Unterbuchner C, Ehehalt K, Graf B
Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
Anaesthesist. 2019 Nov;68(11):744-754. doi: 10.1007/s00101-019-00677-6.
Postoperative residual neuromuscular block (train of four ratio <0.9) is an outcome-relevant problem in balanced anesthesia, which increases postoperative morbidity and mortality. Implementation of medium and short-acting muscle relaxants, quantitative neuromuscular monitoring and pharmacological reversal of muscle relaxation reduce the incidence of residual neuromuscular block. The question arises whether this is suitable to create a pragmatic algorithm integrating these three individual methods to reduce paralysis-associated complications?
A selective literature search was carried out in PubMed and guidelines of national specialist societies were searched using special terms.
The incidence of residual neuromuscular block varied among the studies but was as high as 93%. Using calibrated acceleromyography it is possible to identify a residual relaxation with a negative predictive value of 97% (95% confidence interval, CI 83-100%). Reversal by administration of the acetylcholinesterase inhibitor neostigmine reduces the incidence of residual neuromuscular block to 15.4%, in combination with calibrated acceleromyography to 3.3%. Reversal with sugammadex can nearly completely eliminate residual neuromuscular block. Quantitative neuromuscular monitoring and pharmacological reversal can be suitably integrated into a stage-based, pragmatic treatment algorithm.
The algorithm-based concept of quantitative neuromuscular monitoring and pharmacological reversal using neostigmine and sugammadex enables residual neuromuscular block to be treated within 10 min before extubation of the patient. Ongoing educational programs are essential for implementation of modern muscle relaxant management concepts. Quantitative neuromuscular monitoring should be mandatory for all patients receiving neuromuscular blocking drugs. It would be desirable that German-speaking societies for anesthesiology make appropriate recommendations in guidelines.
术后残余肌松（四个成串刺激比值<0.9）是平衡麻醉中一个与预后相关的问题，会增加术后发病率和死亡率。使用中短效肌肉松弛剂、定量神经肌肉监测以及肌肉松弛的药物逆转可降低残余肌松的发生率。问题在于，将这三种单独方法整合为一种实用算法以减少与麻痹相关的并发症是否合适？
在PubMed中进行了选择性文献检索，并使用特定术语搜索了国家专业学会的指南。
各研究中残余肌松的发生率有所不同，但高达93%。使用校准的加速度肌电图能够识别残余肌松，其阴性预测值为97%（95%置信区间，CI 83 - 100%）。给予乙酰胆碱酯酶抑制剂新斯的明进行逆转可将残余肌松的发生率降至15.4%，联合校准的加速度肌电图则降至3.3%。使用舒更葡糖进行逆转几乎可完全消除残余肌松。定量神经肌肉监测和药物逆转可适当地整合到基于阶段的实用治疗算法中。
基于算法的定量神经肌肉监测以及使用新斯的明和舒更葡糖进行药物逆转的概念，能够在患者拔管前10分钟内治疗残余肌松。持续的教育项目对于实施现代肌肉松弛剂管理概念至关重要。对于所有接受神经肌肉阻滞药物的患者，定量神经肌肉监测应成为强制性操作。希望德语区麻醉学会能在指南中提出适当建议。
