TEMA DEL MES: MITOS Y HECHOS EN FARMACOLOGÍA

TEMA DEL MES: MITOS Y HECHOS EN
FARMACOLOGÍA NEUROMUSCULAR. NUEVOS
PLANTEAMIENTOS EN LA REVERSIÓN DEL
BLOQUEO NEUROMUSCULAR.
Dra María Vila / Dra Sara Arastey ( MIR4)
Servicio de Anestesia Reanimación y Tratamiento del Dolor
Consorcio Hospital General Universitario de Valencia
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
Minerva anestesiologica 2012;
78:473-82
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
FISIOLOGÍA DE LA UNIÓN NEUROMUSCULAR
TRANSDUCCIÓN DE ACTIVIDAD ELÉCTRICA DESDE EL TERMINAL DISTAL DEL NERVIO DE LA
MOTONEURONA A TRAVÉS DEL ESPACIO SINÁPTICO HASTA LA MEMBRANA DE LA CÉCULA PARA GENERAR
CONTRACCIÓN MUSCULAR
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
•
3 PARTES
•
•
PRESINAPSIS (terminal fibra nerviosa)
•
Parte amielínica del axón
•
Liberación del neurotransmisor al espacio sináptico + autoreceptores colinérgicos ( estimulación
mayor liberación Ach)
•
Síntesis NT, incorporación en vesículas y recaptación mediante flujo de iones( proceso activo
altamente energético)
•
HENDIDURA SINAPTICA (5 nm). Lámina basal, Acetilcolinesterasa y otros enzimas y proteínas para la
neurotransmisión
•
MEMBRANA POSTSINÁPTICA (pliegues para ampliar superficie de transmisión). En los codos de los
pliegues receptores nicotínicos en grupos de alta densidad (10000/ mcm2) y en los huecos canales Na voltaje
dependientes.
RECEPTOR NICOTÍNICO: PENTÁMERO (5 unidades rodeando un poro en la membrana celular). Unión de
Ach al canal genera flujo de entrada de Na y Ca >>> despolarización.
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
RECEPTORES DE MEMBRANA ( CANAL IÓNICO).
2 α + 1 β + 1 δ + 1 γ.
2 ACh U 2 S.U.α → cambio conformacional: apertura canal iónico (Na+/K+).
Membrana postsináptica: contracción muscular.
Terminación presináptica: favorecen la liberación de ACh
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
BLOQUEADORES NEUROMUSCULARES
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
BLOQUEADORES NEUROMUSCULARES
DESPOLARIZANTES ( SUCCINILCOLINA)
Mecanismo poco conocido:
- Fasciculación inicial > activación masiva de los
receptores en la membrana celular muscular.
- Parálisis posterior posiblemente por la desensibilización
del receptor por aumento del flujo de K intracelular.
NO INHIBEN RECEPTOR PRESINÁPTICO
NO PRESENTAN FENOMENO DE “FADE”
Monitorización. Single Twitch: disminución de la amplitud
del estímulo,
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
BLOQUEADORES NEUROMUSCULARES
DESPOLARIZANTES ( SUCCINILCOLINA)
NO DESPOLARIZANTES
Mecanismo poco conocido:
- Fasciculación inicial > activación masiva de los
receptores en la membrana celular muscular.
- Parálisis posterior posiblemente por la desensibilización
del receptor por aumento del flujo de K intracelular.
Antagonismo competitivo con la Ach en la 2
subunidades alfa en el receptor.
Acción tanto en receptores postsinápticos (reducción
amplitud de estímulo) como en presinápticos
( FENOMENO DE ATENUACIÓN O “FADE”)
NO INHIBEN RECEPTOR PRESINÁPTICO
Monitorización. TOF/ TOFr/ PTC
NO PRESENTAN FENOMENO DE “FADE”
Monitorización. Single Twitch: disminución de la amplitud
del estímulo,
TOFr: grado bloqueo, estado recuperación, predicción
recuperación del BNM
PTC: predecir aparición de 1ª respuesta TOF
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
BLOQUEADORES NEUROMUSCULARES
DESPOLARIZANTES ( SUCCINILCOLINA)
NO DESPOLARIZANTES
Mecanismo poco conocido:
- Fasciculación inicial > activación masiva de los
receptores en la membrana celular muscular.
- Parálisis posterior posiblemente por la desensibilización
del receptor por aumento del flujo de K intracelular.
Antagonismo competitivo con la Ach en la 2
subunidades alfa en el receptor.
Acción tanto en receptores postsinápticos (reducción
amplitud de estímulo) como en presinápticos
( FENOMENO DE ATENUACIÓN O “FADE”)
NO INHIBEN RECEPTOR PRESINÁPTICO
Monitorización. TOF/ TOFr/ PTC
NO PRESENTAN FENOMENO DE “FADE”
Monitorización. Single Twitch: disminución de la amplitud
del estímulo,
TOFr: grado bloqueo, estado recuperación, predicción
recuperación del BNM
PTC: predecir aparición de 1ª respuesta TOF
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
MITOS
•
MITO 1: BNM ESTÁN “OUT”. SE PUEDE INTUBAR PACIENTES SIN BNM
•
MITO2: SI SE CONOCE LA FARMACOCINÉTICA DE LOS BNM, LA MONITORIZACIÓN Y
REVERSIÓN NO SON NECESARIAS
•
MITO3: LOS EFECTOS DEL BNM RESIDUAL ESTÁN SOBREESTIMADOS
•
MITO 4: BNM RESIDUAL POSTOPERATORIO ESTÁ SOBREESTIMADO EN FUNCIÓN DE SU
INCIDENCIA
•
MITO 5: BNM RESIDUAL PUEDE SER FACILMENTE DIAGNOSTICADO UY TESTADO
CLÍNICAMENTE
•
MITO 6: LOS TESTS SUBJETIVOS (VISUALES/TÁCTILES) SON SUFICIENTES PARA DETECTAR
BNM RESIDUAL
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
• MITO
1: SE PUEDE INTUBAR A UN PACIENTE
SIN BNM
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
British Journal of Anaesthesia 99 (2): 276–81 (2007)
doi:10.1093/bja/aem147
Advance Access publication June 15, 2007
RESPIRATION AND THE AIRWAY
Comparison of two induction regimens using or not using muscle
relaxant: impact on postoperative upper airway discomfort†
X. Combes1 *, L. Andriamifidy2, E. Dufresne2, P. Suen1, S. Sauvat1, E. Scherrer1, P. Feiss2,
J. Marty1 and P. Duvaldestin1
1
Department of Anesthesia, Henri Mondor Hospital (APHP), 51 avenue du Maréchal de Lattre-de-Tassigny,
94100 Créteil cedex, France. 2Department of Anesthesia, Dupuytren Hospital, Limoges, France
Background. Muscle relaxants facilitate tracheal intubation, but they are often not used for
short peripheral surgical procedures. The consequences of this practice on the upper airway
are still a matter of controversy. We therefore compared the incidence of post-intubation
symptoms in a randomized study comparing patients intubated with or without the use of a
muscle relaxant.
Methods. A total of 300 adult patients requiring tracheal intubation for scheduled peripheral
surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either
included or did not include a muscle relaxant (rocuronium). The primary end-point was the
rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were
the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.
Results. Post-intubation symptoms were more frequent in patients intubated without the use
of a muscle relaxant, whether 2 h (57% vs 43% of patients; P,0.05) or 24 h (38% vs 26% of
patients; P,0.05) after extubation. Intubation conditions were better when the muscle relaxant
was used. In patients intubated without a muscle relaxant, difficult intubation was more
common (12% vs 1%; P,0.05), as were arterial hypotension or bradycardia requiring treatment
(12% vs 3% of patients; P,0.05).
Conclusions. The use of a muscle relaxant for tracheal intubation diminishes the incidence of
adverse postoperative upper airway symptoms, results in better tracheal intubation conditions,
and reduces the rate of adverse haemodynamic events.
Br J Anaesth 2007; 99: 276–81
Keywords: anaesthetic techniques, induction; complications, intubation tracheal;
complications, sore throat; pharmacology, rocuronium
Downloaded from http://bja.oxfordjournals.org/ at Servicio Valenciano de Salud on March 7, 2013
*Corresponding author: Service d’anesthésie reanimation, Hôpital Henri-Mondor, 51 avenue du
Maréchal de Lattre-de-Tassigny, 94100 Créteil cedex, France. E-mail: [email protected]
Accepted for publication: April 20, 2007
The main indication for administering a muscle relaxant
during anaesthesia is to facilitate laryngoscopy and tracheal intubation.1 The muscle relaxant paralyses the vocal
cords and limits post-intubation coughing and bucking.2
However, since the availability of propofol, satisfactory
intubating conditions for short surgical procedures have
been achieved without a muscle relaxant, and thus without
any risk of residual postoperative paralysis.3 – 8
The practice of administering a muscle relaxant to
facilitate tracheal intubation may appear self-evident;
however, it has never been rigorously evaluated and
results are conflicting. For instance, in one randomized
controlled trial, postoperative vocal cord dysfunction was
higher when tracheal intubation was performed without
than with a muscle relaxant, whereas in a non-randomized
prospective study, there was no difference in postintubation pharyngolaryngeal symptom frequency between
patients who had or had not received a muscle relaxant.9 10
†
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Presented as an abstract at the annual meeting of the American
Society of Anesthesiologists, San Francisco, October 2003.
