoglycosides, botulinum toxin
- Post synaptic neuromuscular blocker
- Competitive (non depolarizing blockers):
- d- tubocurarine
- Gallamine
- Atracurium
- Pancuronium
- Vecuronium
- Depolarizing blockers: succinylcholine (suxamethonium)
- Competitive (non depolarizing blockers):
- Pre synaptic neuromuscular blocker
- Centrally acting skeletal muscle relaxants
- Baclofen – Diazepam
- Direct acting skeletal muscle relaxants
- Dantrolene
Mechanism of action
- Non depolarizing relaxant drugs
- All neuromuscular blocking agents used in USA except succinylcholine are classifies as non depolarizing agents
- When small doses of nondepolarizing muscle relaxants are administered, they act predominantly at nicotinic receptor site by competing with acetylcholine
- The least potent relaxant (eg. Rocuronium) have the fastest onset and the shortest duration of action
- In large doses, nondepolarizing drugs enter the pore of ion channel to produce a more intense motor blockade. This action further weakens neuromuscular transmission and diminishes the ability of the cholinesterase inhibitor (eg. Neostigmine, edrophonium, pyridostigmine) to antagonize the effect of non depolarizing muscle relaxants.
- They also block prejunctional sodium channels. As a result of this action, muscle relaxants interfere with the metabolization of acetylcholine at the nerve ending.
- Both halothane and succinylcholine increase the intensity and duration of action of pancuronium. (1)
- Depolarizing relaxant drugs
- Phase I block (depolarizing)
- Succinylcholine is the only available depolarizing neuromuscular blocking drug. (2)
- It produces a longer effect at the myoneural junction
- It reacts with the nicotinic receptor to open the channel and cause depolarization of the motor end plate, and this in turn spreads to the adjacent membranes, causing contractions of muscle motor units.
- Because succinylcholine is not metabolized at the synapse, the depolarized membranes remain depolarized and unresponsive to subsequent impulses
- This is called Phase I (depolarizing) block, not reversed by cholinesterase inhibitors
- Phase II block (desensitizing)
- With prolonged exposure to succinylcholine, initial end plate depolarization decreases and the membrane become repolarized
- Despite this repolarization, the membrane cannot be easily depolarized again because it is desensitized
- The channel block is more important than agonist action at the receptor in phase II of succinylcholine’s neuromuscular blocking action
- Later in phase II, the characteristics of the blockade are nearly identical to those of a non depolarizing block (ie, a nonsustained twitch response to a titanic stimulus) with possible reversal by acetylcholinesterase inhibitors
- Phase I block (depolarizing)
- Succinylcholine produce reversible contracture of intrafusal fibers of the muscle spindle and leads to acceleration of the afferent discharge. (3)
- Another study by Martin Jeevendra and Duriex Marcel E found that: (4)
1. Succinylcholine caused initial activation of the muscle AchR followed by desensitization
2. At clinically relevant concentrations, succinylcholine has no stimulatory or inhibitory interactions with α3β2 (presynaptic) or α3β4 (ganglionic) AchRs
3. High doses of succinylcholine caused inhibition of both α3β2 and α3β4 receptor.
Pharmacokinetics of neuromuscular blocking drugs
- Succinylcholine has the fastest onset of action among all the muscle relaxants. (5)
- The elimination of succinylcholine appears to follow first order kinetics with linear relationship between intensity of the effect and logarithm of the dose. The rate of recovery is independent of dose for each age group. The rate of recovery is faster in children than in infants; the rate of recovery is faster in infants than in adults. The elimination rate constant for infabts was similar to that of children, but is dissimilar from those of adults. (6)
| Drug | Elimination | Clearance (mL/kg/min) | Approximate duration of action (minutes) | Approximate potency relative to Tubocurarine |
| Atracurium | Spontaneous | 6.6 | 20-35 | 1.5 |
| Cisatracurium | Mostly spontaneous | 5-6 | 25-44 | 1.5 |
| Doxacurium | Kidney | 2.7 | > 35 | 6 |
| Metocurine | Kidney (40%) | 1.2 | > 35 | 4 |
| Mivacurium | Plasma ChE (Butyrylcholinesterase) | 70-95 | 10-20 | 4 |
| Tubocurarine | Kidney (40%) | 2.3-2.4 | > 50 | 1 |
| Pancuronium | Kidney (80%) | 1.7-1.8 | > 35 | 6 |
| Pipecuronium | Kidney (60%) and liver | 2.5-3.0 | > 35 | 6 |
| Rocuronium | Liver (75-90%) and kidney | 2.9 | 20-35 | 0.8 |
| Vecuronium | Liver (75-90%) and kidney | 3-5.3 | 20-35 | 6 |
| Succinylcholine | Plasma ChE (100%) (Butyrylcholinesterase) | >100 | < 8 | 0.4 |
Soutce: Bertram G. Katzung, Susan B. Masters and Anthony J. Trevor. Basic amd Clinical Pharmacology. 11th Edition. Chapter 27. Skeletal Muscle Rexants. Page 451-465.
