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Clinical use of neuromuscular blocking agents in anesthesia

Johnathan Ross Renew, MD
Mohamed Naguib, MD
Sorin J Brull, MD, FCARCSI (Hon)
Section Editor
Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor
Marianna Crowley, MD


Neuromuscular blocking agents (NMBAs) are usually administered during anesthesia to facilitate endotracheal intubation and/or to improve surgical conditions. NMBAs may decrease the incidence of hoarseness and vocal cord injuries during intubation, and can facilitate mechanical ventilation in patients with poor lung compliance [1-5].

This topic will discuss the clinical use and pharmacology of the commonly used NMBAs and reversal of neuromuscular block. Monitoring neuromuscular blockade is discussed separately. (See "Monitoring neuromuscular blockade".)


The selection of the appropriate neuromuscular blocking agent (NMBA) depends on the clinical application and patient factors. For patients without contraindications to succinylcholine (eg, hyperkalemia, burns, stroke, susceptibility to malignant hyperthermia), options include the following (see 'Adverse effects of succinylcholine' below):

For endotracheal intubation for short procedures (<30 minutes), or if neuromonitoring will be used soon after intubation, a short duration of neuromuscular block is required. Options for endotracheal intubation include succinylcholine, intubation without an NMBA (eg, high dose remifentanil intubation), or rocuronium or vecuronium if sugammadex is available for rapid reversal of block. (See 'Sugammadex' below.)

For endotracheal intubation for longer procedures (≥30 minutes), succinylcholine or any of the short or intermediate acting nondepolarizing NMBAs can be used for endotracheal intubation (rocuronium, vecuronium, mivacurium, atracurium, or cisatracurium). The choice among these agents depends on availability, cost, and patient factors that affect metabolism. Pancuronium is a rarely used, long acting alternative. (See 'Nondepolarizing neuromuscular blocking agents' below.)

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Literature review current through: Oct 2017. | This topic last updated: Nov 01, 2017.
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