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
British Journal of Anaesthesia 99 (2): 276–81 (2007)
doi:10.1093/bja/aem147
Advance Access publication June 15, 2007
RESPIRATION AND THE AIRWAY
Comparison of two induction regimens using or not using muscle
relaxant: impact on postoperative upper airway discomfort†
X. Combes1 *, L. Andriamifidy2, E. Dufresne2, P. Suen1, S. Sauvat1, E. Scherrer1, P. Feiss2,
J. Marty1 and P. Duvaldestin1
1
Department of Anesthesia, Henri Mondor Hospital (APHP), 51 avenue du Maréchal de Lattre-de-Tassigny,
94100 Créteil cedex, France. 2Department of Anesthesia, Dupuytren Hospital, Limoges, France
Background. Muscle relaxants facilitate tracheal intubation, but they are often not used for
short peripheral surgical procedures. The consequences of this practice on the upper airway
are still a matter of controversy. We therefore compared the incidence of post-intubation
symptoms in a randomized study comparing patients intubated with or without the use of a
muscle relaxant.
Methods. A total of 300 adult patients requiring tracheal intubation for scheduled peripheral
surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either
included or did not include a muscle relaxant (rocuronium). The primary end-point was the
rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were
the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.
Results. Post-intubation symptoms were more frequent in patients intubated without the use
of a muscle relaxant, whether 2 h (57% vs 43% of patients; P,0.05) or 24 h (38% vs 26% of
patients; P,0.05) after extubation. Intubation conditions were better when the muscle relaxant
was used. In patients intubated without a muscle relaxant, difficult intubation was more
common (12% vs 1%; P,0.05), as were arterial hypotension or bradycardia requiring treatment
(12% vs 3% of patients; P,0.05).
Conclusions. The use of a muscle relaxant for tracheal intubation diminishes the incidence of
adverse postoperative upper airway symptoms, results in better tracheal intubation conditions,
and reduces the rate of adverse haemodynamic events.
Br J Anaesth 2007; 99: 276–81
Keywords: anaesthetic techniques, induction; complications, intubation tracheal;
complications, sore throat; pharmacology, rocuronium
Downloaded from http://bja.oxfordjournals.org/ at Servicio Valenciano de Salud on March 7, 2013
*Corresponding author: Service d’anesthésie reanimation, Hôpital Henri-Mondor, 51 avenue du
Maréchal de Lattre-de-Tassigny, 94100 Créteil cedex, France. E-mail: [email protected]
Accepted for publication: April 20, 2007
The main indication for administering a muscle relaxant
during anaesthesia is to facilitate laryngoscopy and tracheal intubation.1 The muscle relaxant paralyses the vocal
cords and limits post-intubation coughing and bucking.2
However, since the availability of propofol, satisfactory
intubating conditions for short surgical procedures have
been achieved without a muscle relaxant, and thus without
any risk of residual postoperative paralysis.3 – 8
The practice of administering a muscle relaxant to
facilitate tracheal intubation may appear self-evident;
however, it has never been rigorously evaluated and
results are conflicting. For instance, in one randomized
controlled trial, postoperative vocal cord dysfunction was
higher when tracheal intubation was performed without
than with a muscle relaxant, whereas in a non-randomized
prospective study, there was no difference in postintubation pharyngolaryngeal symptom frequency between
patients who had or had not received a muscle relaxant.9 10
†
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Presented as an abstract at the annual meeting of the American
Society of Anesthesiologists, San Francisco, October 2003.
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
British Journal of Anaesthesia 99 (2): 276–81 (2007)
doi:10.1093/bja/aem147
Advance Access publication June 15, 2007
RESPIRATION AND THE AIRWAY
Comparison of two induction regimens using or not using muscle
relaxant: impact on postoperative upper airway discomfort†
X. Combes1 *, L. Andriamifidy2, E. Dufresne2, P. Suen1, S. Sauvat1, E. Scherrer1, P. Feiss2,
J. Marty1 and P. Duvaldestin1
1
Department of Anesthesia, Henri Mondor Hospital (APHP), 51 avenue du Maréchal de Lattre-de-Tassigny,
94100 Créteil cedex, France. 2Department of Anesthesia, Dupuytren Hospital, Limoges, France
Background. Muscle relaxants facilitate tracheal intubation, but they are often not used for
short peripheral surgical procedures. The consequences of this practice on the upper airway
are still a matter of controversy. We therefore compared the incidence of post-intubation
symptoms in a randomized study comparing patients intubated with or without the use of a
muscle relaxant.
Methods. A total of 300 adult patients requiring tracheal intubation for scheduled peripheral
surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either
included or did not include a muscle relaxant (rocuronium). The primary end-point was the
rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were
the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.
Downloaded from http://bja.oxfordjournals.org/ at Servicio Valenciano de Salud on March 7, 2013
*Corresponding author: Service d’anesthésie reanimation, Hôpital Henri-Mondor, 51 avenue du
Maréchal de Lattre-de-Tassigny, 94100 Créteil cedex, France. E-mail: [email protected]
IOT satisfactorias sin BNM se relacionan más a mayores riesgos de
bradicardia
e hipotensión por uso de dosis superiores de hipnóticos para
Results. Post-intubation symptoms were more frequent in patients intubated without the use
a muscle relaxant, whether
2 h (57% vs 43%
of patients;
or 24 h (38% vs
26% of
obtener ofcondiciones
óptimas
para
la P,0.05)
intubación
(relajación
mandibular,
patients; P,0.05) after extubation. Intubation conditions were better when the muscle relaxant
movimiento
cuerdas
tos...).
was used.
In patientsvocales,
intubated without
a muscle relaxant, difficult intubation was more
common (12% vs 1%; P,0.05), as were arterial hypotension or bradycardia requiring treatment
(12% vs 3% of patients; P,0.05).
Por ello, Conclusions.
menor incidencia
IOT
satisfactorias
The use of a musclede
relaxant
for tracheal
intubation diminishesythemayor
incidence of incidencia de IOT
adverse postoperative upper airway symptoms, results in better tracheal intubation conditions,
difíciles and
y reduces
posibilidad
de haemodynamic
lesionesevents.
laríngeas (ronquera o lesión de cuerdas
the rate of adverse
vocales Br J Anaesth 2007; 99: 276–81
Keywords: anaesthetic techniques, induction; complications, intubation tracheal;
complications, sore throat; pharmacology, rocuronium
Accepted for publication: April 20, 2007
The main indication for administering a muscle relaxant
during anaesthesia is to facilitate laryngoscopy and tracheal intubation.1 The muscle relaxant paralyses the vocal
cords and limits post-intubation coughing and bucking.2
However, since the availability of propofol, satisfactory
intubating conditions for short surgical procedures have
been achieved without a muscle relaxant, and thus without
any risk of residual postoperative paralysis.3 – 8
The practice of administering a muscle relaxant to
facilitate tracheal intubation may appear self-evident;
however, it has never been rigorously evaluated and
results are conflicting. For instance, in one randomized
controlled trial, postoperative vocal cord dysfunction was
higher when tracheal intubation was performed without
than with a muscle relaxant, whereas in a non-randomized
prospective study, there was no difference in postintubation pharyngolaryngeal symptom frequency between
patients who had or had not received a muscle relaxant.9 10
†
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Presented as an abstract at the annual meeting of the American
Society of Anesthesiologists, San Francisco, October 2003.
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
British Journal of Anaesthesia 99 (2): 276–81 (2007)
doi:10.1093/bja/aem147
Advance Access publication June 15, 2007
RESPIRATION AND THE AIRWAY
Comparison of two induction regimens using or not using muscle
relaxant: impact on postoperative upper airway discomfort†
X. Combes1 *, L. Andriamifidy2, E. Dufresne2, P. Suen1, S. Sauvat1, E. Scherrer1, P. Feiss2,
J. Marty1 and P. Duvaldestin1
1
Department of Anesthesia, Henri Mondor Hospital (APHP), 51 avenue du Maréchal de Lattre-de-Tassigny,
94100 Créteil cedex, France. 2Department of Anesthesia, Dupuytren Hospital, Limoges, France
Background. Muscle relaxants facilitate tracheal intubation, but they are often not used for
short peripheral surgical procedures. The consequences of this practice on the upper airway
are still a matter of controversy. We therefore compared the incidence of post-intubation
symptoms in a randomized study comparing patients intubated with or without the use of a
muscle relaxant.
Methods. A total of 300 adult patients requiring tracheal intubation for scheduled peripheral
surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either
included or did not include a muscle relaxant (rocuronium). The primary end-point was the
rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were
the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.
Downloaded from http://bja.oxfordjournals.org/ at Servicio Valenciano de Salud on March 7, 2013
*Corresponding author: Service d’anesthésie reanimation, Hôpital Henri-Mondor, 51 avenue du
Maréchal de Lattre-de-Tassigny, 94100 Créteil cedex, France. E-mail: [email protected]
IOT satisfactorias sin BNM se relacionan más a mayores riesgos de
bradicardia
e hipotensión por uso de dosis superiores de hipnóticos para
Results. Post-intubation symptoms were more frequent in patients intubated without the use
a muscle relaxant, whether
2 h (57% vs 43%
of patients;
or 24 h (38% vs
26% of
obtener ofcondiciones
óptimas
para
la P,0.05)
intubación
(relajación
mandibular,
patients; P,0.05) after extubation. Intubation conditions were better when the muscle relaxant
movimiento
cuerdas
tos...).
was used.