Pharmacology of Neuromuscular blocking drugs
| Drug | ED95a (mg/kg) | Intubating dose (mg/kg) | Onset timeb (s) | Clinical durationc(min) | |
| Succinylcholine | 0.3 | 1.0d | 60 | 10 | |
| Benzylisoquinolone | Tubocurarine | 0.5 | 0.5-0.6 | 220 | 80+ |
| Atracurium | 0.23 | 0.5 | 110 | 43 | |
| Mivacurium | 0.08 | 0.15-0.2 | 170 | 16 | |
| Doxacurium | 0.025 | 0.05 | 250 | 83 | |
| Cisatracurium | 0.05 | 0.1 | 150 | 45 | |
| Aminosteroids | Pancuronium | 0.07 | 0.1 | 220 | 75 |
| Vecuronium | 0.05 | 0.1 | 180 | 33 | |
| Pipecuronium | 0.045 | 0.08 | 300 | 95 | |
| Rocuronium | 0.3 | 0.6 | 75 | 33 | |
| Rapacuronium | 1.2 | 1.5 | <75 | 15 | |
a: The dose that depresses the twitch height by 95%
b: time to 95% depression of first twitch of train-of-four
c: time to 25% recovery of first twitch of train-of-four
d: This is about three times the ED95
Source: Jonnas Appiah-Ankam, Jennifer M Hunter. Pharmacology of neuromuscular blocking drugs. Contin Educ Anaesth Crit Care Pain. 2004;4(1):2-7.
Side effects of succinylcholine: (2)
- Cardiovascular effects: bradycardia. It can cause arrhythmias when administered with halothane anesthesia
- Muscle pain: experienced the day after surgery and is worse in ambulatory patients. It is more common in the young and healthy with a large muscle mass. The pain is thought to be a result of the initial fasciculations and occurs in unusual sites, such as the diaphragm, intercostal muscles and between the scapulae.
- Hyperkalemia: Administration of succinylcholine 1.0 mg kg−1 produces a small increase (∼0.5 mmol litre−1) in serum potassium concentration in patients undergoing halothane anaesthesia.
- Malignant hyperthermia: Succinylcholine is a recognized trigger factor for malignant hyperthermia and may also precipitate muscle contracture in patients with myotonic dystrophies.
- Hypersensitivity: Succinylcholine accounts for about 50% of hypersensitivity reactions to NMBDs. The incidence is estimated to be 1 in 4000 administrations.
- Increased intraocular pressure: The average increase in intra-ocular pressure after succinylcholine 1.0 mg kg−1 is 4–8 mm Hg. The increase occurs promptly after intravenous injection, peaking at 1–2 min and lasting as long as the neuromuscular block.
- Increased intragastric pressure:
- This complication is likely to occur in patients with delayed gastric emptying (those with diabetes), traumatic injury, esophageal dysfunction and morbid obesity.
- Prolonged paralysis: Reduced plasma cholinesterase activity, a result of inherited or acquired factors, may alter the duration of action of succinylcholine, leading to prolonged paralysis.
