TEK DOZ ORTA ETKİLİ KAS GEVŞETİCİLERE BAĞLI POSTOPERATİF REZİDÜEL NÖROMUSKÜLER BLOK İNSİDANSI VE ETKİ EDEN FAKTÖRLER

Year 2011, Volume: 12 Issue: 2, 17 - 22, 01.08.2011

Nil Kaan Özlem Kocatürk İbrahim Kurt Halil Çiçek Emel Memetoğlu

Abstract

AMAÇ:Bu çalışmanın amacı sağlıklı, erişkin hastalarda endotrakeal entübasyon için uygulanan tek doz orta etkisüreli kas gevşeticilerine (atrakuryum, vekuronyum ve rokuronyum) bağlı erken postoperatif rezidüelnöromusküler blok (PRNB) insidansını ve buna etki eden sonra faktörleri araştırmaktır.GEREÇ ve YÖNTEM:Çalışma prospektif, gözlemsel olarak, anestezi sırasında sadece endotrakealentübasyonu kolaylaştırmak için tek doz vekuronyum, atrakuryum veya rokuronyum kullanılan ve ameliyatbittikten sonra derlenme odasına alınan hastalarda yapıldı. Derlenme odasında akselomiyograf ile nöromuskülerileti monitorize edildi ve dörtlü uyarıya yanıt (TOF) oranı ölçüldü; 0,9'un altındaki değerler “PRNB var” olarakkaydedildi. Hastalara kullanılan anestezikler ve kas gevşeticisinin seçimi, antidot (neostigmin) kullanımı,ekstübasyon ve derlenme odasına alınma kararları hastayı takip eden anestezi doktoruna bırakıldı. Yaş, kilo,cinsiyet, antidot kullanımı, anestezi süresi, ekstübasyondan sonra derlenme odasına alınma süreleri PRNB içinrisk faktörü olarak alındı, stepwise lojistik regresyon analizi yapıldı.BULGULAR:Çalışmaya 84 hasta alındı, vekuronyum, atrakuryum, rokuronyum kullanılan hasta sayısısırasıyla 29, 28, 27 oldu. Hastaların % 58,3'ne neostigmin yapıldı. Medyan anestezi süresi 80 dakikaydı.Derlenme odasında PRNB insidansı (TOF<0,90) % 13,1 bulundu. Regresyon analizinde cinsiyetin PRNB'uetkilediği; kadın cinsiyetin, PRNB riskini artırdığı bulundu (OR: 7,250, %95 CI:1,019-51,593). Diğer riskfaktörlerinin PRNB'a anlamlı etkisi saptanmadı.SONUÇ:Klinik olarak ameliyat nedeni dışında ek risk faktörü taşımayan ve anestezi süresi bir saatten uzun olanhastalarda, “cinsiyet” tek doz orta etkili kas gevşeticilerine bağlı PRNB insidansını etkileyebilir

Keywords

Nöromusküler blok, rezidüel paralizi, nöromusküler monitörizasyon, kas gevşeticisi, atrakuryum, vekuronyum, rokuronyum

The Incidence of Residual Neuromuscular Blockade Associated with Single Dose of Intermediate-acting Non-depolarizing Neuromuscular Blocking

Abstract

PURPOSE: The goal of this study is to investigate the incidence of postoperative residual neuromuscular blockade (PRNB) associated with single-dose intermediate-acting muscle relaxants (atracurium, vecuronium, rocuronium) administered to adult patients for endotracheal intubation during early postoperative period and subsequent factors affecting this. MATERIALS and METHODS: This prospective and observational study was conducted after obtaining the permission of the local ethics committee. Adult, ASA I, II patients who received a single dose of vecuronium, atracurium or rocuronium during general anesthesia for elective surgical procedure were included in the study. The decisions about the anesthetics and muscle relaxants used on the patients, reversal with neostigmine, extubation and transfer to the recovery room were left to be made by the anesthesiologist following the patient. The patient who was taken into the recovery room had neuromuscular monitoring using accelomyography. Train-of-four (TOF) ratios under 0.9 were recorded as “PRNB present”. Age, weight, gender, reversal, anesthesia duration, time for transfer to the recovery room after extubation were considered risk factors for PRNB, stepwise logistic regression analysis was conducted. RESULTS: This study included 84 patients and the number of patients that were given vecuronium, atracurium, rocuronium were 29, 28, and 27, respectively. After the end of the operation, reversal was performed with neostigmine in 58.3% of the patients. The median length of anesthesia was 80 minutes. PRNB incidence (TOF<0.90) in the recovery room was determined to be 13.1%. Based on the regression analysis, gender was determined to affect PRNB; female gender increased PRNB risk (OR: 7.250, 95%, CI:1.019-51.593). The remaining factors did not have any significant effect on PRNB. CONCLUSION: In patients who do not have other risk factors in addition to the operation reason and whose anesthesia duration is longer than one hour, “gender” may affect PRNB incidence associated with single-dose intermediate-acting muscle relaxants.