In patientsvocales,
intubated without
a muscle relaxant, difficult intubation was more
common (12% vs 1%; P,0.05), as were arterial hypotension or bradycardia requiring treatment
(12% vs 3% of patients; P,0.05).
Por ello, Conclusions.
menor incidencia
IOT
satisfactorias
The use of a musclede
relaxant
for tracheal
intubation diminishesythemayor
incidence of incidencia de IOT
adverse postoperative upper airway symptoms, results in better tracheal intubation conditions,
difíciles and
y reduces
posibilidad
de haemodynamic
lesionesevents.
laríngeas (ronquera o lesión de cuerdas
the rate of adverse
vocales Br J Anaesth 2007; 99: 276–81
Keywords: anaesthetic techniques, induction; complications, intubation tracheal;
complications, sore throat; pharmacology, rocuronium
Accepted for publication: April 20, 2007
The main indication for administering a muscle relaxant
during anaesthesia is to facilitate laryngoscopy and tracheal intubation.1 The muscle relaxant paralyses the vocal
cords and limits post-intubation coughing and bucking.2
However, since the availability of propofol, satisfactory
intubating conditions for short surgical procedures have
been achieved without a muscle relaxant, and thus without
any risk of residual postoperative paralysis.3 – 8
The practice of administering a muscle relaxant to
facilitate tracheal intubation may appear self-evident;
however, it has never been rigorously evaluated and
results are conflicting. For instance, in one randomized
controlled trial, postoperative vocal cord dysfunction was
higher when tracheal intubation was performed without
than with a muscle relaxant, whereas in a non-randomized
prospective study, there was no difference in postintubation pharyngolaryngeal symptom frequency between
patients who had or had not received a muscle relaxant.9 10
†
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Presented as an abstract at the annual meeting of the American
Society of Anesthesiologists, San Francisco, October 2003.
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
Anesthesiology 2003; 98:1049 –56
© 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Laryngeal Morbidity and Quality of Tracheal Intubation
A Randomized Controlled Trial
Thomas Mencke, M.D.,* Mathias Echternach, M.D.,† Stefan Kleinschmidt, M.D.,* Philip Lux,‡ Volker Barth, M.D.,†
Peter K. Plinkert, M.D.,§ Thomas Fuchs-Buder, M.D.!
Background: Vocal cord sequelae and postoperative hoarseness during general anesthesia are a significant source of morbidity for patients and a source of liability for anesthesiologists.
Several risk factors leading to laryngeal injury have been identified in the past. However, whether the quality of tracheal
intubation affects their incidence or severity is still unclear.
Methods: Eighty patients were randomized in two groups
(n ! 40 for each) to receive a propofol–fentanyl induction
regimen with or without atracurium. Intubation conditions
were evaluated with the Copenhagen Score; postoperative
hoarseness was assessed at 24, 48, and 72 h by a standardized
interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness
or vocal cord sequelae persisted, follow-up examination was
performed until complete restitution.
Results: Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients; P ! 0.02). The number of
days with postoperative hoarseness was higher when atracurium was omitted (25 vs. 6 patients; P < 0.001). Similar
findings were observed for vocal cord sequelae (incidence of
vocal cord sequelae: 15 vs. 3 patients, respectively, P ! 0.002;
days with vocal cord sequelae: 50 vs. 5 patients, respectively,
P < 0.001). Excellent intubating conditions were less frequently
associated with postoperative hoarseness compared to good or
poor conditions (11, 29, and 57% of patients, respectively; excellent vs. poor: P ! 0.008). Similar findings were observed for
vocal cord sequelae (11, 22, and 50% of patients, respectively;
excellent vs. poor: P ! 0.02).
Conclusions: The quality of tracheal intubation contributes to
laryngeal morbidity, and excellent conditions are less frequently associated with postoperative hoarseness and vocal
cord sequelae. Adding atracurium to a propofol–fentanyl induction regimen significantly improved the quality of tracheal in-
!
!
This article is featured in “This Month in Anesthesiology.”
Please see this issue of ANESTHESIOLOGY, page 5A.
Additional material related to this article can be found on the
ANESTHESIOLOGY Web site. Go to the following address, click on
Enhancements Index, and then scroll down to find the appropriate article and link. http://www.anesthesiology.org
* Staff, Department of Anesthesia and Critical Care, † Staff, § Professor and
Chairman, Department of Otorhinolaryngology, ‡ Medical Student, University of
the Saarland. ! Staff, Department of Anesthesia and Critical Care, University of
the Saarland. Current position: Associate Professor of Anesthesia, Université
Henri Poincaré, Nancy 1, Faculté de Médecine de Nancy, France.
tubation and decreased postoperative hoarseness and vocal
cord sequelae.
INJURIES to the airway are well-recognized complications of anesthesia, and claims for airway injuries are
frequent in the American Society of Anesthesiologists
Closed Claims database.1 According to this database, the
most common site of injuries to the airway is the larynx,
representing 33% of all airway injury claims. The most
frequent types of laryngeal injury are vocal cord paralysis
and hematoma or granuloma of the vocal cords. Moreover, hoarseness is a common postoperative complication with an incidence varying between 14.4 and 50%; it
affects patient satisfaction and can affect a patient’s activities even after leaving the hospital.2–13 Indeed, prolonged or even permanent hoarseness may occur in 1%
of patients.11
In the past, several risk factors for laryngeal injury and
postoperative hoarseness (PH) have been identified, including endotracheal tube size, cuff design, and cuff
pressure, as well as demographic factors such as sex or
even the type of surgery.3,8,12,14 However, whether the
quality of tracheal intubation affects the incidence of
laryngeal injury has not yet been systematically investigated. Kambic and Radsel15 examined 1,000 patients
postoperatively using the indirect mirror technique and
reported 6.2% direct lesions. These were mainly hematoma or lacerations of the vocal cords. Similar results
were reported by Peppard and Dickens16 in a cohort of
475 patients. The authors of both studies speculated that
poor muscle relaxation at the moment of intubation may
have been causative for many of the observed laryngeal
injuries, although this assumption still has not been
proved by any randomized controlled trial. Therefore,
the purpose of the current study was to test the follow!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
ing hypothesis: An induction technique including propo- ,
fol, fentanyl,
and a neuromuscular blocking
+7;-18/7,<=,2-,>75?4,2-,<@AB
, agent
(NMBA), i.e., atracurium, results in a lower incidence of
vocal cord sequelae (VCS) or PH compared to a propofol–fentanyl regimen without NMBA.
Anesthesiology 2003; 98:1049 –56
© 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Laryngeal Morbidity and Quality of Tracheal Intubation
A Randomized Controlled Trial
Thomas Mencke, M.D.,* Mathias Echternach, M.D.,† Stefan Kleinschmidt, M.D.,* Philip Lux,‡ Volker Barth, M.D.,†
Peter K. Plinkert, M.D.,§ Thomas Fuchs-Buder, M.D.!
Background: Vocal cord sequelae and postoperative hoarse-
tubation and decreased postoperative hoarseness and vocal
Estudio
muestra
significativamente
condiciones
para IOT tras
ness during general
anesthesia
are a significant sourcemejores
of morcord
sequelae.
bidity for patients and a source of liability for anesthesiologists.
administración
BNM,
y menor
incidencia
Several risk factors leading
to laryngeal
injury have
been iden- de trauma laringe/ ronquera/
INJURIES to the airway are well-recognized complicatified in the
past. However,
whether
the quality of granuloma,
tracheal
lesión
cuerdas
vocales
(
hematoma,
etc).
tions
of anesthesia, and claims for airway injuries are
intubation affects their incidence or severity is still unclear.
frequent inde
the complicaciones
American Society of Anesthesiologists
Methods: Eighty
patientsIOT
were randomized
in two groups
Relación
entre
satisfactoria
e incidencia
(n ! 40 for each) to receive a propofol–fentanyl induction
Closed Claims database.1 According to this database, the
laringeas
y
duración
de
las
mismas
regimen with or without atracurium. Intubation conditions
most common site of injuries to the airway is the larynx,
were evaluated with the Copenhagen Score; postoperative
hoarseness was assessed at 24, 48, and 72 h by a standardized
interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness
or vocal cord sequelae persisted, follow-up examination was
performed until complete restitution.
Results: Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients; P ! 0.02). The number of
days with postoperative hoarseness was higher when atracurium was omitted (25 vs. 6 patients; P < 0.001). Similar
findings were observed for vocal cord sequelae (incidence of
vocal cord sequelae: 15 vs. 3 patients, respectively, P ! 0.002;
days with vocal cord sequelae: 50 vs. 5 patients, respectively,
P < 0.001). Excellent intubating conditions were less frequently
associated with postoperative hoarseness compared to good or
poor conditions (11, 29, and 57% of patients, respectively; excellent vs. poor: P ! 0.008). Similar findings were observed for
vocal cord sequelae (11, 22, and 50% of patients, respectively;
excellent vs. poor: P ! 0.02).
Conclusions: The quality of tracheal intubation contributes to
laryngeal morbidity, and excellent conditions are less frequently associated with postoperative hoarseness and vocal
cord sequelae. Adding atracurium to a propofol–fentanyl induction regimen significantly improved the quality of tracheal in-
!
!
This article is featured in “This Month in Anesthesiology.”
Please see this issue of ANESTHESIOLOGY, page 5A.
