Allosteric inhibition of muscle-type nicotinic acetylcholine receptors by a neuromuscular blocking agent pancuronium.

Muscle relaxants are indispensable for surgical anesthesia. Early studies suggested that a classical non-depolarizing muscle relaxant pancuronium competitively binds to the ligand binding site to block nicotinic acetylcholine receptors (nAChR). Our group recently showed that nAChR which has two distinct subunit combinations are expressed in zebrafish muscles, αßδε and αßδ, for which potencies of pancuronium are different. Taking advantage of the distinct potencies, we generated chimeras between two types of nAChRs and found that the extracellular ACh binding site is not associated with the pancuronium sensitivity. Furthermore, application of either 2 µM or 100 µM ACh in native αßδε or αßδ subunits yielded similar IC50 of pancuronium. These data suggest that pancuronium allosterically inhibits the activity of zebrafish nAChRs.

Curare and pancuronium compared: effects on previously undepressed mammalian myoneural junctions.

Curare and pancuronium have multiple effects on previously undepressed rat diaphragm; these include depression of transmitter output and prolongation of the refractory period of prejunctional structures. The effect of curare on motor nerve terminals is greater than that of pancuronium. Both drugs depress postjunctional receptors; but curare, in addition, raises the threshold for the generation of muscle action potentials. In addition, these results raise questions about the validity of statistical methods used to calculate transmitter output.

Pancuronium improves the neuromuscular transmission defect of human organophosphate intoxication.

Two patients with acute severe organophosphate intoxication showed (1) single evoked compound muscle action potentials (CMAP) with repetitive discharges and (2) prominent decremental responses of CMAP with 20 and 50 Hz supramaximal nerve stimulation. Following the intravenous injection of single small doses of pancuronium, marked improvement in these abnormalities occurred and persisted for several hours. We postulate that the physiologic improvement following low-dose pancuronium results from blockade of acetylcholine receptors, especially those located on the terminal axon responsible for antidromic backfiring.

Intratracheal suctioning in sick preterm infants: prevention of intracranial hypertension and cerebral hypoperfusion by muscle paralysis.

In a prospective nonrandomized study, using each baby as his or her own control, we compared intracranial pressure (anterior fontanel pressure as measured with the Digilab pneumotonometer), cerebral perfusion pressure, BP, heart rate, transcutaneous Po2, and transcutaneous Pco2 before, during, and after endotracheal suctioning, with and without muscle paralysis, in 28 critically ill preterm infants with respiratory distress syndrome. With suctioning, there was a small but significant increase in intracranial pressure in paralyzed patients (from 13.7 [mean] +/- 4.4 mm Hg [SD] to 15.8 +/- 5.2 mm Hg) but a significantly larger (P less than .001) increase when they were not paralyzed (from 12.5 +/- 3.6 to 28.5 +/- 8.3 mm Hg). Suctioning led to a slight increase in BP with (from 45.3 +/- 9.1 to 48.0 +/- 8.7 mm Hg) and without muscle paralysis (from 45.1 +/- 9.4 to 50.0 +/- 11.7 mm Hg); but there was no significant difference between the two groups. The cerebral perfusion pressure in paralyzed infants did not show any significant change before, during, and after suctioning (31.5 +/- 9.1 mm Hg before v 32.0 +/- 8.7 mm Hg during suctioning), but without muscle paralysis cerebral perfusion pressure decreased (P less than .001) from 32.8 +/- 9.7 to 21.3 +/- 13.1 mm Hg. Suctioning induced a slight decrease in mean heart rate and transcutaneous Po2, but pancuronium did not alter these changes. There was no statistical difference in transcutaneous Pco2 before, during, and after suctioning with and without muscle paralysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of pithing and of nerve stimulation on the depletion of noradrenaline by reserpine in the rat anococcygeus muscle and vas deferens.

