4. Pharmacokinetics: Nondepolarizing (competitive) blockers

4. Pharmacokinetics: All neuromuscular-blocking agents are injected intravenously because their uptake via oral absorption is minimal. These agents possess two or more quaternary amines in their bulky ring structure, making them orally ineffective. They penetrate membranes very poorly and do not enter cells or cross the blood-brain barrier. Many of the drugs are not metabolized, and their actions are terminated by redistribution. For example, pancuronium is excreted unchanged in urine. Atracurium is degraded spontaneously in plasma and by ester hydrolysis. [Note: Atracurium has been replaced by its isomer, cisatracurium. Atracurium releases histamine and is metabolized to laudanosine, which can provoke seizures. Cisatracurium, which has the same pharmacokinetic properties as atracurium, is less likely to have these effects.] The amino steroid drugs (vecuronium and rocuronium) are deacetylated in the liver, and their clearance may be prolonged in patients with hepatic disease. These drugs are also excreted unchanged in bile. The choice of an agent will depend on how quickly muscle relaxation is needed and on the duration of the muscle relaxation. The onset and duration of action, as well as other characteristics of the neuromuscular blocking drugs