利用临床测试开发一种算法以避免术后残余神经肌肉阻滞。
Development of an algorithm using clinical tests to avoid post-operative residual neuromuscular block.
作者信息
Unterbuchner Christoph, Blobner Manfred, Pühringer Friedrich, Janda Matthias, Bischoff Sebastian, Bein Berthold, Schmidt Annette, Ulm Kurt, Pithamitsis Viktor, Fink Heidrun
机构信息
Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany.
Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauss-Allee, 11 93051, Regensburg, Germany.
出版信息
BMC Anesthesiol. 2017 Aug 4;17(1):101. doi: 10.1186/s12871-017-0393-4.
BACKGROUND
Quantitative neuromuscular monitoring is the gold standard to detect postoperative residual curarization (PORC). Many anesthesiologists, however, use insensitive, qualitative neuromuscular monitoring or unreliable, clinical tests. Goal of this multicentre, prospective, double-blinded, assessor controlled study was to develop an algorithm of muscle function tests to identify PORC.
METHODS
After extubation a blinded anesthetist performed eight clinical tests in 165 patients. Test results were correlated to calibrated electromyography train-of-four (TOF) ratio and to a postoperatively applied uncalibrated acceleromyography. A classification and regression tree (CART) was calculated developing the algorithm to identify PORC. This was validated against uncalibrated acceleromyography and tactile judgement of TOF fading in separate 100 patients.
RESULTS
After eliminating three tests with poor correlation, a model with four tests (r = 0.844) and uncalibrated acceleromyography (r = 0.873) were correlated to electromyographical TOF-values without losing quality of prediction. CART analysis showed that three consecutively performed tests (arm lift, head lift and swallowing or eye opening) can predict electromyographical TOF. Prediction coefficients reveal an advantage of the uncalibrated acceleromyography in terms of specificity to identify the EMG measured train-of-four ratio < 0.7 (100% vs. 42.9%) and <0.9 (89.7% vs. 34.5%) compared to the algorithm. However, due to the high sensitivity of the algorithm (100% vs. 94.4%), the risk to overlook an awake patient with a train-of-four ratio < 0.7 was minimal. Tactile judgement of TOF fading showed poorest sensitivity and specifity at train of four ratio < 0.9 (33.7%, 0%) and <0.7 (18.8%, 16.7%).
CONCLUSIONS
Residual neuromuscular blockade can be detected by uncalibrated acceleromyography and if not available by a pathway of four clinical muscle function tests in awake patients. The algorithm has a discriminative power comparable to uncalibrated AMG within TOF-values >0.7 and <0.3.
TRIAL REGISTRATION
Clinical Trials.gov (principal investigator's name: CU, and identifier: NCT03219138) on July 8, 2017.
背景
定量神经肌肉监测是检测术后残余肌松（PORC）的金标准。然而，许多麻醉医生使用的是不敏感的定性神经肌肉监测方法或不可靠的临床检查。这项多中心、前瞻性、双盲、评估者对照研究的目的是开发一种肌肉功能测试算法以识别PORC。
方法
拔管后，一名不知情的麻醉医生对165例患者进行了八项临床检查。将检查结果与校准后的肌电图四个成串刺激（TOF）比值以及术后应用的未校准加速度肌电图进行相关性分析。计算分类回归树（CART）以开发识别PORC的算法。在另外100例患者中，将该算法与未校准加速度肌电图和TOF消退的触觉判断进行验证。
结果
在剔除三项相关性较差的检查后，包含四项检查的模型（r = 0.844）和未校准加速度肌电图（r = 0.873）与肌电图TOF值相关，且不损失预测质量。CART分析表明，连续进行的三项检查（手臂抬起、抬头和吞咽或睁眼）可预测肌电图TOF。预测系数显示，与该算法相比，未校准加速度肌电图在识别肌电图测量的四个成串刺激比值<0.7（100%对42.9%）和<0.9（89.7%对34.5%）时具有更高的特异性优势。然而，由于该算法具有较高的敏感性（100%对94.4%），漏诊四个成串刺激比值<0.7的清醒患者的风险极小。在四个成串刺激比值<0.9（33.7%，0%）和<0.7（18.8%，16.7%）时，TOF消退的触觉判断显示出最差的敏感性和特异性。
结论
未校准加速度肌电图可检测残余神经肌肉阻滞，若无法进行该检查，清醒患者可通过四项临床肌肉功能测试途径进行检测。在TOF值>0.7和<0.3范围内，该算法具有与未校准加速度肌电图相当的鉴别能力。
试验注册
2017年7月8日在ClinicalTrials.gov（主要研究者姓名：CU，标识符：NCT03219138）注册。
Zotero 插件