1 The depletion of noradrenaline (NA) in the rat anococcygeus muscle and vas deferens by reserpine and the effect on this of the abolition of nerve activity by pithing and reinforcement of nerve activity by stimulation of the spinal cord outflows has been studied.2 NA depletion of the anococcygeus and vas deferens measured 24 h after reserpine was similar and was related to dose. The heart was depleted faster than the two smooth muscle tissues.3 In the absence of reserpine neither abolition of nerve activity by pithing nor its reinforcement by nerve stimulation had a detectable influence on NA content of the anococcygeus or vas deferens.4 In rats given reserpine (200 mug/kg), increasing nerve activity by spinal stimulation significantly increased NA depletion in both the anococcygeus and the vas deferens when compared with animals pithed but not stimulated. These results confirm that nerve impulse traffic can be an important factor in determining the rate of depletion of NA by reserpine.5 The mechanical response to nerve stimulation in both the vas deferens and anococcygeus was resistant to quite severe depletion of their NA content, with the exception of the initial fast component of the response in the vas. The implications of these results for motor transmission in the vas deferens are discussed.

A comparison of the effects of pancuronium bromide and its monoquaternary analogue, ORG NC 45, on autonomic and somatic neurotransmission in the rat.

1 Potentiation by pancuronium of the effects of adrenergic nerve stimulation, previously shown in cardiovascular tissues, was also found in rat anococcygeus and vas deferens, in vitro or in vivo. 2 In the pithed rat, in the presence of pancuronium, pre-junctional alpha-adrenoceptor-mediated feedback inhibition of cardiac sympathetic transmission was uncovered at relatively low stimulation frequencies by phentolamine or yohimbine. 3 The effects of pancuronium and its mono-quaternary analogue Org NC 45 on autonomic and somatic neuromuscular transmission were compared, in the pithed rat. Org NC 45 was less potent than pancuronium at blocking somatic neuromuscular transmission by a factor of 2.1, at blocking cardiac, parasympathetic transmission by a factor of 538 and at potentiating sympathetic transmission by a factor of 33.

Different mechanisms of Ca2(+)-handling following nicotinic acetylcholine receptor stimulation, P2U-purinoceptor stimulation and K(+)-induced depolarization in C2C12 myotubes.

1. The increase in intracellular CA2+ on nicotinic acetylcholine receptor (nAChR) stimulation, P2U-purinoceptor stimulation and K(+)-induced depolarization was investigated in mouse C2C12 myotubes by use of fura-2 fluorescence to characterize the intracellular organisation of Ca2+ releasing stores and Ca(2+)-entry process. 2. Stimulation of nAChRs with carbachol induced a rapid rise in internal Ca2+ (EC50 = 0.85 +/- 0.09 microM), followed by a sustained phase. The Ca2+ response evoked by carbachol (10 microM) was completely blocked by the nAChR antagonist, pancuronium (3 microM), but was not affected by the muscarinic antagonist, atropine (3 microM), or under conditions when Ca2+ entry was blocked by La3+ (50 microM) or diltiazem (10 microM). Addition of pancuronium (3 microM) during the sustained phase of the carbachol-evoked response did not affect this phase. 3. Stimulation of P2U purinoceptors with ATP (1 mM) induced a somewhat higher biphasic Ca2+ response (EC50 of the rapid phase: 8.72 +/- 0.08 microM) than with carbachol. Pretreatment with La3+ abolished the sustained phase of the ATP-induced Ca2+ response, while the response was unaffected by diltiazem or pancuronium. 4. Stimulation of the cells with high K+ (60 mM), producing the same depolarization as with carbachol (10 microM), induced a rapid monophasic Ca2+ response, insensitive to diltiazem, pancuronium or La3+. 5. Under Ca(2+)-free conditions, the sustained phase of the carbachol- and ATP-evoked responses were abolished. Pre-emptying of depolarization-sensitive stores by high K+ under Ca(2+)-free conditions did not affect the carbachol- or ATP-evoked Ca2+ mobilization and vice versa. Preincubation of the cells with ATP in the absence of extracellular Ca2+ decreased the amplitude of the subsequent carbachol-induced Ca2+ response to 11%, while in the reverse procedure the ATP-induced response was decreased to 65%. Ca2+ mobilization evoked by simultaneous addition of optimal concentrations of carbachol and ATP was increased compared to levels obtained with either agonist. 6. Preincubation with high K+ under normal conditions abolished the sustained phase of the ATP-evoked Ca2+ response. The carbachol response consisted only of the sustained phase in the presence of high K+. 7. The carbachol-induced Ca2+ response was completely abolished under low Na+/Ca(2+)-free conditions, while under low Na+ conditions only a sustained Ca2+ response was observed. The ATP- and K(+)-induced responses were changed compared to Ca(2+)-free conditions. 8. ATP (300 microM) induced the formation of Ins(1,4,5)P3 under Ca(2+)-free conditions with a comparable time course to that found for the rise in internal Ca2+. In contrast to ATP, carbachol (10 microM) did not affect Ins(1,4,5)P3 levels under Ca(2+)-free conditions. 9. It is concluded that the Ca2+ release from discrete stores of C2C12 myotubes is induced by stimulation of nAChRs, P2U-purinoceptors and by high K+. Only the P2U-purinoceptor and nAChR activated stores show considerable overlap in releasable Ca2+. Sustained Ca(2+)-entry is activated by stimulation of nAChRs and P2U-purinoceptors via separate ion-channels, which are different from the skeletal muscle nAChR-coupled cation-channel.