Additional material related to this article can be found on the
ANESTHESIOLOGY Web site. Go to the following address, click on
Enhancements Index, and then scroll down to find the appropriate article and link. http://www.anesthesiology.org
* Staff, Department of Anesthesia and Critical Care, † Staff, § Professor and
Chairman, Department of Otorhinolaryngology, ‡ Medical Student, University of
the Saarland. ! Staff, Department of Anesthesia and Critical Care, University of
the Saarland. Current position: Associate Professor of Anesthesia, Université
Henri Poincaré, Nancy 1, Faculté de Médecine de Nancy, France.
representing 33% of all airway injury claims. The most
frequent types of laryngeal injury are vocal cord paralysis
and hematoma or granuloma of the vocal cords. Moreover, hoarseness is a common postoperative complication with an incidence varying between 14.4 and 50%; it
affects patient satisfaction and can affect a patient’s activities even after leaving the hospital.2–13 Indeed, prolonged or even permanent hoarseness may occur in 1%
of patients.11
In the past, several risk factors for laryngeal injury and
postoperative hoarseness (PH) have been identified, including endotracheal tube size, cuff design, and cuff
pressure, as well as demographic factors such as sex or
even the type of surgery.3,8,12,14 However, whether the
quality of tracheal intubation affects the incidence of
laryngeal injury has not yet been systematically investigated. Kambic and Radsel15 examined 1,000 patients
postoperatively using the indirect mirror technique and
reported 6.2% direct lesions. These were mainly hematoma or lacerations of the vocal cords. Similar results
were reported by Peppard and Dickens16 in a cohort of
475 patients. The authors of both studies speculated that
poor muscle relaxation at the moment of intubation may
have been causative for many of the observed laryngeal
injuries, although this assumption still has not been
proved by any randomized controlled trial. Therefore,
the purpose of the current study was to test the follow!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
ing hypothesis: An induction technique including propo- ,
fol, fentanyl,
and a neuromuscular blocking
+7;-18/7,<=,2-,>75?4,2-,<@AB
, agent
(NMBA), i.e., atracurium, results in a lower incidence of
vocal cord sequelae (VCS) or PH compared to a propofol–fentanyl regimen without NMBA.
Anesthesiology 2003; 98:1049 –56
© 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Laryngeal Morbidity and Quality of Tracheal Intubation
A Randomized Controlled Trial
Thomas Mencke, M.D.,* Mathias Echternach, M.D.,† Stefan Kleinschmidt, M.D.,* Philip Lux,‡ Volker Barth, M.D.,†
Peter K. Plinkert, M.D.,§ Thomas Fuchs-Buder, M.D.!
Background: Vocal cord sequelae and postoperative hoarse-
tubation and decreased postoperative hoarseness and vocal
Estudio
muestra
significativamente
condiciones
para IOT tras
ness during general
anesthesia
are a significant sourcemejores
of morcord
sequelae.
bidity for patients and a source of liability for anesthesiologists.
administración
BNM,
y menor
incidencia
Several risk factors leading
to laryngeal
injury have
been iden- de trauma laringe/ ronquera/
INJURIES to the airway are well-recognized complicatified in the
past. However,
whether
the quality of granuloma,
tracheal
lesión
cuerdas
vocales
(
hematoma,
etc).
tions
of anesthesia, and claims for airway injuries are
intubation affects their incidence or severity is still unclear.
frequent inde
the complicaciones
American Society of Anesthesiologists
Methods: Eighty
patientsIOT
were randomized
in two groups
Relación
entre
satisfactoria
e incidencia
(n ! 40 for each) to receive a propofol–fentanyl induction
Closed Claims database.1 According to this database, the
laringeas
y
duración
de
las
mismas
regimen with or without atracurium. Intubation conditions
most common site of injuries to the airway is the larynx,
were evaluated with the Copenhagen Score; postoperative
hoarseness was assessed at 24, 48, and 72 h by a standardized
interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness
or vocal cord sequelae persisted, follow-up examination was
performed until complete restitution.
Results: Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients; P ! 0.02). The number of
days with postoperative hoarseness was higher when atracurium was omitted (25 vs. 6 patients; P < 0.001). Similar
findings were observed for vocal cord sequelae (incidence of
vocal cord sequelae: 15 vs. 3 patients, respectively, P ! 0.002;
days with vocal cord sequelae: 50 vs. 5 patients, respectively,
P < 0.001). Excellent intubating conditions were less frequently
associated with postoperative hoarseness compared to good or
poor conditions (11, 29, and 57% of patients, respectively; excellent vs. poor: P ! 0.008). Similar findings were observed for
vocal cord sequelae (11, 22, and 50% of patients, respectively;
excellent vs. poor: P ! 0.02).
Conclusions: The quality of tracheal intubation contributes to
laryngeal morbidity, and excellent conditions are less frequently associated with postoperative hoarseness and vocal
cord sequelae. Adding atracurium to a propofol–fentanyl induction regimen significantly improved the quality of tracheal in-
!
!
This article is featured in “This Month in Anesthesiology.”
Please see this issue of ANESTHESIOLOGY, page 5A.
Additional material related to this article can be found on the
ANESTHESIOLOGY Web site. Go to the following address, click on
Enhancements Index, and then scroll down to find the appropriate article and link. http://www.anesthesiology.org
* Staff, Department of Anesthesia and Critical Care, † Staff, § Professor and
Chairman, Department of Otorhinolaryngology, ‡ Medical Student, University of
the Saarland. ! Staff, Department of Anesthesia and Critical Care, University of
the Saarland. Current position: Associate Professor of Anesthesia, Université
Henri Poincaré, Nancy 1, Faculté de Médecine de Nancy, France.
representing 33% of all airway injury claims. The most
frequent types of laryngeal injury are vocal cord paralysis
and hematoma or granuloma of the vocal cords. Moreover, hoarseness is a common postoperative complication with an incidence varying between 14.4 and 50%; it
affects patient satisfaction and can affect a patient’s activities even after leaving the hospital.2–13 Indeed, prolonged or even permanent hoarseness may occur in 1%
of patients.11
In the past, several risk factors for laryngeal injury and
postoperative hoarseness (PH) have been identified, including endotracheal tube size, cuff design, and cuff
pressure, as well as demographic factors such as sex or
even the type of surgery.3,8,12,14 However, whether the
quality of tracheal intubation affects the incidence of
laryngeal injury has not yet been systematically investigated. Kambic and Radsel15 examined 1,000 patients
postoperatively using the indirect mirror technique and
reported 6.2% direct lesions. These were mainly hematoma or lacerations of the vocal cords. Similar results
were reported by Peppard and Dickens16 in a cohort of
475 patients. The authors of both studies speculated that
poor muscle relaxation at the moment of intubation may
have been causative for many of the observed laryngeal
injuries, although this assumption still has not been
proved by any randomized controlled trial. Therefore,
the purpose of the current study was to test the follow!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
ing hypothesis: An induction technique including propo- ,
fol, fentanyl,
and a neuromuscular blocking
+7;-18/7,<=,2-,>75?4,2-,<@AB
, agent
(NMBA), i.e., atracurium, results in a lower incidence of
vocal cord sequelae (VCS) or PH compared to a propofol–fentanyl regimen without NMBA.
Anesthesiology 2003; 98:1049 –56
© 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Laryngeal Morbidity and Quality of Tracheal Intubation
A Randomized Controlled Trial
Thomas Mencke, M.D.,* Mathias Echternach, M.D.,† Stefan Kleinschmidt, M.D.,* Philip Lux,‡ Volker Barth, M.D.,†
Peter K. Plinkert, M.D.,§ Thomas Fuchs-Buder, M.D.!
Background: Vocal cord sequelae and postoperative hoarse-
tubation and decreased postoperative hoarseness and vocal
Estudio
muestra
significativamente
condiciones
para IOT tras
ness during general
anesthesia
are a significant sourcemejores
of morcord
sequelae.
bidity for patients and a source of liability for anesthesiologists.
administración
BNM,
y menor
incidencia
Several risk factors leading
to laryngeal
injury have
been iden- de trauma laringe/ ronquera/
INJURIES to the airway are well-recognized complicatified in the
past. However,
whether
the quality of granuloma,
tracheal
lesión
cuerdas
vocales
(
hematoma,
etc).
tions
of anesthesia, and claims for airway injuries are
intubation affects their incidence or severity is still unclear.
frequent inde
the complicaciones
American Society of Anesthesiologists
Methods: Eighty
patientsIOT
were randomized
in two groups
Relación
entre
satisfactoria
e incidencia
(n ! 40 for each) to receive a propofol–fentanyl induction
Closed Claims database.1 According to this database, the
laringeas
y
duración
de
las
mismas
regimen with or without atracurium. Intubation conditions
most common site of injuries to the airway is the larynx,
were evaluated with the Copenhagen Score; postoperative
hoarseness was assessed at 24, 48, and 72 h by a standardized
interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness
or vocal cord sequelae persisted, follow-up examination was
performed until complete restitution.
Results: Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients; P ! 0.02). The number of
days with postoperative hoarseness was higher when atracurium was omitted (25 vs. 6 patients; P < 0.001). Similar
findings were observed for vocal cord sequelae (incidence of
vocal cord sequelae: 15 vs. 3 patients, respectively, P ! 0.002;
days with vocal cord sequelae: 50 vs. 5 patients, respectively,
P < 0.001). Excellent intubating conditions were less frequently
associated with postoperative hoarseness compared to good or
poor conditions (11, 29, and 57% of patients, respectively; excellent vs. poor: P ! 0.008). Similar findings were observed for
vocal cord sequelae (11, 22, and 50% of patients, respectively;
excellent vs. poor: P ! 0.02).
