围术期TOF监测与残余肌松潘库溴铵与维库溴铵的比较

目的研究潘库溴铵与维库溴铵术后残余肌松发生率,探讨围术期应用TOF监测降低术后残余肌松发生率的可行性.方法81例ASAⅠ～Ⅱ级成年择期手术病人,随机分为维库溴铵监测(V+M)组;维库溴铵未监测(V)组;潘库溴铵监测(P+M)组及潘库溴铵未监测(P)组4组.麻醉方法为静脉注射2.0～2.5mg/kg异丙酚,潘库溴铵或维库溴铵0.08～0.12mg/kg,3min后气管插管,麻醉维持应用50%N2O、异氟醚,间断给予芬太尼.使用TOF-GUARD监测仪监测肌松.P+M组和V+M组在TOF计数出现1～2个颤搐反应时给新斯的明0.04mg@kg-1、阿托品0.02mg@kg-1.拮抗;P组和V组根据临床反应判断是否给予拮抗及剂量.观察各组病人到ICU后残余肌松发生率(T4/T1＜0.70)及持续时间.结果4组病人到ICU后残余肌松发生率分别为V+M组23.80%、V组39.13%、P+M组42.11%、P组83.33%,P组残余肌松发生率显著高于V组(P＜0.01),而且监测组残余肌松发生率显著低于未监测组(P＜0.05).4组残余肌松持续时间分别为V+M组(11.11±5.48)min、V组(30.00±15.12)min、P+M组(21.15±11.62)min、P组(44.87±31.39)min,未监测组明显长于监测组(P＜0.05).未监测组潘库溴铵及维库溴铵总的用药量分别大于监测组(P＜0.05).结论1.围术期TOF监测可明显降低残余肌松发生率;2.潘库溴铵残余肌松发生率及持续时间均显著高于维库溴铵,在无神经肌肉功能监测的情况下,应用潘库溴铵应严加注意;3.应用非去极化肌松药阻滞后进行术后肌松拮抗是必要的.

Perioperative TOF monitoring and residual curarization: pancuronium versus vecuronium

Objective To investigate the incidence of postoperative residual neuromuscular blockade following the use of pancuronium and vecuronium and the feasibility of reducing the incidence of postoperative residual curarization(PORC) by perioperative TOF monitoring. Methods 81 adults ASA I -Ⅱ patients(male 46, female 35) undergoing elective surgery under general anesthesia were prospectively randomized to one of the four groups: group V+ M:vecuronium with TOF monitoring( n = 21 ), group V:vecuronium without TOF monitoring( n = 23), group P + M: pancuronium with TOF monitoring( n = 19)and group P: pancuronium without TOF monitoring( n = 18). Patients with renal, liver and neuromuscular diseases were excluded. The patients were premedicated with intramuscular pethidine 50mg and promethazine 25mg and subcutaneous atropine 0.5mg. Anesthesia was induced with propofol 2.0-2.5mg/kg, fentanyl 100μg and droperidol 5mg. When the patients lost consciousness TOF was monitored by stimulation of ulnar nerve using acceleromyograph(TOF-Guard, Biometer, Denmark). Then pancuronium or vecuvenium 0.08-0.12mg/kg was given iv and 3min later the patients were intubated and mechanically ventilated. PET CO2 was maintained at 32-38mmHg. Anesthesia was maintained with inhalation of 50% N2O and low concentration of isoflurane( ＜ 0.75 % ) and intermittent iv boluses of fentanyl(0.05-0.10μg/kg). During operation muscle relaxation was maintained with small increments of pancuronium or vecuronium when T2 returned(in group P + M and group V + M) or on clinical evaluation(in group P and group V). At the end of operation neostigmine 0.04mg/kg and atropine 0.02mg/kg were given iv when T2returned in group P + M and group V + M. In group V and group P the anesthesiologist made the decision if the reversal was necessary. In ICU the incidence and duration of residual neuromuscular blockade were recorded. TOF ratio(T4/T1 )＜ 0.70 was the criterion of residual neuromuscular blockade. Results The incidence of postoperative residual neuromuscular blockade (T4/T1 ＜ 0.70) was greater in group V (39.13%) and group P(83.33%) than that in group V+ M(23.8%) and group P+ M (42.11%). The duration of PORC was longer in group V (30.00 + 15.12)min] and group P (44.87 + 31.39)min] than that in group V+ M(11.00+5.48)min] and group P+M(21.15+ 11.62)min]. The total dose of pancuronium and vecuronium in group V and P was significantly larger than that in group V + M and P +M. Conclusions Perioperative TOF monitoring decreases the incidence and duration of PORC following the use of non-depolarizing muscle relaxant. The incidence of PORC is significantly greater and duration longer after pancuronium than vecuronium. It is necessary to antagonize the residual paralysis produced by non-depolarizing muscle relaxant routinely.