Neuromuscular disorder in intensive care unit patients treated with pancuronium bromide. Occurrence in a cluster group of seven patients and two sporadic cases, with electrophysiologic and histologic examination.

During six consecutive months, seven patients admitted to our ICU (15 beds, general ICU, approximately 300 intubated patients per year) for acute respiratory failure requiring intubation and mechanical ventilation presented with a peculiar neuromuscular disorder. After the occurrence of this cluster group of patients, we detected two more similar but isolated cases in the following 18 months, ie, altogether 9 patients in 2 years of observation, or 1.55 percent of all intubated patients in our ICU. Sedation was achieved using midazolam, curarization was effected with the neuromuscular non-depolarizing agent pancuronium bromide (PB), and corticosteroids were administered to eight patients. Shortly after discontinuation of sedation and curarization, we observed a persistent tetraparetic syndrome and/or peroneal palsy with a concomitant increase of serum creatine kinase (CK). None of the patients was septic or had the multisystem organ failure. A strong association between CK increase and PB administration was found, whereas no patient suffered severe liver or kidney failure. The duration of the neurologic deficit ranged from 4 to 52 weeks, with only partial recovery for some patients; the duration of dysfunction was apparently related to the total dose of corticosteroids received. Two patients had difficulty being weaned from the respirator and required tracheostomy. Electrophysiologic studies showed signs of axonal neuropathy and myopathic changes, ie, motor units of brief duration, small amplitude, overly abundant for the voluntary effort being exerted. Muscle biopsies showed significant myopathic alterations, with foci of muscle necrosis in most patients and minimal lymphocytic inflammation in one patient. The neurologic complication described differs from the polyneuropathy in critically ill patients. Furthermore, PB or corticosteroids or both appear to be the causal agents. The duration of the neuromuscular dysfunction may be related to concomitant steroid therapy. The CK enzyme seems to be a marker of the disorder. This disorder is associated with myopathic alterations and axonal degeneration in some patients. Pancuronium bromide should be used with caution, particularly when associated with steroids therapy, and it may cause difficulty in weaning patients from the respirator.

Nerve-induced tachykinin-mediated vasodilation in skeletal muscle is dependent on nitric oxide formation.

Nerve-induced vasodilatation was studied by intravital microscopy of the rabbit tenuissimus muscle, pretreated with pancuronium, phentolamine, and guanethidine. Nerve stimulation of the tenuissimus nerve induced a vasodilatation which was frequency and pulse duration-dependent and insensitive to atropine and propanolol but abolished by tetrodotoxin. The nitric oxide synthase inhibitor, N omega-nitro-L-arginine methyl ester (L-NAME, 100 microM), but not its enantiomer, D-NAME, markedly inhibited the vasodilation induced by nerve stimulation or by exogenous substance P or neurokinin A. Vasodilatation due to calcitonin gene-related peptide, prostaglandin E2 or nitroprusside was unaffected. The substance P antagonist, spantide (30 microM), significantly attenuated nerve-induced vasodilatation, in parallel with L-NAME. Our results indicate that nerve-induced vasodilatation in skeletal muscle can be attributed to the release of substance P and/or other tachykinins and that nitric oxide subsequently mediates the response to endogenous tachykinins released from nerves.