Effects of muscle relaxants:
- Vecuronium, pipecuronium, doxacurium, cisatracurium and rocuronium all have minimal cardiovascular effects
- Pancuronium, atracurium and mivacurium produce cardiovascular effects that are mediated by either autonomic or histamine receptors
- Tubocurarine and to lesser extent metocurine, mivacuronium and atracurium can produce hypotension as a result of histamine release
- With larger doses, ganglionic blockade may occur with tubocurarine and metocurine
- Pancuronium causes a moderate increase in heart rate and a smaller increase in cardiac output, with little or no change in systemic vascular resistance
- Pancuronium induced tachycardia is primarily due to vagolytic action, release of norepinephrine from adrenergic nerve endings and blockade of neuronal uptake of norepinephrine may be secondary mechanisms
| Drug | Effect on autonomic ganglia | Effect on cardiac muscarinic receptors | Tendency to cause histamine release |
| Atracurium | None | None | Slight |
| Cisatracurium | None | None | None |
| Doxacurium | None | None | None |
| Metocurine | Weak block | None | Slight |
| Mivacurium | None | None | Moderate |
| Tubocurarine | Weak block | None | Moderate |
| Pancuronium | None | Moderate block | None |
| Pipecuronium | None | None | None |
| Rocuronium | None | Slight | None |
| Vecuronium | None | None | None |
| Gallamine | None | Strong block | None |
| Succinylcholine | Stimulation | Stimulation | Slight |
Source: Bertram G. Katzung, Susan B. Masters and Anthony J. Trevor. Basic amd Clinical Pharmacology. 11th Edition. Chapter 27. Skeletal Muscle Rexants. Page 451-465.
Interactions with other drugs
- Anesthetics
- Inhaled anesthetic potentiate the neuromuscular blockade produced by non depolarizing muscle relaxants in dose dependent fashion
- Inhaled anesthetic augment the effect of muscle relaxants in the following order:
Isoflurane (most); sevoflurane, desflurane, enflurane and halothane; nitrous oxide (least)
- Rare interaction of succinylcholine with volatile anesthetics results in malignant hyperthermia
- Isobolographic and fractional analysis of the suxamethonium-mivacurium and suxamethonium-atracurium combinations demonstrated antagonistic interactions. (7)
- The recovery from the effects of one nondepolarizing muscle relaxant given after partial recovery from another, more resembles the recovery from the muscle relaxant given first. (8)
- Antibiotics
- Neuromuscular blockade is enhanced by antibiotics (eg. aminoglycosides)
- For patients treated with gentamycin and tobramycin, atracurium offers advantage over vecuronium when prolonged block is not desired. (9)
- Many antibiotics have shown to cause a depression of evoked release of acetylcholine similar to that caused by administering magnesium. The mechanism of this prejunctional effect appears to be blockade of specific P-type calcium channels in the motor nerve terminal
- Antiarrhythmic drugs and local anesthetics
- The antiarrhythmics lidocaine, procainamide, propanolol and diphenylhydantoin increase the intensity and duration of d-Tubocurarine neuromuscular blockade. (10)
- Higher concentrations of bupivacaine have been associated with cardiac arrhythmias independent of the muscle relaxant used.
- In small doses, local anesthetics can depress posttetanic potentiation via a prejunctional neural effect.
- In large doses, local anesthetics can block neuromuscular transmission
- With higher doses, local anesthetics block acetylcholine- induced muscle contractions as a result of blockade of the nicotinic receptor ion channels
- Neuromuscular blocking agents potentiate the action of local anesthetics by acting on different sites of the neuromuscular junction. The block caused by combination of local anesthetic and neuromuscular blocking agent can be reversed by 4-aminopyridine. (11)
- Other neuromuscular blocking drugs
- The end plate depolarizing effect of succinylcholine can be antagonized by administering a small dose of non depolarizing blocker
- To prevent the fasciculation associated with succinylcholine administration, a small non paralyzing dose of a nondepolarizing drug can be given before succinylcholine (eg. d-tubourarine, 2 mg IV, or pancuronium, 0.5 mg iv)
- Lithium: Lithium enhances the myoneural blocking effects of suxamethonium, pancuronium and vecuronium. (12)
Reversal of nondepolarizing neuromuscular blockade
- The cholinesterase inhibitors effectively antagonize the neuromuscular blockade caused by nondepolarizing drugs
- Neostigmine and pyridostigmine antagonize the nondepolarizing neuromuscular blockade by increasing the availability of acetylcholine at the motor end plate, mainly by inhibition of acetylcholinesterase
- Edrophonium antagonized the neuromuscular blockade purely by inhibiting acetylcholinesterase activity. Edrophonium has a more rapid onset of action but may be less effective than neostigmine in reversing the effects of nondepolarizing blockers in the presence of a profound degree of neuromuscular blockade.
- A novel cyclodextrin reversal drug, sugammadex, has been submitted for FDA approval. It can rapidly inactivate steroidal neuromuscularblocking drugs by forming an inactive complex, which is excreted in the urine.
References:
- Katz Ronald L. Modification of the action of pancuronium by succinylcholine and halothane. Anesthesiology December 1971;35(6).
- Jonnas Appiah-Ankam, Jennifer M Hunter. Pharmacology of neuromuscular blocking drugs. Contin Educ Anaesth Crit Care Pain. 2004;4(1):2-7.
- Cedric M Smith, Earl Eldred. Mode of action of succinylcholine on sensory endings of mammalian muscle spindles. JPET February 1961;131(2):237-242.
- Martyn Jeevendra, Durieux Marcel E. Succinylcholine: New insights into mechanism of action of old drug. Anesthesiology April 2006;104(4):633-634.
- Sluga M, Ummenhofer W, Studer W, Seigemund M, Marsch SC. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: A prospective, randomized trial in emergent cases. Anesth Analg 2005;101:1356-61.
- Cook DR, Wingard LB, Taylor FH. Pharmacokinetics of succinylcholine in infants, children and adults. Clinical Pharmacology and Therapeutics. 1976;20(4):493-498.
- KS Kim, DJ Na, SU Chon. Interactions between suxamethonium and mivacurium or atracurium. British Journal of Anesthesia. 1996;77:612-616.
- Harrop-Griffiths AW, Hood JR. Interactions between non depolarizing muscle relaxants. Anesthesiology 1997;86(1):263.
- JY Dupuis, R Martin, JP Tetrault. Atracurium and vecuronium interaction with gentamycin and tobramycin. Can J Anaesth. 1989;36(4):407-11.
- Katzung BG, Walter M, Harrah Marvin D. The interactions of d-Tubocurarine with Antiarrhythmic drugs. Anesthesiology October 1970;33(4).
- Matsuo S, Rao DBS, Chaudry I, Foldes FF. Interaction of muscle relaxant and local anesthetics at the neuromuscular junction. Anesthesia & Analgesia. September/October 1978;57(5).
- Saarnivaara L, Ertama P. Interactions between lithium/rubidium and six muscle relaxants. A study on the rat phrenic nerve-hemidiaphragm preperation. Des Anaesthesist. 1992;41(12):760-764.
 | Validity of the Straight-Leg Raise Test for Patients With Sciatic Pain With or Without Lumbar Pain Using Magnetic Resonance Imaging Results as a Reference Standard | |
 | Pathogenesis. Baastrup’s disease is a term referring to close approximation of adjacent spinous processes due to general degenerative changes of the spine. | |
Dr. Rosenblum Discusses the management and treatment of
Femoral Neuropathy
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David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medical Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 49-50
Dr. Rosenblum Discusses the management and treatment of
Hip OA and anesthetic management
PainExam Podcast
For the Full version Subscribe to the premium subscription via our App
or Purchase our Full Lecture Library at PainExam.com
AnesthesiaExam Podcast
For Board Review and Practice Management Updates TEXT the word
ANESTHESIAEXAM to the number 33444
For more information, CME credit and MOCA and Primary Board Prep,
For more information, CME credit and MOCA and Primary Anesthesiology Board Prep,
For Basic and Advanced Anesthesia Exam Review,
For CRNA Board Prep, go to CRNABoardPrep.com
For the Pediatric Anesthesiology Board Review, Go to PedsAE.com
David Rosenblum, MD specializes in Pain Management and is the Director of Pain Management at Maimonides Medical Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPai
Pain Management and is the Director of Pain Management at Maimonides Medical Center and AABP Pain Managment
For evaluation and treatment of a Painful Disorder, go to www.AABPPain.com
718 436 7246
DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.
You should regularly consult a physician in matters relating to yours or another’s health. You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.
Copyright © 2015 QBazaar.com, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.
References
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.
Copyright © 2008 Saunders, An Imprint of Elsevier Chapter 48
https://www.hss.edu/professional-conditions_anesthesia-analgesia-for-total-knee-hip-replacement.asp