Conclusions: The quality of tracheal intubation contributes to
laryngeal morbidity, and excellent conditions are less frequently associated with postoperative hoarseness and vocal
cord sequelae. Adding atracurium to a propofol–fentanyl induction regimen significantly improved the quality of tracheal in-
!
!
This article is featured in “This Month in Anesthesiology.”
Please see this issue of ANESTHESIOLOGY, page 5A.
Additional material related to this article can be found on the
ANESTHESIOLOGY Web site. Go to the following address, click on
Enhancements Index, and then scroll down to find the appropriate article and link. http://www.anesthesiology.org
* Staff, Department of Anesthesia and Critical Care, † Staff, § Professor and
Chairman, Department of Otorhinolaryngology, ‡ Medical Student, University of
the Saarland. ! Staff, Department of Anesthesia and Critical Care, University of
the Saarland. Current position: Associate Professor of Anesthesia, Université
Henri Poincaré, Nancy 1, Faculté de Médecine de Nancy, France.
representing 33% of all airway injury claims. The most
frequent types of laryngeal injury are vocal cord paralysis
and hematoma or granuloma of the vocal cords. Moreover, hoarseness is a common postoperative complication with an incidence varying between 14.4 and 50%; it
affects patient satisfaction and can affect a patient’s activities even after leaving the hospital.2–13 Indeed, prolonged or even permanent hoarseness may occur in 1%
of patients.11
In the past, several risk factors for laryngeal injury and
postoperative hoarseness (PH) have been identified, including endotracheal tube size, cuff design, and cuff
pressure, as well as demographic factors such as sex or
even the type of surgery.3,8,12,14 However, whether the
quality of tracheal intubation affects the incidence of
laryngeal injury has not yet been systematically investigated. Kambic and Radsel15 examined 1,000 patients
postoperatively using the indirect mirror technique and
reported 6.2% direct lesions. These were mainly hematoma or lacerations of the vocal cords. Similar results
were reported by Peppard and Dickens16 in a cohort of
475 patients. The authors of both studies speculated that
poor muscle relaxation at the moment of intubation may
have been causative for many of the observed laryngeal
injuries, although this assumption still has not been
proved by any randomized controlled trial. Therefore,
the purpose of the current study was to test the follow!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
ing hypothesis: An induction technique including propo- ,
fol, fentanyl,
and a neuromuscular blocking
+7;-18/7,<=,2-,>75?4,2-,<@AB
, agent
(NMBA), i.e., atracurium, results in a lower incidence of
vocal cord sequelae (VCS) or PH compared to a propofol–fentanyl regimen without NMBA.
•
MITO 2: SI CONOCES LA FARMACOCINÉTICA DE LOS
BNMS , LA MONITORIZACIÓN Y LA REVERSIÓN NO
SON NECESARIAS
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Anaesthesia, 2007, 62, pages 12–17
doi:10.1111/j.1365-2044.2006.04862.x
.....................................................................................................................................................................................................................
Incidence and duration of residual paralysis at the end of
surgery after multiple administrations of cisatracurium
and rocuronium
D. M. Maybauer,1,6 G. Geldner,1 M. Blobner,2 F. Pühringer,3 R. Hofmockel,4 C. Rex,3
H. F. Wulf,1 L. Eberhart,1 C. Arndt1 and M. Eikermann5
1
2
3
4
5
6
Klinik für Anästhesiologie und Intensivmedizin, Philipps-Universität Marburg, Germany
Klinik für Anästhesiologie, Technische Universität München, Germany
Klink für Anästhesiologie und operative Intensivmedizin, Kreiskliniken Reutlingen, Germany
Klinik und Poliklinik fur Anasthesiologie und Intensivtherapie, Universitat Rostock, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Germany
Summary
In a randomised, controlled, double-blind, multicentre trial in 338 patients, we assessed the
incidence of residual paralysis following administration of cisatracurium or rocuronium. The
incidence at the end of surgery was significantly lower in patients treated with rocuronium (62
of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In
contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28)
min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top-up
dose to recovery of the train-of-four ratio to 0.9) was significantly longer and more variable
for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and
variability of duration of action are greater with rocuronium compared with cisatracurium. These
pharmacodynamic differences do not necessarily translate into a higher incidence of residual
paralysis, because clinicians compensate for the longer duration of action and variability of
rocuronium by terminating administration of the neuromuscular blocking earlier.
. ......................................................................................................
Correspondence to: M. Eikermann
E-mail: [email protected]
Accepted: 11 September 2006
Adequate control of the duration and quality of neuromuscular blockade during surgery is essential for safe and
successful surgery. Inadequate paralysis can endanger
patients, particularly during abdominal surgery [1]. On
the other hand, residual paralysis may slow the throughput of patients in the operation room by increasing
the waiting time at the end of the case [2] and, more
importantly, may put patients at additional risk [3–6].
Dysphagia [3, 5], aspiration [3], or partial upper airway
obstruction [4, 5] may occur, even in the absence of
respiratory symptoms at a train-of-four ratio (T4 ⁄ T1) of
0.5–0.9 [3–6]. Residual neuromuscular blockade after
administration of the long-acting neuromuscular blocking
drug (NBD) pancuronium increases the risk for severe
postoperative pulmonary complications [6]. Furthermore,
postoperative residual neuromuscular blockade occurs in as
many as two-thirds of patients treated with NBDs with an
intermediate duration of action [7].
There are two strategies that help avoid postoperative
residual paralysis and its consequences. The first is reversal
of NBD effects with cholinesterase inhibitors, which is
a technique preferred by Anglo-American anaesthetists.
In contrast, in some European countries such as Germany
and Belgium, cholinesterase inhibitors are applied in only
about 25% of cases, suggesting that this approach is not
the first line strategy throughout the world [8, 9]. An
,
alternative!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
strategy is to avoid overdosing patients with
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
NBD via careful monitoring
and thorough titration of the
muscle relaxant [10]. Nonetheless, residual paralysis can
only be avoided by using NBDs that exhibit a rapid and
predictable spontaneous recovery profile. These properties
may be provided by benzylisoquinolines rather than by
Anaesthesia, 2007, 62, pages 12–17
doi:10.1111/j.1365-2044.2006.04862.x
.....................................................................................................................................................................................................................
Incidence and duration of residual paralysis at the end of
surgery after multiple administrations of cisatracurium
and rocuronium
D. M. Maybauer,1,6 G. Geldner,1 M. Blobner,2 F. Pühringer,3 R. Hofmockel,4 C. Rex,3
H. F. Wulf,1 L. Eberhart,1 C. Arndt1 and M. Eikermann5
1
2
3
4
5
6
Klinik für Anästhesiologie und Intensivmedizin, Philipps-Universität Marburg, Germany
Klinik für Anästhesiologie, Technische Universität München, Germany
Klink für Anästhesiologie und operative Intensivmedizin, Kreiskliniken Reutlingen, Germany
Klinik und Poliklinik fur Anasthesiologie und Intensivtherapie, Universitat Rostock, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Germany
Summary
In a randomised, controlled, double-blind, multicentre trial in 338 patients, we assessed the
incidence of residual paralysis following administration of cisatracurium or rocuronium. The
incidence at the end of surgery was significantly lower in patients treated with rocuronium (62
of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In
contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28)
min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top-up
dose to recovery of the train-of-four ratio to 0.9) was significantly longer and more variable
for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and
variability of duration of action are greater with rocuronium compared with cisatracurium. These
pharmacodynamic differences do not necessarily translate into a higher incidence of residual
paralysis, because clinicians compensate for the longer duration of action and variability of
rocuronium by terminating administration of the neuromuscular blocking earlier.
. ......................................................................................................
Correspondence to: M. Eikermann
E-mail: [email protected]
Accepted: 11 September 2006
Adequate control of the duration and quality of neuromuscular blockade during surgery is essential for safe and
successful surgery. Inadequate paralysis can endanger
patients, particularly during abdominal surgery [1]. On
the other hand, residual paralysis may slow the throughput of patients in the operation room by increasing
the waiting time at the end of the case [2] and, more
importantly, may put patients at additional risk [3–6].
Dysphagia [3, 5], aspiration [3], or partial upper airway
obstruction [4, 5] may occur, even in the absence of
respiratory symptoms at a train-of-four ratio (T4 ⁄ T1) of
0.5–0.9 [3–6]. Residual neuromuscular blockade after
administration of the long-acting neuromuscular blocking
drug (NBD) pancuronium increases the risk for severe
postoperative pulmonary complications [6]. Furthermore,
postoperative residual neuromuscular blockade occurs in as
many as two-thirds of patients treated with NBDs with an
intermediate duration of action [7].
There are two strategies that help avoid postoperative
residual paralysis and its consequences. The first is reversal
of NBD effects with cholinesterase inhibitors, which is
a technique preferred by Anglo-American anaesthetists.
In contrast, in some European countries such as Germany
and Belgium, cholinesterase inhibitors are applied in only
about 25% of cases, suggesting that this approach is not
the first line strategy throughout the world [8, 9]. An
,
alternative!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
strategy is to avoid overdosing patients with
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
NBD via careful monitoring
and thorough titration of the
muscle relaxant [10]. Nonetheless, residual paralysis can
only be avoided by using NBDs that exhibit a rapid and
predictable spontaneous recovery profile. These properties
may be provided by benzylisoquinolines rather than by
Anaesthesia, 2007, 62, pages 12–17
doi:10.1111/j.1365-2044.2006.04862.x
.....................................................................................................................................................................................................................
