拇短屈肌和拇内收肌加速度监测用于阿曲库铵诱导的神经肌肉阻滞的比较:前瞻性观察研究
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A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography A prospective observational study
背景与目的
神经肌肉阻滞(NMB)监测是避免残留NMB的关键。虽然拇内收肌是推荐监测的部位,但并非总是有效的。拇短屈肌可能是一个很好的选择。本研究旨在比较这两个部位NMB的起效和恢复情况。
方 法
将2016年1月至2017年9月期间,计划使用神经肌肉阻滞剂行全麻手术的60名患者纳入研究。最终仅对56例患者的资料进行了分析,其中11例患者在麻醉复苏时使用新斯的明和阿托品拮抗。注射阿曲库铵后,同时监测拇内收肌和拇短屈肌NMB的起效和恢复情况。主要结果指标——NMB的起效时间(定义为四个成串刺激[TOF]计数等于0)及NMB恢复时间(TOF=1、TOF=4、T4/T1比值=0.75、T4/T1比值>0.90)。
结 果
拇短屈肌NMB起效时间较慢,平均为4.4±1.5min,拇内收肌为3.7min±1.2min (P≤0.0001)。拇短屈肌恢复到TOF=1的速度明显较慢,而TOF=4无差异。拇短屈肌NMB完全恢复(T4/T1>0.9)明显快于拇内收肌,平均恢复时间分别为59.5±9.9min和64.5min ±10.7min(P<0.0001),两者之间相差4.9min。使用药物拮抗后,拇短屈肌(53.0± 12.2min)和拇内收肌(53.0±12.2min)NMB完全恢复之间的差异消除然而,在个别患者中,NMB的起效和恢复并不遵循相同的规律。
结 论
拇内收肌NMB无法监测时,拇短屈肌可作为NMB监测的替代选择。然而,在无药物拮抗情况下,应谨慎使用拇短屈肌监测,避免发生肌松残留。
原始文献摘要
Le Merrer M, Frasca D, Dupuis M,et,al.A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography A prospective observational study .[J].Eur J Anaesthesiol 2020 Jan;37(1) DOI:10.1097/EJA.0000000000001090
BACKGROUND Neuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative.
OBJECTIVE The aim of our study was to compare NMB onset and recovery at both sites.
DESIGN Prospective observational study.
SETTING Operating rooms at the University Hospital of Poitiers, France.
PATIENTS Sixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia.
INTERVENTION After atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously.
MAIN OUTCOME MEASURES The time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF= 4, T4/T1 ratio= 0.75 and T4/T1 ratio more than 0.90.
RESULTS NMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4±1.5 versus 3.7±1.2 min at adductor pollicis (P= 0.0001). Recovery to TOF= 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF= 4. The full recovery of NMB (T4/T1> 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ±9.9 versus 64.5±10.7 min at adductor pollicis (P< 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0±12.2 min at flexor hallucis brevis versus 54.0±12.4min at adductor pollicis (P= 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients.
CONCLUSION Flexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis.
麻醉学文献进展分享
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翻译:牛振瑛 编辑:冯玉蓉 审校:王贵龙