Neuromuscular transmission and its pharmacological blockade. Part 3: Continuous infusion of relaxants and reversal and monitoring of relaxation.

Continuous infusion is an attractive method of administration when muscle relaxation is needed for a longer period. The pharmacokinetic behaviour of a drug is an important determining factor for the suitability of relaxants for continuous infusion. At present mainly intermediately long acting relaxants are used for this purpose. At the end of surgery residual curarization may exist and thus anaesthesiologists prefer to be able to reverse the relaxants. The anticholinesterases neostigmine, pyridostigmine, and edrophonium are used clinically for this reason. Their effect is prolonged in patients with renal failure, and also affected during acid-base disturbances. Some other drugs have been used experimentally for the reversal of neuromuscular blockade, but are inadequate. Special problems can arise when reversal of a mivacurium-induced or antibiotic-induced blockade is wanted, or mivacurium was administered. Monitoring neuromuscular transmission is an important feature to determine the effect of relaxant administration or to detect residual curarization. It is based on stimulation of peripheral nerves with either single twitch, train of four, tetanic or double burst stimulation. The evoked response can be quantitated with mechanomyography, electromyography, or accelerography. The response of the various muscles to nerve stimulation varies due to the different characteristics of the muscles. Clinically, the use of the adductor pollicis muscle is advised.