Perioperative TOF Monitoring and Residual Curarization: Pancuronium Versus Vecuronium<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

郑　晖　　苏　跃　　李明远　　金清尘
ZHENG Hui, SU Yue, LI Mingyuan, et al.
Department of Anesthesiololgy, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149 ,China

Abstract

　　Objective：To investigate the incidence of postoperative residual neuromuscular blockade following the use of pancuronium and vecuronium and the feasibility of reducing the incidence of postoperative residual curarization(PORC) by perioperative TOF monitoring.

Methods：81adults ASA I～II patients (male 46, female 35) undergoing elective surgery under general anesthesia were prospectively randomized to one of the four groups; group V+M: vecuronium with TOF monitoring (n=21). group V: vecuronium without TOF monitoring (n=23), group P+M: pancuronium with TOF monitoring (n=19) and group P: pancuronium without TOF monitoring (n=18). Patients with renal, liver and neuromuscular diseases were excluded. The patients were premedicated with intramuscular pethidine 50mg and promethazine 25mg and subcutaneous atropine 0.5mg. Anesthesia was induced with propofol 2.0-2.5mg/kg, fentanyl 100μg and droperidol 5mg. When the patients lost consciousness TOF was monitored by stimulation of ulnar nerve using acceleromyograph (TOF-Guard, Biometer, Denmark). Then pancuronium or vecuvenium 0.08-0.12mg/kg was given iv and 3min later the patients were intubated and mechanically ventilated. P_ETCO₂ was maintained at 32-38 mmHg. Anesthesia was maintained with inhalation of 50% N₂O and low concentration of islfourand(<0.75%) and  intermittent iv boluses of fentanyl (0.05-0.10

μg/kg). During operation muscle relaxation was maintained with small increments of pancuronium or vecuronium when T₂ ruturned (in group P+M and group V+M) or on clinical evaluation (in group P and group V). At the end of operation neostigmine 0.04mg/kg and atropine 0.02mg/kg were given? when T₂ returned in group P+M and group V+M. In group V and group P the anesthesiologist made the decision if the reversal was necessary. In ICU the incidence and duration of residual neuromuscular blockade were recorded. TOF ratio (T₄/T₁<0.70) was the criterion of residual neuromuscular blockade.
　　Results：The incidence of postoperative residual neuromuscular blockade (T₄/T₁<0.70) was greater in group V (39.13%) and group P(83.33%) than that in group V+M (23.8%) and group P+M (42.11%). The duration of PORC was longer in group V（30.00±15.12）min] and group P[（44.87±31.39）min] than that in group V+M[（11.00±5.48）min] and group P+M[（21.15±11.62）min]. The total dose of pancuronium and vecuronium in group V and P was significantly larger than that in group V+M and P+M.
　　Conclusions：Perioperative TOF monitoring decreases the incidence and duration of PORC following the use of non-depolarizing muscle relaxant.The incidence of PORC is significantly greater and duration longer after pancuonium than vecuronium. It is necessary to antagonize the residual paralysis produced by non-depolarizing muscle relaxant routinely.
　　Key Words：Pancuronium; Vecuronium; Monitoring, intraoperative; Neuromuscular block<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

　　自从Ali^[l] 提出应用四次成串（train-of-four，TOF）刺激监测肌松药的残余作用以来，残余肌松一直是人们关注的课题。长效肌松药（如潘库溴铵）引起的残余肌松发生率显著高于中效肌松药（如维库溴铵、阿曲库铵）^[2-4]。但对于应用TOF监测能否降低残余肌松的发生率，所得结论不尽相同^[5-7]。本文通过应用加速度仪对肌松程度进行监测，以了解TOF监测对残余肌松的影响，旨在探讨安全应用肌松药、减少麻醉并发症的有效方法。

                       资料与方法<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

81例成年人18～61岁，男女比例为46:35，ASAⅠ～Ⅱ级，无肝肾功能不全。全部病例麻醉时间均在90 min以上。所有病例均无神经肌肉疾病，体重在体重标准25%以内。对气管插管困难，或对所用药物过敏或已用影响神经肌肉传导药物的病例均不列入本研究。病人均知情同意。
　　病人术前30min 肌肉注射哌替啶50mg、异丙嗪25 mg，术前15 min皮下注射阿托品0.5 mg。全部病例随机分为维库溴铵监测（V+M）组、维库溴铵未监测（V）组、潘库溴铵监测（P+M）组、潘库溴铵未监测（P）组4组。病人入手术室后建立二条静脉通道。随机固定一侧上肢用于监测神经肌肉功能，刺激电极、温度和加速度传感器均在麻醉前放置于该上肢。麻醉方法为2.0～2.5 mg／kg异丙酚静脉注射，加氟芬合剂4ml，待病人意识消失后启动加速度监测仪（TOF-GUARD，Biometer, Denmark），应用TOF方式刺激尺神经设立对照值，电流强度为60mA,间隔20s。而后静脉注射潘库溴铵或维库溴铵0.08～0.12 mg／kg, 3min后气管插管，行机械通气。呼气末C₂O气压（P_ETCO₂）维持在32～38min Hg(1kPa=7.5mm Hg)。麻醉维持应用50%N₂O、异氟醚（呼气末浓度低于0.75%），间断给予芬太尼（0.05～0.10μm／kg）。P+M组和V+M组在TOF计数（TOF count）出现1～2个颤搐反应时追加肌松药（P+M组0.1～0.2mg/次、V+M组0.2～0.4 mg/次）。P组和V组通过临床反映，如气道压增高，或有自主呼吸或自主运动时追加肌松药。手术结束时停止麻醉。P+M组和V+M组在TOF计数出现1～2个颤搐反映时给予新斯的明0.04 mg／kg、阿托品0.02mg／kg；P组和V组根据临床反映决定是否给予拮抗及剂量。所有病例随机由3名熟练的麻醉科医师完成。神经肌肉功能监测由另一名医师负责。麻醉科医师并不知晓有关检测的参数，只依据通气量、睁眼、握手、抬头5s等临床测试来决定拔管及返回ICU。
　　记录V+M组及P+M组拮抗时、拮抗后5、10、15、20、30、40、50及60min时的TOF率（TOF ratio T₄/T₁）。记录各组病例肌松药总量，在拔管时、出手术室、入ICU时即刻的TOF率，入ICU后残余肌松发生率及残余肌松持续时间。当TOF率<0.70时提示有残余肌松。
　　计量资料以均数±标准差（±s）表示，应用SPSS统计软件包，计量资料行分组t检验，计数资料行x²检验 。P<0.05为有统计学差异。

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