Incidence and duration of residual paralysis at the end of
surgery after multiple administrations of cisatracurium
and rocuronium
D. M. Maybauer,1,6 G. Geldner,1 M. Blobner,2 F. Pühringer,3 R. Hofmockel,4 C. Rex,3
H. F. Wulf,1 L. Eberhart,1 C. Arndt1 and M. Eikermann5
1
2
3
4
5
6
Klinik für Anästhesiologie und Intensivmedizin, Philipps-Universität Marburg, Germany
Klinik für Anästhesiologie, Technische Universität München, Germany
Klink für Anästhesiologie und operative Intensivmedizin, Kreiskliniken Reutlingen, Germany
Klinik und Poliklinik fur Anasthesiologie und Intensivtherapie, Universitat Rostock, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Germany
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Germany
Summary
In a randomised, controlled, double-blind, multicentre trial in 338 patients, we assessed the
incidence of residual paralysis following administration of cisatracurium or rocuronium. The
incidence at the end of surgery was significantly lower in patients treated with rocuronium (62
of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In
contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28)
min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top-up
dose to recovery of the train-of-four ratio to 0.9) was significantly longer and more variable
for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and
variability of duration of action are greater with rocuronium compared with cisatracurium. These
pharmacodynamic differences do not necessarily translate into a higher incidence of residual
BNM
RESIDUAL:
entre
paralysis, because clinicians compensate for the longer duration
of action
and variabilityoscila
of
rocuronium by terminating administration of the neuromuscular blocking earlier.
el 4-64% dependiendo del fármaco.
Para evitarlo: reversión, evitar sobredosificación mediante monitorización del BNM
. ......................................................................................................
Tras administraciones repetidas de BNM, la duración de acción y su variabilidad son superiores con rocuronio, aunque no se
Correspondence to: M. Eikermann
E-mail: [email protected]
traduzca en una mayor incidencia de bloqueo residual.
Accepted: 11 September 2006
LA RECUPERACIÓN VISTA A TRAVÉS DE TOF PARA LA EXIOT NO PUEDE PREDECIRSE Y LA
Adequate control of theDURACIÓN
duration and quality ofDEL
neuro- BLOQUEO
many as two-thirds of
patients treatedUN
with NBDs
with an>0’9 TIENE UNA GRAN VARIABILIDAD
HASTA
TOFr
muscular blockade during surgery is essential for safe and
intermediate duration of action [7].
INTERINDIVIDUAL.
successful surgery. Inadequate paralysis can endanger
There are two strategies that
help avoid postoperative
patients, particularly during abdominal surgery [1]. On
residual paralysis and its consequences. The first is reversal
the other hand, residual paralysis may slow the throughof NBD effects with cholinesterase inhibitors, which is
put of patients in the operation room by increasing
a technique preferred by Anglo-American anaesthetists.
the waiting time at the end of the case
[2] and, more
In MONITORIZACIÓN
contrast, in some European countries suchCUANTITATIVA
as Germany
NECESARIA
DE
importantly, may put patients at additional risk [3–6].
and Belgium, cholinesterase inhibitors are applied in only
Dysphagia [3, 5], aspiration [3], or partial upper airway
about 25% of cases, suggesting that this approach is not
obstruction [4, 5] may occur, even in the absence of
the first line strategy throughout the world [8, 9]. An
,
respiratory symptoms at a train-of-four ratio (T4 ⁄ T1) of
alternative!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
strategy is to avoid overdosing patients with
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
0.5–0.9 [3–6]. Residual neuromuscular blockade after
NBD via careful monitoring
and thorough titration of the
administration of the long-acting neuromuscular blocking
muscle relaxant [10]. Nonetheless, residual paralysis can
drug (NBD) pancuronium increases the risk for severe
only be avoided by using NBDs that exhibit a rapid and
postoperative pulmonary complications [6]. Furthermore,
predictable spontaneous recovery profile. These properties
postoperative residual neuromuscular blockade occurs in as
may be provided by benzylisoquinolines rather than by
CUALQUIER BNM
• MITO3: LOS
EFECTOS DEL BNM RESIDUAL
ESTÁN SOBREESTIMADOS
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
BNM residual ( TOFr<0’9) asocia:
- Disminución de la presión del esfínter esofágico inferior, menor coordinacón de la musculatira faringiesofágica
>>>>>>> MAYOR RIESGO ASPIRACIÓN
- Reducción del estímulo ventilatorio hipóxico y capacidad de reaccionar a desaturación aumentando vol/min
INCIDENCIA SIGNIFICATIVAMENTE MENOR CUANDO SE EMPLEAN REVERSORES
NEUROMUSCULARES
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
ANESTESIA
REVIEWS
A
MINERVA ANESTESIOL 2006;72:97-109
The residual effects of neuromuscular blocking
agents may persist into the early postoperative
recovery period, even when neuromuscular
blockade is carefully monitored and reversed
in the operating room. Recent data suggest that
mild degrees of residual paresis (train-of-four
TOF ratios of 0.7-0.9) may be associated with
significant impairment of respiratory and pharyngeal muscle function. Therefore, the new
gold standard reflecting acceptable neuromuscular recovery is a TOF ratio !0.9. Several investigations have demonstrated that many patients
continue to arrive in the postanesthesia care
unit with TOF ratios <0.7-0.9. Several techniques
may be used to reduce the risk of postoperative
residual paresis, which include avoidance of
long-acting muscle relaxants, use of neuromuscular monitoring in the operating room,
routine reversal of neuromuscular blockade at
a TOF count of 2-3, and early administration of
reversal agents. Careful management of neuromuscular blockade may limit the occurrence of
adverse events associated with residual postoperative paralysis. Large-scale outcome studies are needed to clearly define the impact of
residual neuromuscular block on major morbidity and mortality in surgical patients.
Key words: Neuromuscular blockage - Paresis Paralysis - Neuromuscular blocking agents Neuromuscular monitoring - Acceleromyography - Train-of-four ratio.
G. S. MURPHY
®
M
IN
OP ER
V
YR A
IG ME
HT D
IC
Residual neuromuscular blockade: incidence,
assessment, and relevance
in the postoperative period
Department of Anesthesiology
Evanston Northwestern Healthcare
Northwestern University
Feinberg School of Medicine, IL, USA
R
esidual neuromuscular blockade is frequently observed in the Post Anesthesia
Care Unit (PACU) when neuromuscular
blocking agents (NMBAs) are administered
in the operating room. The presence of significant muscle weakness is commonly documented in the early postoperative period, even when intermediate-acting NMBAs
are used and routinely monitored and
reversed.
The impact of residual neuromuscular
block on major adverse outcomes following surgery has been poorly studied.
However, studies
suggest that the residual
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
,
effects of NMBAs can prolong postoperative
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
recovery, adversely affect
respiratory function, impair airway protective reflexes, and
produce unpleasant symptoms of muscle
weakness.1 The purpose of this article is
to review the definitions of residual neu-
ANESTESIA
REVIEWS
A
MINERVA ANESTESIOL 2006;72:97-109
The residual effects of neuromuscular blocking
agents may persist into the early postoperative
recovery period, even when neuromuscular
blockade is carefully monitored and reversed
in the operating room. Recent data suggest that
mild degrees of residual paresis (train-of-four
TOF ratios of 0.7-0.9) may be associated with
significant impairment of respiratory and pharyngeal muscle function. Therefore, the new
gold standard reflecting acceptable neuromuscular recovery is a TOF ratio !0.9. Several investigations have demonstrated that many patients
continue to arrive in the postanesthesia care
unit with TOF ratios <0.7-0.9. Several techniques
may be used to reduce the risk of postoperative
residual paresis, which include avoidance of
long-acting muscle relaxants, use of neuromuscular monitoring in the operating room,
routine reversal of neuromuscular blockade at
a TOF count of 2-3, and early administration of
reversal agents. Careful management of neuromuscular blockade may limit the occurrence of
adverse events associated with residual postoperative paralysis. Large-scale outcome studies are needed to clearly define the impact of
residual neuromuscular block on major morbidity and mortality in surgical patients.
Key words: Neuromuscular blockage - Paresis Paralysis - Neuromuscular blocking agents Neuromuscular monitoring - Acceleromyography - Train-of-four ratio.
multifactorial (cirugía, tipo paciente, tipo anestesia).
- En pacientes con eventos respiratorios críticos (hipoxemia severa,
obstrucción VAS) en URPQ, incidencia oscila entre 1’2-6’9%. El 70%
relacionados por tasas de BNM residual con TOFr<0’7.
- 0’1% de pacientes presentaron insuficiencia respiratoria y requirieron
REIOT. En ellos TOFr 0’36 +/- 0’17.
G. S. MURPHY
®
M
IN
OP ER
V
YR A
IG ME
HT D
IC
Residual neuromuscular blockade: incidence,
assessment, and relevance
in the postoperative period
- Complicaciones respiratorias críticas en el postoperatorio: etiología
Department of Anesthesiology
Evanston Northwestern Healthcare
Northwestern University
Feinberg School of Medicine, IL, USA
R
esidual neuromuscular blockade is frequently observed in the Post Anesthesia
Care Unit (PACU) when neuromuscular
blocking agents (NMBAs) are administered
in the operating room. The presence of significant muscle weakness is commonly documented in the early postoperative period, even when intermediate-acting NMBAs
are used and routinely monitored and
reversed.