Open channel and competitive block of nicotinic receptors by pancuronium and atracurium.

Mouse myotubes were used to investigate effects of the nondepolarizing neuromuscular blocking drugs pancuronium and atracurium on embryonic-type nicotinic acetylcholine receptor channels. Experiments were performed using patch-clamp techniques in combination with devices for ultra-fast solution exchange at outside--out patches. Application of 0.1 mM acetylcholine resulted in a fast current transient. When the peak amplitude was achieved, the current decayed monoexponentially due to desensitization. After application of drugs (pancuronium or atracurium), two different mechanisms of block were observed: (1) open channel block of embryonic-type nicotinic acetylcholine receptor channels after coapplication of blocker and acetylcholine, characterized by decrease of the time constant of current decay; (2) competitive block of embryonic-type nicotinic acetylcholine receptor channels by pancuronium or atracurium after preincubation of outside-out patches with the respective blocker. Different affinities of pancuronium (K(B) approximately 0.01 microM) and atracurium (K(B) approximately 1 microM) to embryonic-type nicotinic acetylcholine receptor channels were observed.

The actions of muscle relaxants at nicotinic acetylcholine receptor isoforms.

The pharmacological diversity of the different isoforms of the nicotinic acetylcholine receptor arises from the diversity of the subunits that assemble to form the native receptors. The aim of this study was to investigate the actions of the muscle relaxants d-tubocurarine, pancuronium and vecuronium on different isoforms of nicotinic acetylcholine receptors (mouse foetal muscle, mouse adult muscle and a rat neuronal), using the Xenopus oocyte expression system. Oocytes were injected with cRNAs for alpha, beta, gamma, delta subunits (the native foetal muscle subunit combination), or with cRNAs for alpha, beta, epsilon, delta subunits (the native adult muscle subunit combination), or with cRNAs for alpha4beta2 subunits (a putative native neuronal subunit combination). Acetylcholine had a similar potency at all three subunit combinations (EC50 11.6, 17.4 and 19.1 microM, respectively). At all three receptor types, d-tubocurarine and pancuronium blocked the responses elicited by acetylcholine in a reversible manner. Furthermore, the inhibition of the acetylcholine currents for the foetal and adult nicotinic acetylcholine receptor by pancuronium and d-tubocurarine was independent of the holding voltage over the range -100 to -40 mV. In oocytes expressing the foetal muscle nicotinic acetylcholine receptors the inhibition of the current in response to 100 microM acetylcholine by 10 nM d-tubocurarine was 29 +/- 5% (mean +/- S.E.M.; n = 7), and the inhibition by 10 nM pancuronium was 39 +/- 6% (mean +/- S.E.M.; n = 8; P > 0.05 vs. d-tubocurarine). However, in the adult form of the muscle nicotinic acetylcholine receptor, 10 nM d-tubocurarine and 10 nM pancuronium were both more effective at blocking the response to 100 microM acetylcholine compared to the foetal muscle nicotinic acetylcholine receptor, with values of 55 +/- 5% (P < 0.01; n = 12) and 60 +/- 4% (P < 0.001; n = 10), respectively. Thus the developmental switch from the gamma to the epsilon subunit alters the antagonism of the nicotinic acetylcholine receptor for both pancuronium and d-tubocurarine. Vecuronium was more potent than pancuronium. One nM vecuronium reduced the response to 100 microM acetylcholine by 71 +- 6% (n = 10) for foetal and 63 +/- 5% (n = 4) for adult nicotinic acetylcholine receptors. In the alpha4beta2 neuronal nicotinic acetylcholine receptor combination, 10 nM pancuronium was a more effective antagonist of the response to 100 microM acetylcholine (69 +/- 6%, n = 6) than 10 nM d-tubocurarine (30 +/- 5%; n = 6; P < 0.05 compared to pancuronium). This is in contrast to the adult muscle nicotinic acetylcholine receptor, where pancuronium and d-tubocurarine were equieffective. The expression of the beta2 subunit with muscle alpha, epsilon and delta subunits formed a functional receptor which was blocked by pancuronium and d-tubocurarine in a similar manner to the alphabeta1epsilondelta subunit consistent with the hypothesis that the beta subunit is not a major determinant in the action of this drug at the adult muscle nicotinic acetylcholine receptor.