Keywords

Neuromuscular block, residual paralysis, neuromuscular monitoring, muscle relaxant, atracurium, vecuronium, rocuronium

References

• 1. Murphy GS, Brull SJ. Residual neuromuscular block: Lessons unlearned. Part I: Definitions, incidence, and adverse physiologic effects of residual neuromuscular block.AnesthAnalg 2010;111:120-8.
• 2. Naguib M. Pharmacology of muscle relaxant and their antagonist neuromuscular physiology and pharmacology. In: Miller RD, ed. Anaesthesia. 6 ed. Philadelphia, Churchil Livingston, 2006:481-572.
• 3. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minevra Anestesiol 2006;72:97- 109.
• 4. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008;107:130- 7.
• 5. Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia Care unit recovery times and neuromuscular blocking drugs: a prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium. AnesthAnalg 2004;98:193-200.
• 6. Eikermann M, Groeben H, Hüsing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade.Anesth 2003;98:1333-7.
• 7. Eriksson LI, Satoo M, Severinghaus JW. Effect of vecuronium induced partial neuromuscular block on hipoxic ventilatory response.Anesth 1993;78:693-9.
• 8. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br JAnaesth 2007;98:302-16.
• 9. Tsai CC, Chung HS, Chen PL, Yu CM, Chen MS, Hong CL. Postoperative residual curarization: Clinical observation in the post-anesthesia care unit. Chang Gung Med J 2008;31:364-8,
• 10. Houghton IT, Aun CS, Oh TE. Vecuronium: an anthropometric comparison.Anaesth 1992;47:741-6.
• 11. Semple P, Hope DA, Clyburn P, Rodbert A. Relative potency of vecuronium in male and female patients in Britain andAustralia. Br JAnaesth 1994;72:190-4.
• 12. Xue F, Liao X, Liu J et al. Dose-response curve and timecourse of effect of vecuronium in male and female patients. Br JAnaesth 1998;80:720-4.
• 13. Xue FS, An G, Liao X, Zou Q, Luo LK. The pharmacokinetics of vecuronium in male and female patients.AnesthAnalg 1998;86:1322-7.
• 14. M. Adamus, T. Gabrhelik, O. Marek. Influence of gender on the course of neuromuscular block following a single bolus dose of cisatracurium or rocuronium. Eur JAnaesth 25: 589595
• 15. Xue FS, Tong SY, Liao X, Liu JH, An G, Luo LK. Doseresponse and time course of effect of rocuronium in male and female anesthetized patients. Anesth Analg 1997;85:667-71.
• 16. Parker CJ, Hunter JM, Snowdon SL. Effect of age, sex and anaesthetic technique on the pharmacokinetics of atracurium. Br JAnaesth 1992;69:439-43
• 17. Xue FS, Zhang YM, Liao X, Liu JH, An G. Influences of age and gender on dose response and time course of effect of atracurium in anesthetized adult patients. J ClinAnesth 1999;11:397-405.
• 18. Alkhazrajy W, Khorasanee AD, Russell WJ. Muscle weakness after muscle relaxants: an audit of clinical practice.Anaesth Intens Care 2004;32:256-9.
• 19. Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997;41:1095- 103.
• 20. Brull Sorin J. Naguib Mohamed, Miller Ronald D. Residual neuromuscular block: Rediscovering the obvious. AnestAnalg 2008; 107:11-14.
• 21. Miller RD, Ward TA. Monitoring and pharmacologic reversal of a nondepolarizing neuromuscular blockade should be routine.AnestAnalg 2010;111:3-5
• 22. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness.AnesthAnalg 2010;111:129-40.
• 23. Viby-Mogensen J. Postoperative residuel curarization and evidence-based anaesthesia. Br J Anaesth 2000;84:301-2.
• 24. Bevan DR, Smith C, Donati F. Postoperative neuromuscular blockade: A comparison between atracurium, vecuronium, and pancuronium. Anesthesiology 1988;69:272-6
• 25. McCaul C, Tobin E, Boylan JF, McShane AJ. Atracurium is associated with postoperative residual curarization. Br JAnaesth 2002; 89:766-9.
• 26. Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermedi