Abstract
BackgroundA nondepolarizing neuromuscular blocking agent (NMBA) with a succinylcholine-like quick onset and offset has been the holy grail of the science of neuromuscular blockade. Although this drug is still elusive, the advent of promising new drug combinations like rocuronium–sugammadex and gantacurium–l-cysteine may achieve the same end result. The type of NMBA; the type, timing, and dose of their reversal drugs; the means of monitoring NMB; and the site of monitoring are potentially on the verge of a paradigm shift.Main textA comprehensive search using PubMed and Google Scholar and Medline search was made by using keywords gantacurium, l-cysteine, calabadion, and newer neuromuscular blocking agents for peer-reviewed English language manuscripts published before December 2019. Out of the 97 articles screened, 16 were found to be eligible (original articles) and included in this review.ConclusionQuantitative, objective neuromuscular monitoring should be included in the minimum monitoring standards. Gantacurium is a new promising nondepolarizing NMBA with desirable succinylcholine-like onset and duration of action without its side effects. A broad-spectrum reversal agent (calabadion) can be used for both depolarizing and nondepolarizing NMB as well as general anesthetics (etomidate and ketamine). A novel drug (WP [6]) can block the side effects of succinylcholine; all are staring at us from the horizon.
Highlights
A comprehensive search using PubMed and Google Scholar and Medline search was made via using keywords gantacurium, L-cysteine, calabadion, and newer neuromuscular blocking agents for peer-reviewed English language manuscripts published before December 2019
The existing nondepolarizing neuromuscular blocking agent (NMBA) were replaced by pancuronium the first aminosteroidal NMBA introduced in 1964 and its congener vecuronium (1984)
We may soon witness a paradigm shift from neostigmine to this promising new agent calabadion-2 that can reverse NMB caused by both benzylisoquinolium and aminosteroid NMBA
Summary
Mivacurium (Mivacron; Abbott Laboratories Inc.) Mivacurium comprises a choline-like bis-benzyl-tetrahydroisoquinolinium diesteric nondepolarizing NMBA. Spatial orientation of the methylated phenolic moiety results in three (cis-trans, trans-trans, cis-cis) stereoisomers (Lien 2013). It undergoes butyrylcholinesterase metabolism albeit slower than succinylcholine. Mivacurium is the shortest acting nondepolarizing NMBA available, its. Gantacurium is a single isomer just like cisatracurium (unlike mixed-isomers atracurium and mivacurium) (Savarese et al 2010; Boer and Carlos 2018; Heerdt et al 2015; Lien et al 2009) and needs reconstitution before administration (Heerdt et al 2015). Gantacurium (Table 1) is a rapid onset, nondepolarizing NMBA currently undergoing clinical trials. Compared with the depolarizing muscle relaxant succinylcholine, gantacurium (2–3 × ED95) causes a 100% neuromuscular block at the laryngeal adductors within 60 s, whereas succinylcholine (3 × ED95) reaches its maximal effect in 45 s (Boer and Carlos 2018).
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