Role of adenosine in functional hyperemia in skeletal muscle as indicated by pharmacological tools.

The hypothesis that adenosine mediates blood flow increments in contracting skeletal muscle was evaluated by intravital microscopy of the microcirculation in the tenuissimus muscle of anesthetized rabbits. Motor nerve stimulation elicited muscle contractions and frequency-dependent arteriolar dilatation, particularly in terminal arterioles. The pulse duration (0.05 ms) and voltage (1.5-5 V) precluded activation of vasoconstrictor fibers, as also indicated by the lack of effect of phentolamine on resting vascular tone and on the hyperemic response to nerve stimulation. The specific adenosine receptor antagonist, 1,3-dipropyl-8-p-sulfo-phenylxanthine (DPSPX; 10(-5) M), attenuated the hyperemic response to muscle contractions. The adenosine uptake inhibitor dipyridamole (10(-8)-10(-6) M) dose-dependently dilated microvessels, an effect prevented by DPSPX (10(-5) M). Moreover, dipyridamole (10(-7) M) augmented contraction-induced hyperemia. The enhancement by dipyridamole was reversed by DPSPX (10(-5) M). The effects of adenosine uptake inhibitor and antagonist were invariably more marked in terminal than in transverse arterioles, and also more pronounced at higher stimulation frequencies. Motor nerve stimulation failed to induce alterations in vascular diameters when the neuromuscular junction was blocked by pancuronium. Thus, our observations indicate that functional hyperemia after motor nerve-induced contractions of the skeletal muscle was of postjunctional origin. Apparently, activation of adenosine receptors was responsible for a part of the evoked vasodilation.

Neuromuscular complications in patients given Pavulon (pancuronium bromide) during artificial ventilation.

This paper reports on 12 patients in a 3-year period (from 1st July 1980 to 1st July 1983) who were treated with artificial ventilation and with the muscle relaxant pancuronium bromide (Pavulon), over a period of 6 days or longer. After discontinuation of this drug these patients developed severe tetraparesis with areflexia, sometimes combined with disturbances of the extraocular and facial muscles and diffuse muscular atrophy, without sensory disturbances. Seven patients recovered completely after 2-5 months, two made an incomplete recovery and three died due to the primary disease. It is suggested that these neuromuscular complications were caused by prolonged high-dosage Pavulon treatment in combination with renal and hepatic disturbances and/or the use of aminoglucosides.

On the pharmacology of Org 6338 (2beta, 16beta-dipiperidino - 5alpha - androstan - 3alpha - ol acetate dimethobromide), a new steroidal neuromuscular blocking agent.

Org 6368 is a homologue of pancuronium bromide. Its interactions with other agents in the cat sciatic nerve-gastrocnemius muscle preparation revealed that paralysis was of the non-depolarizing type. This was confirmed in experiments using avian muscle. Org 6368 is a potent muscle relaxant being 2-4 times as potent as (+)-tubocurarine in the cat. Paralysis in the cat is rapid in onset and of appreciably shorter duration than that of pancuronium and (+)-tubocurarine. Repeated injections of the same dose of Org 6368 show no cumulative effect. Muscle relaxant doses generally cause a slight increase in both blood pressure and heart rate. Although its histamine-releasing capacity is greater than that of pancuronium it is less than that of (+)-tubocurarine. Org 6368 shares with pancuronium a very weak effect on both the muscarinic receptor and ganglionic transmission. Differences in the muscle relaxant profiles of Org 6368 and pancuronium are discussed.

The effect of famotidine on neuromuscular transmission.

We have investigated the effects of the H2 receptor antagonist famotidine on the neuromuscular transmission by using the sciatic nerve--gastrocnemius muscle preparation of rat in vitro. Famotidine, administered by I.V. injection, potentiates the neuromuscular blockade induced by d-tubocurarine, pancuronium and aminoglycoside antibiotics. Moreover, the drug alone is capable of producing a blockade on the preparation stimulated at high frequency. The neuromuscular blockade induced by famotidine is reversed by 4-aminopyridine but not by dimaprit. Similar results have previously been obtained with cimetidine.

