de Menezes Cássio Campelo, Peceguini Lilian Akemi Moore, Silva Enis Donizetti, Simões Claudia Marquez
São Paulo Serviços Médicos de Anestesiologia (SMA), Brazil.
Rev Bras Anestesiol. 2012 Jul;62(4):543-7. doi: 10.1016/S0034-7094(12)70153-8.
Neuromuscular blockers (NMB) have been used for more than half of a century in anesthesia and have always been a challenge for anesthesiologists. Until recently, the reversal of nondepolarizing neuromuscular blockers had only one option: the use of anticholinesterase agents. However, in some situations, such as deep neuromuscular blockade after high doses of relaxant, the use of anticholinesterase agents does not allow adequate reversal of neuromuscular blockade. Recently, sugammadex, a gamma-cyclodextrin, proved to be highly effective for reversal of NMB induced by steroidal agents.
A female patient who underwent an emergency exploratory laparotomy after rapid sequence intubation with rocuronium 1.2mg.kg(-1). At the end of surgery, the patient received neostigmine reversal of NMB. However, neuromuscular junction monitoring did not show the expected recovery, presenting residual paralysis. Sugammadex 2mg.kg(-1) was used and the patient had complete reversal of NMB in just 2 minutes time.
Adequate recovery of residual neuromuscular blockade is required for full control of the pharynx and respiratory functions in order to prevent complications. Adequate recovery can only be obtained by neuromuscular junction monitoring with TOF ratio greater than 0.9. Often, the reversal of NMB with anticholinesterase drugs may not be completely reversed. However, in the absence of objective monitoring this diagnosis is not possible. The case illustrates the diagnosis of residual NMB even after reversal with anticholinesterase agents, resolved with the administration of sugammadex, a safe alternative to reverse the NMB induced by steroidal non-depolarizing agents.
神经肌肉阻滞剂（NMB）在麻醉领域已使用了半个多世纪，一直是麻醉医生面临的一项挑战。直到最近，非去极化神经肌肉阻滞剂的逆转仅有一个选择：使用抗胆碱酯酶药物。然而，在某些情况下，如大剂量肌松药后出现深度神经肌肉阻滞时，使用抗胆碱酯酶药物并不能使神经肌肉阻滞得到充分逆转。最近，γ-环糊精舒更葡糖钠被证明对甾体类药物诱导的神经肌肉阻滞的逆转非常有效。
一名女性患者在快速序贯诱导插管时使用了1.2mg·kg⁻¹罗库溴铵，随后接受了急诊剖腹探查术。手术结束时，患者接受了新斯的明以逆转神经肌肉阻滞。然而，神经肌肉接头监测未显示预期的恢复，仍存在残余麻痹。使用了2mg·kg⁻¹舒更葡糖钠，患者在短短2分钟内神经肌肉阻滞就完全逆转。
为预防并发症，充分恢复残余神经肌肉阻滞对于全面控制咽喉和呼吸功能至关重要。只有通过神经肌肉接头监测且四个成串刺激比值大于0.9才能实现充分恢复。通常，使用抗胆碱酯酶药物逆转神经肌肉阻滞可能无法完全逆转。然而，在缺乏客观监测的情况下，无法做出此诊断。该病例说明了即使在使用抗胆碱酯酶药物逆转后仍存在残余神经肌肉阻滞的诊断情况，使用舒更葡糖钠可解决这一问题，舒更葡糖钠是逆转甾体类非去极化药物诱导的神经肌肉阻滞的一种安全替代药物。
