From the Service d'anesthésie-réanimation, CHU de Poitiers (MLM, DF, MD, BD, MB), Université de Poitiers, UFR Médecine-Pharmacie, Poitiers (DF, BD, MB), Inserm U1246, SPHERE, Methods in Patients-Centered Outcomes and Health Research, Nantes (DF) and Inserm U1070, Pôle Biologie Santé, Poitiers, France (MB).
Eur J Anaesthesiol. 2020 Jan;37(1):38-43. doi: 10.1097/EJA.0000000000001090.
Neuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative.
The aim of our study was to compare NMB onset and recovery at both sites.
Prospective observational study.
Operating rooms at the University Hospital of Poitiers, France.
Sixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia.
After atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously.
The time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF = 4, T4/T1 ratio = 0.75 and T4/T1 ratio more than 0.90.
NMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4 ± 1.5 versus 3.7 ± 1.2 min at adductor pollicis (P = 0.0001). Recovery to TOF = 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF = 4. The full recovery of NMB (T4/T1 > 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ± 9.9 versus 64.5 ± 10.7 min at adductor pollicis (P < 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0 ± 12.2 min at flexor hallucis brevis versus 54.0 ± 12.4 min at adductor pollicis (P = 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients.
Flexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis.
ClinicalTrials.gov (NCT02825121).
神经肌肉阻滞(NMB)监测对于避免残留的 NMB 至关重要。虽然内收肌是监测恢复的推荐部位,但并非总是可及的。短屈肌可能是一个有趣的替代部位。
本研究旨在比较两个部位的 NMB 起始和恢复情况。
前瞻性观察性研究。
法国普瓦捷大学医院的手术室。
2016 年 1 月至 2017 年 9 月期间,共有 60 名接受全身麻醉和神经肌肉阻滞剂手术的患者入选。最终对 56 名患者的数据进行了分析。其中,11 名患者在麻醉苏醒前接受新斯的明和阿托品的药物逆转。
在注射阿曲库铵后,同时监测内收肌和短屈肌的 NMB 起始和恢复。
NMB 起始时间,定义为四个成串刺激(TOF)计数等于 0 的时间,以及 NMB 恢复时间:TOF=1、TOF=4、T4/T1 比值=0.75 和 T4/T1 比值大于 0.90。
短屈肌的 NMB 起始明显较慢,平均起始时间为 4.4±1.5 分钟,而内收肌为 3.7±1.2 分钟(P=0.0001)。短屈肌恢复到 TOF=1 的速度明显较慢。TOF=4 无差异。短屈肌的 NMB 完全恢复(T4/T1>0.90)明显较快,平均恢复时间为 59.5±9.9 分钟,而内收肌为 64.5±10.7 分钟(P<0.0001),两个部位之间相差 4.9 分钟。在药物逆转后,这种差异并不存在,短屈肌的平均恢复时间为 53.0±12.2 分钟,内收肌为 54.0±12.4 分钟(P=0.28)。然而,在个体患者中,NMB 的起始和恢复并不遵循相同的模式。
在内收肌不可用时,短屈肌可能是监测 NMB 的一个有趣替代部位。然而,在没有药物逆转的情况下,应谨慎使用短屈肌监测来检测残留的瘫痪。
ClinicalTrials.gov(NCT02825121)。