Govindarajan Ramasamy, Shah Ajay, Reddy Vemuru Sunil, Parithivel Vellore, Ravikumar Saiganesh, Livingstone Dave
Department of Anesthesia (A division of North American Partners in Anesthesia), Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, USA.
Department of Surgery, Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, USA.
J Clin Med Res. 2015 Apr;7(4):282-5. doi: 10.14740/jocmr2025w. Epub 2015 Feb 9.
Intra-operative nerve monitoring (IONM) is rapidly becoming a standard of care in many institutions across the country. In the absence of neuromuscular blocking agents to facilitate the IONM, the depth of anesthesia required to abolish the laryngo tracheal reflexes often results in profound hemodynamic instability during surgery, necessitating the use of large doses of sympathomimetic amines. The excessive alpha and beta adrenergic effects exhibited by these agents are undesirable in the presence of cardiovascular co-morbidities. Trying to strike a balance frequently results in an unsatisfactory intra-operative course. In the course of the near total thyroidectomy performed on a 60-year-old female, we employed lidocaine infusion at 1.5 mg/kg/hour following a bolus dose of 1 mg/kg. The troublesome laryngo tracheal reflexes were successfully blunted and we were able to moderate the depth of anesthesia resulting in stable hemodynamics. A bispectral index monitor was employed to guard against "recall" and a train of four monitor was used to ensure the absence of inadvertent neuromuscular blockade. During the surgery, there was loss of signal on the left recurrent laryngeal nerve (RLN). The signal strength was restored by rotating the endotracheal tube on its long axis to realign the electrode with the vocal cords under Glidescope(®) visualization.
术中神经监测（IONM）在全国许多机构正迅速成为一种标准的治疗手段。在没有神经肌肉阻滞剂以促进IONM的情况下，消除喉气管反射所需的麻醉深度常常会导致手术期间严重的血流动力学不稳定，因此需要使用大剂量的拟交感神经胺。在存在心血管合并症的情况下，这些药物表现出的过度α和β肾上腺素能效应是不理想的。试图达到平衡常常会导致不满意的术中过程。在对一名60岁女性进行近全甲状腺切除术的过程中，我们在给予1mg/kg的负荷剂量后，以1.5mg/（kg·小时）的速度输注利多卡因。令人烦恼的喉气管反射成功得到抑制，我们能够调整麻醉深度，从而使血流动力学保持稳定。使用脑电双频指数监测仪防止“术中知晓”，并使用四个成串刺激监测仪确保没有意外的神经肌肉阻滞。手术过程中，左侧喉返神经（RLN）出现信号丢失。通过在Glidescope（®）可视化下沿气管导管的长轴旋转导管，使电极与声带重新对齐，信号强度得以恢复。