Out of step with the Lancet homeopathy meta-analysis: more objections than objectivity?

The meta-analysis of homeopathy trials that appeared in the Lancet in 1997 seemed to endorse the experience of practitioners and patients that homeopathic medicines have specific clinically relevant effects. However, results from later unsuccessful trials, and negative inferences from a review of trials for a condition excluded from the meta-analysis--delayed onset muscle soreness (DOMS)--have since been presented to suggest that the meta-analysis may well have overestimated the positive effects of homeopathy, and that the "placebo question is still not resolved." This article reviews the evidence underlying this challenge to the meta-analysis and homeopathy, and demonstrates that it would be valid if it were based on: a comprehensive literature search; appropriate classification of primary studies; clear discrimination between clinical effectiveness and placebo questions; sound and transparent review methods; and a reliable and unconfounded clinical treatment model for testing the ultramolecular hypothesis. It is suggested that different models are needed to answer different questions.

Residual non-depolarising neuromuscular block assessed by train-of-four stimulation in the dog.

A technique is described for assessing the extent of residual neuromuscular block following non-depolarising agents in the dog. The ulnar nerve was electrically stimulated with a train-of-four impulses and the muscle responses recorded. Heights of the control and, following the administration of the muscle relaxant, the first, second and fourth twitch tensions (T1, T2 and T4) of the train were measured. There was a highly significant linear correlation between the ratio T1/control, used to determine the extent of neuromuscular block, and the other ratios T2/T1 and T4/T1. Both of the ratios T2/T1 and T4/T1 avoid the use of control heights.

Effect of prior administration of suxamethonium on non-depolarising muscle relaxants in the dog.

The depolarising muscle relaxant suxamethonium (0.3 mg kg-1) was administered to six dogs. At 50 per cent return of the neuromuscular activity, as measured by the train-of-four technique, a non-depolarising muscle relaxant was administered. Three drugs, alcuronium (0.1 mg kg-1), gallamine (1.0 mg kg-1) and pancuronium (0.06 mg kg-1) were injected intravenously. At the 50 per cent return of neuromuscular activity, atropine and neostigmine were administered to reverse the neuromuscular block. The duration of action of the three non-depolarising relaxants was reduced by the prior administration of suxamethonium.

Effect of prior administration of a non-depolarising muscle relaxant on the action of suxamethonium in the dog.

The non-depolarising muscle relaxants alcuronium (0.1 mg kg-1), gallamine (1 mg kg-1) and pancuronium (0.06 mg kg-1) were administered to six dogs. At 50 per cent return of neuromuscular activity, as measured by the train-of-four technique, the depolarising muscle relaxant suxamethonium (0.3 mg kg-1) was injected intravenously. At 50 per cent return of neuromuscular activity, atropine and neostigmine were administered to reverse the neuromuscular block. The duration of action of suxamethonium was reduced by each of the non-depolarising muscle relaxants.

Neuromuscular and cardiovascular effects of pancuronium bromide in calves anesthetized with halothane.

Pancuronium bromide was administered to calves to define the dosage level necessary to produce surgical relaxation (90% to 99% reduction of base-line evoked, hindlimb digital-extensor muscle twitch tension). Initial dosage level requirement was 43 +/- 9 micrograms/kg of body weight. Calves with this degree of relaxation required 26 +/- 14 minutes to achieve 50% recovery and 43 +/- 19 minutes to achieve complete return of base-line muscle twitch. Calves given a repeat injection of pancuronium at base-line muscle twitch required 27 +/- 9 micrograms/kg to achieve relaxation similar to that of the 1st dose. The 2nd dose did not last as long as the 1st, with complete recovery occurring in 37 +/- 12 minutes. Maximum evoked tension occurred at 200- to 400-g resting tension on the hoof. There was an absence of heart rate or blood pressure changes after injection of relaxant and a variable and inconsistent fade response to train-of-four and tetanic stimulus of the facial muscles. Acid-base values were alkalemic (pHa 7.5 +/- 0.08) when ventilation was controlled at eucapnia (PaCO2, 25 to 45 mm of Hg).