The impact of residual neuromuscular
block on major adverse outcomes following surgery has been poorly studied.
However, studies
suggest that the residual
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727
,
effects of NMBAs can prolong postoperative
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
recovery, adversely affect
respiratory function, impair airway protective reflexes, and
produce unpleasant symptoms of muscle
weakness.1 The purpose of this article is
to review the definitions of residual neu-
ANESTESIA
REVIEWS
A
MINERVA ANESTESIOL 2006;72:97-109
M
IN
OP ER
V
YR A
IG ME
HT D
IC
Residual neuromuscular blockade: incidence,
assessment, and relevance
in the postoperative period
- Complicaciones respiratorias críticas en el postoperatorio: etiología
multifactorial (cirugía, tipo paciente, tipo anestesia).
- En pacientes con eventos respiratorios críticos (hipoxemia severa,
obstrucción VAS) en URPQ, incidencia oscila entre 1’2-6’9%. El 70%
relacionados por tasas de BNM residual con TOFr<0’7.
- 0’1% de pacientes presentaron insuficiencia respiratoria y requirieron
REIOT. En ellos TOFr 0’36 +/- 0’17.
G. S. MURPHY
®
CLÍNICOS CARECEN DE CONOCIMIENTO TOTAL DE LA RECUPERACIÓN COMPLETA DEL BNM Y
MONITORIZAN INFRECUENTEMENTE EL GRADO DE BLOQUEO
The residual effects of neuromuscular blocking
Department of Anesthesiology
agents may persist into the early postoperative
Evanston Northwestern Healthcare
Northwestern University
recovery period,
even when
neuromuscular MANEJO INTRAOPERATORIO
SE DEBE
REALIZAR
CUIDADOSO DEL BNM ( MINIMIZAR DOSIS,
Feinberg School of Medicine, IL, USA
blockade is carefully monitored and reversed
REVERSION
TEMPRANA,
in the
operating room. Recent
data suggest that MONITORIZACIÓN CUANTITATIVA ESTRECHA CON ACELEROMIOGRAFÍA),
mild degrees of residual paresis (train-of-four
ASÍ
REDUCIR
LA INCIDENCIA
DE PARESIA RESIDUAL Y COMPLICACIONES RESPIRATORIAS EN EL
TOF ratios
of 0.7-0.9)
may be associated
with
significant impairment of respiratory and phaPOSTOPERATORIO INMEDIATO
ryngeal muscle function. Therefore, the new
esidual neuromuscular blockade is fregold standard reflecting acceptable neuromuscular recovery is a TOF ratio !0.9. Several invesquently observed in the Post Anesthesia
tigations have demonstrated that many patients Care Unit (PACU) when neuromuscular
continue to arrive in the postanesthesia care blocking agents (NMBAs) are administered
unit with TOF ratios <0.7-0.9. Several techniques
may be used to reduce the risk of postoperative in the operating room. The presence of sigresidual paresis, which include avoidance of nificant muscle weakness is commonly doclong-acting muscle relaxants, use of neuro- umented in the early postoperative perimuscular monitoring in the operating room, od, even when intermediate-acting NMBAs
routine reversal of neuromuscular blockade at are used and routinely monitored and
a TOF count of 2-3, and early administration of reversed.
reversal agents. Careful management of neuroThe impact of residual neuromuscular
muscular blockade may limit the occurrence of
block
on major adverse outcomes followadverse events associated with residual postoperative paralysis. Large-scale outcome stud- ing surgery has been poorly studied.
ies are needed to clearly define the impact of However, studies suggest that the residual
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
residual neuromuscular block on major mor- effects of NMBAs
can prolong postoperative
bidity and mortality in surgical patients.
+7;-18/7,<=,2-,>75?4,2-,<@AB
,
recovery, adversely affect
respiratory funcKey words: Neuromuscular blockage - Paresis - tion, impair airway protective reflexes, and
Paralysis - Neuromuscular blocking agents produce unpleasant symptoms of muscle
Neuromuscular monitoring - Acceleromyograweakness.1 The purpose of this article is
phy - Train-of-four ratio.
R
to review the definitions of residual neu-
Y
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
Con CRC
Controles
p<0,0001
100
p<0,0001
90,5
90
Pacientes (%)
80
73,8
70
60
50
40
p<0,366
30
20
10
16,7
9,5
9,5
0
0
TOF >0,9
TOF <0,7
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
Con CRC
Controles
p<0,0001
100
p<0,0001
90,5
90
Pacientes (%)
80
EL BNM RESIDUAL AUMENTA EL RIESGO
DE COMPLICACIONES RESPIRATORIAS CRÍTICAS
73,8
70
60
50
40
p<0,366
30
20
10
16,7
9,5
9,5
0
0
TOF >0,9
TOF <0,7
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
EL BNM RESIDUAL AUMENTA EL RIESGO
DE COMPLICACIONES RESPIRATORIAS CRÍTICAS
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
EL BNM RESIDUAL AUMENTA EL RIESGO
DE COMPLICACIONES RESPIRATORIAS CRÍTICAS
CONSECUENCIAS POTENCIALES DEL BNM RESIDUAL
Alteración regulación de la ventilación >>> HIPOXIA
Disfunción de la musculatura faríngea
Riesgo de aspiración y obstrucción de VAS
Complicaciones pulmonares postoperatorias ( neumonías)
Aumento estancia hospitalaria/ costos
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CLÁSICAMENTE TOFr 0’7-0’9>> reflejos protectores de la vía aérea alterados,
obstrucción VAS, recuperación neuromuscular incompleta.
GOLD STANDARD >0’9
EL BNM RESIDUAL AUMENTA EL RIESGO
DE COMPLICACIONES RESPIRATORIAS CRÍTICAS
CONSECUENCIAS POTENCIALES DEL BNM RESIDUAL
Alteración regulación de la ventilación >>> HIPOXIA
Disfunción de la musculatura faríngea
CRC de mayor incidencia en la URPA (N=61)
Complicaciones pulmonares postoperatorias ( neumonías)
Aumento estancia hospitalaria/ costos
Frecuencia relativa (%)
Riesgo de aspiración y obstrucción de VAS
70
60
59
50
34,4
40
30
34,4
19,7
20
10
0
Hipoxemia grave
Obstruc vías
respirat sup
Hipoxemia leve
Tipo de CRC
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
Varias CRC
• MITO
4: BNM RESIDUAL POSTOPERATORIO
ESTÁ SOBREESTIMADO.
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
En voluntarios sanos, TOFr 0’8: incidencia 20% actividad musculatura
faringea alterada y reducción P esfinter esofágico inferior.
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
En voluntarios sanos, TOFr 0’8: incidencia 20% actividad musculatura
faringea alterada y reducción P esfinter esofágico inferior.
Incluso con reversión BNM, 41% pacientes presentaban TOFr <0’7,
58% TOFr 0’7-0’9, 88% TOFr <0’9.
Valoración estrecha de la recuperación de la función neuromuscular
previo a ExIOT para garantizar corecta recuperación de la fuerza
musculatura faringea y respiratoria
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
En voluntarios sanos, TOFr 0’8: incidencia 20% actividad musculatura
faringea alterada y reducción P esfinter esofágico inferior.
Incluso con reversión BNM, 41% pacientes presentaban TOFr <0’7,
58% TOFr 0’7-0’9, 88% TOFr <0’9.
Valoración estrecha de la recuperación de la función neuromuscular
previo a ExIOT para garantizar corecta recuperación de la fuerza
musculatura faringea y respiratoria
Incluso dosis única de BNM previa a IOT puede ocasionar BNM
residual postoperatorio.
Reversión rutinaria BNM no elimina el riesgo de BNM residual
( estudios con BNM residual TOFr 0’7-0’9 16-45%, presente en el
25% de pacientes tras reversión)
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
En voluntarios sanos, TOFr 0’8: incidencia 20% actividad musculatura
faringea alterada y reducción P esfinter esofágico inferior.
Incluso con reversión BNM, 41% pacientes presentaban TOFr <0’7,
58% TOFr 0’7-0’9, 88% TOFr <0’9.
Valoración estrecha de la recuperación de la función neuromuscular
previo a ExIOT para garantizar corecta recuperación de la fuerza
musculatura faringea y respiratoria
Incluso dosis única de BNM previa a IOT puede ocasionar BNM
residual postoperatorio.
Reversión rutinaria BNM no elimina el riesgo de BNM residual
( estudios con BNM residual TOFr 0’7-0’9 16-45%, presente en el
25% de pacientes tras reversión)
NECESIDAD DE MONITORIZAR Y
REVERTIR BNM!!
Garantizar bloqueo neuromuscular suficiente y
eficaz.
Determinar cuando es posible la intubación
orotraqueal.
Determinar cuando es posible revertir BNM.
Garantizar la reversión completa del BNM.
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
•
Baillard, 1995. Monitorización del BNM se inicia a partir de 1995
•
62% pacientes presentan un TOFr< 0’9 en URPQ
•
Monitorización aumentó hasta 60% de pacientes // Reversión BNM pasó de 6- 42%
•
•
REDUCCIÓN BNM RESIDUAL HASTA 3’5% EN 2004
Reducción de 35% de efectos adversos tras la aplicación de monitorización
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
•
Baillard, 1995. Monitorización del BNM se inicia a partir de 1995
•
62% pacientes presentan un TOFr< 0’9 en URPQ
•
Monitorización aumentó hasta 60% de pacientes // Reversión BNM pasó de 6- 42%
•
•
REDUCCIÓN BNM RESIDUAL HASTA 3’5% EN 2004
Reducción de 35% de efectos adversos tras la aplicación de monitorización
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
•
MITO 5: BNM PUEDE SER FÁCILMENTE DIAGNOSTICADO Y
TESTADO CLÍNICAMENTE.
•
MITO 6: TESTS SUBJETIVOS ( VISUALES/ TACTILES) SON
SUFICIENTES PARA DIAGNOSTICAR BNM RESIDUAL.
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
TESTS SUBJETIVOS (apertura ocular, protrusión lengua, levantar brazo, cabeza >5 segundos, volumen /min adecuado) NO son del
todo fiables porque
1- puede que el paciente no sea capaz de realizarlos por BNM residualo por dosificación de opioides
2- pacientes puedan realizarlos au comn cierto grado de bloqueo residual ( levantar cabeza 5 seg requiere TOFr>0’5)
La detección visual/ táctil no se observa hasta que no se alcanza un TOFr>0’5
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
TESTS SUBJETIVOS (apertura ocular, protrusión lengua, levantar brazo, cabeza >5 segundos, volumen /min adecuado) NO son del
todo fiables porque
1- puede que el paciente no sea capaz de realizarlos por BNM residualo por dosificación de opioides
2- pacientes puedan realizarlos au comn cierto grado de bloqueo residual ( levantar cabeza 5 seg requiere TOFr>0’5)
La detección visual/ táctil no se observa hasta que no se alcanza un TOFr>0’5
TESTS SUBJETIVOS SE PUEDEN EMPLEAR, PERO NO PUEDEN REEMPLAZAR LA MONITORIZACIÓN
CUANTITATIVA OBJETIVA
ES NECESARIO DICHA MONITORIZACIÓN PARA VALORAR LA PROFUNDIDAD DEL BLOQUEO Y EL
GRADO DE RECUPERACION DEL MISMO
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
CUÁNDO Y CÓMO REVERTIR BNM?
SIEMPRE QUE SE EMPLEEN BNM Y SEGÚN
DATOS OBTENIDOS EN LA MONITORIZACIÓN.
!"#$%&'()*+,!-./01,2-,345678/01,'4191:727,
+7;-18/7,<=,2-,>75?4,2-,<@AB,
REVERSIÓN DEL BNM
•
INHIBIDORES DE LA COLINESTERASA (NEOSTIGMINA/EDROFONIO...)
•
Inactivan el enzima en el hueco sináptico (aumentan concentración Ach en hueco sináptico)
•
Reversión clásica: efecto máximo se alcanza a partir de los 10 min, incluso cuando se
administra tras obtener T2.
•
Techo de dosis (> dosis o 2ª administración no ofrece beneficio en la reversión).
•
Efectos secundarios: náuseas/vómitos, bradicardia, aumento QT, broncoconstricción, sialorrea,
miosis (efectos muscarínicos)
•
MONITORIZACION ESENCIAL PARA EVITAR BNM RESIDUAL.
•
Importancia de la profundidad del BNM a la hora de administrar el fármaco ( se
recomienda TOF 2, ya que aumenta el tiempo de recuperación si TOF 1-2)
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NUEVOS REVERSORES: CICLODEXTRINAS
(SUGAMMADEX)
•
Estructura en anillo conformando un cono truncado
•
Molécula hidrosoluble que rodea por la cavidad central
lipofílica los 4 anillos esteroides del rocuronio.
•
VD 18 litros. Aclaramiento renal 120 ml/min
•
Baja unión a proteínas, no pasa BHE, bajo paso placentario,
no presenta actividad intrínseca, no genera toxicidad ni
teratogenicidad
•
Complejo de inclusión 1:1 con rocuronio/vecuronio/
pancuronio, finalizando su acción Unión a las moléculas
libres en plasma, creando gradiente de concentración, que
promueve el movimiento de las moléculas de la unión
neuromuscular hacia el plasma, donde se encapsula con el
resto de sugammadex libre
•
Efecto dosis- dependiente
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EVIDENCIA CLÍNICA DEL SUGAMMADEX
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EVIDENCIA CLÍNICA DEL SUGAMMADEX
REVERSIÓN BLOQUEO PROFUNDO ( TOF 0, PTC>1): dosis 4 mg/kg. Reversión a TOFr 0’9 en <3min
REVERSIÓN INMEDIATA ( RESCATE EN BLOQUEO INTENSO, TOF0, PTC 0): en situaciones de pacientes no
intubables, no ventilables ( en inducciones de secuencia rápida con dosis de rocuronio 1’2 mg/kg): dosis de 16
mg/kg recupera hasta TOFr 0’9 en 1’6 min)
Efecto no se ve alterado en pacientes con insuficiencia renal
Se ha observado recurarización cuando las dosis son insuficientes ( RESPETAR DOSIS CORRECTAS)
No aparente efectos secundarios severos. Más seguro que neostigmina
Se puede readministrar con seguridad respetando tiempos de espera
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
EVIDENCIA CLÍNICA DEL SUGAMMADEX
REVERSIÓN BLOQUEO PROFUNDO ( TOF 0, PTC>1): dosis 4 mg/kg. Reversión a TOFr 0’9 en <3min
REVERSIÓN INMEDIATA ( RESCATE EN BLOQUEO INTENSO, TOF0, PTC 0): en situaciones de pacientes no
intubables, no ventilables ( en inducciones de secuencia rápida con dosis de rocuronio 1’2 mg/kg): dosis de 16
mg/kg recupera hasta TOFr 0’9 en 1’6 min)
Efecto no se ve alterado en pacientes con insuficiencia renal
Se ha observado recurarización cuando las dosis son insuficientes ( RESPETAR DOSIS CORRECTAS)
No aparente efectos secundarios severos. Más seguro que neostigmina
Se puede readministrar con seguridad respetando tiempos de espera
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
COMPARA REVERSIÓN CON SUGAMMADEX DE BLOQUEO
PROFUNDO ( TOF0 PTC >1) CON REVERSIÓN CON
NEOSTIGMINA DE BLOQUEO MODERADO ( TOF2)
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
COMPARA REVERSIÓN CON SUGAMMADEX DE BLOQUEO
PROFUNDO ( TOF0 PTC >1) CON REVERSIÓN CON
NEOSTIGMINA DE BLOQUEO MODERADO ( TOF2)
TIEMPO DESDE ADMINISTRACION DE FÁRMACO
HASTA TOFR 0’9: 3’4 VECES MÁS RÁPIDO
( 2’4-8’4 min)
TIEMPO DE RECUPERACION DESDE LA ULTIMA
DOSIS DE ROCURONIO HASTA TOFr 0’9:
13’3-35’2 min
EFECTOS ADVERSOS ( menor incidencia de
bradicardia)
NO SE OBSERVARON BNM RESIDUALES
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
COMPARA REVERSIÓN CON SUGAMMADEX DE BLOQUEO
PROFUNDO ( TOF0 PTC >1) CON REVERSIÓN CON
NEOSTIGMINA DE BLOQUEO MODERADO ( TOF2)
TIEMPO DESDE ADMINISTRACION DE FÁRMACO
HASTA TOFR 0’9: 3’4 VECES MÁS RÁPIDO
( 2’4-8’4 min)
TIEMPO DE RECUPERACION DESDE LA ULTIMA
DOSIS DE ROCURONIO HASTA TOFr 0’9:
13’3-35’2 min
EFECTOS ADVERSOS ( menor incidencia de
bradicardia)
NO SE OBSERVARON BNM RESIDUALES
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
SUGAMMADEX EN SITUACIONES ESPECIALES
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+7;-18/7,<=,2-,>75?4,2-,<@AB,
ENFERMEDADES NEUROMUSCULARES
•
Casos descritos en Miastenia Gravis, Distrofias musculares, Distrofia miotónica de Steinert, ELA, Dermatomiositis, atrofia
muscular espinal, miopatías, Síndrome Rett...
•
Miastenia Gravis ( casos clínicos sobre cirugía de timectomía).
•
Generalmente poca sensibilidad a succinilcolina/ reversion con anticolinesterásicos incompleta ( interferencia con
medicación habitual. En ocasiones TOFr basales 0’5-0’6
•
Sugammadex no interfiere en la regulación colinérgica>> se puede combinar con la medicación anticolinesterásica
habitual (preservación de la función muscular).
•
Fármaco seguro incluso en BNM profundos, no BNM residual
•
Aunque dosis de BNM menores ( mayor sensibilidad a los BNMND por “down regulation” de receptores
postsinápticos), reversión precisa de dosis completas
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INSUFICIENCIA RENAL TERMINAL
•
I.Renal prolonga la acción del rocuronio ( posibilidad de despertar prolongado, BNM residual y recurarización)
•
Sugammadex: reversión segura, TOFr>0’9, no diferencias significativas en tiempo respecto a pacientes con ClCr normal, NO
bloqueo residual.
•
Cuando se emplea sugammadex, la reversión del rocuronio depende del desplazamiento del fármaco de la unión neuromuscular,
más que de la eliminación renal del mismo.
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PACIENTES CRÍTICOS (UCI)
Residual Neuromuscular Blockade in Critical Care
Jason Wilson, Angela S. Collins and Brea O. Rowan
Crit Care Nurse 2012;32:e1-e10 doi: 10.4037/ccn2012107
© 2012 American Association of Critical-Care Nurses
Published online http://www.cconline.org
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GRACIAS
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