Atracurium

• •Intraoperative relaxation — useful in hepatic/renal failure

Onset 2–3 min. Duration 30–45 min. Hofmann elimination + nonspecific esterases — independent of hepatic/renal function.

HISTAMINE release with rapid/large doses → hypotension, tachycardia, flushing, bronchospasm.

• !Histamine release (dose/rate-dependent)
• !Laudanosine metabolite (CNS excitation/seizure at very high cumulative doses — theoretical)

• ×Reactive airway disease (relative — histamine)

Neostigmine + glycopyrrolate (NOT sugammadex — benzylisoquinolinium)

• ★Organ-independent Hofmann elimination → good choice in combined hepatic + renal failure.
• ★Histamine release distinguishes it from cisatracurium (which does not release histamine).
• ★NOT reversible by sugammadex.

• Succinylcholine

  Acetylcholine receptor agonist at the NMJ; sustained depolarization → fasciculations → flaccid paralysis. Hydrolyzed by plasma cholinesterase.

• Rocuronium

  Competitive antagonist at the NMJ nicotinic receptor.

• Sugammadex

  Encapsulates rocuronium > vecuronium > pancuronium in 1:1 complex. No effect on cisatracurium, atracurium, sux.

• Cisatracurium

  Competitive antagonist at the post-synaptic nicotinic ACh receptor at the neuromuscular junction. Single cis-cis isomer of atracurium (4× more potent, lower laudanosine production).

• Vecuronium

  Competitive nicotinic ACh-receptor antagonist at the NMJ. Aminosteroid → reversible by sugammadex.

• Pancuronium

  Competitive nicotinic antagonist. Also blocks cardiac muscarinic receptors (vagolytic) → tachycardia.

• Mivacurium

  Competitive nicotinic antagonist. UNIQUE among non-depolarizers: metabolized by PLASMA CHOLINESTERASE (like succinylcholine) → shortest-acting NDMR.

Browse all classes: /reference/drugs

• •Stoelting & Hines, Pharmacology & Physiology in Anesthetic Practice, 6e
• •Miller's Anesthesia, 9e
• •FDA package insert