Giải giãn cơ: nên hay không nên?

Giải giãn cơ: nên hay không nên?

Gii gin c sau m: nn hay khng nn? GS.TS Nguyn Quc Knh Khoa GMHS, bv Vit c 1 Gii gin c h thng? Pros Cons Khng cn gii gin c: - Dng thuc gin c tc dng ngn hoc trung bnh - Cc tt lm sng cho thy ht tc dng thuc gin c - H hp: fr, Vt, kh mu: bt Gii gin c: Cn gii gin c:

- Phong b ko di d thuc gin c ngn hoc trung bnh - Cc tt lm sng: Sn, Sp km nn khng tin cy - T l gin c tn d cao gy bin chng h hp Gii gin c: - Phi i phc hi TOF - - Tc dng khng mong mun - Cha chc ht gin c tn d - Tn thm tin - Khng hoc c th gii gin c su Khng hoc c tc dng khng mong mun Ht gin c tn d nu TOF > 0,9 Cn xem xt benefit/Cost 2 Xc nh gin c tn d sau m

nh ngha: - in sinh l: Cn mt t l chim RAch hu synap c vn giai on sau m - Lm sng: Cn du hiu phong b thn kinh c sau m Chn on: - Gold standard: T4/T1 < 0.9 (trc 1990: < 0.7) 3 nh gi lm sng Du hiu tin cy ca dn truyn thn kinh c y : Nng u (Head lift) x 5 s Nhc chn (Leg lift) x 5 s Nm tay mnh nh trc m x 5 s Cn

Nh canule ming Du hiu c ch nhng khng tin cy Bnh thng v Vt , Vc + ho Savarese JJ, Caldwell JE, Lien CA, Miller RD: 2000 Gi tr chn on ca tt nng u n =186 TOF < 0,7 TOF < 0,9 nhy (%) 19 11 c hiu (%) 85

87 Gi tr tin lng + (%) 19 53 Gi tr tin lng - (%) 85 58 DEBAENE B. Anesthesiology 2003 ; 98 : 1024-8 5 Khng cn gin c tn d c khng nh bi T4 / T1 90 %. Khng monitoring = Khng chc chn loi tr gin c tn d 100

Rocuronium 0,6 mg/kg T1 (%control) 75 Laryngeal muscles 50 Corrugator supercilii 25 Adductor pollicis 0 0 5 10 15 20 25

30 35 40 45 50 Time (min) 6 Mt s nghin cu VN Nguyn Tt Nghim v CS: Rocuronium: TOF < 0,7: 12,5% BN khi rt NKQ & 2,5% sau 30 pht TOF < 0,9: 37,5% .. & 26,3% Hong Vn Khi: Panc, pipec, vec: > 50% c TOF < 0,7 ti P. hi tnh Nguyn Th Minh Thu: - TOF < 0,9 c yu t nguy c: 50 tui, T 0 < 350C, Hb < 10g/dl - Neostigmin: HR 16 CK/min, m ri 18%, PONV 15,3%.

8 Gin c tn d sau mt liu trung bnh t NKQ 1 70 TOF < 0.7 60 ,9 ,8 TOF < 0.9 ,7 TOF ratio 50 40 % bnh

nhn 30 20 ,6 ,5 ,4 ,3 ,2 10 ,1 0 0 < 60 [60-90] [90-120] > 120 min

0 50 100 150 200 250 300 350 400 time (min) Thi gian t lc tim n lc vo phng hi tnh (min) DEBAENE B. Anesthesiology 2003 ; 98 : 1042-8 9

Hu qu ca gin c tn d p ng thng kh vi thiu oxy mu Ri lon chc nng c thanh qun v c tht trn thc qun. Tro ngc Sc phi nguy c bin chng h hp sau m . 10 p ng thng kh vi thiu oxy mu % /% valeur gi tr contrle chng 100 Volume courant Th tch lu thng

Thng khminute pht Volume * chng * 50 * 0 Contrle Chng TdQ > 0,70 TOF 0.7 TdQ TOF >> 0,90 0.9 ERIKSSON LI Acta Anaesthesiol Scand 1992 ; 36 : 710-5

11 Khng gii c hon ton mc phong b gin c su Neostigmin gy phong b gin c kh cc Ri lon chc nng c gin (dilator muscle) ng th trn = tc ng th trn sau m Ri lon chc nng c hu hng Ghi hnh v ghi in c cc c hu hng Thi gian phc hi phn x nut Trng lc c tht trn thc qun 120

mmHg 150 100 * * 80 100 50 ms * * * 60 *

40 20 0 0 TOF 0,60 TOF 0,70 TOF 0,80 TOF > 0,90 Contrle Trung bnh cng ; * p < 0,05 14 ngi tnh nguyn, vecuronium ERIKSSON LI. Anesthesiology 1997 ; 7 : 1035-43 TOF 0,60 TOF 0,70

TOF 0,80 TOF > 0,90 Contrle Trung v ; * p < 0,03 20 ngi tnh nguyn, atracurium SUNDMAN E. Anesthesiology 2000 ; 92 : 977-84 13 Gin c tn d: Bin chng h hp sau m Pancuronium (n = 226) S BN Atracurium v Vecuronium (n = 450) BCHH sau m n %

S BN BCHH sau m n % TOF 0,70 167 8 4,8 426 23 5,4 TOF < 0,70 59 10

16,9 * 24 1 4,2 * p < 0,02 so vi cc bnh nhn cng nhm c TOF 0,7 BCHH sau m : Bin chng h hp sau m. BERG H. Acta Anaesthesiol Scand 1997 ; 41 : 1095-1 14 Thuc gii gin c l tng Thi gian khi pht nhanh Tc dng iu tr nhanh Tc dng ph ti thiu:

c bit tc dng cholinergic ti thiu cho php trnh dng cc thuc khng h muscarinic. Khng tch ly t chc C kh nng nhanh chng gii phong b c su Hiu qu ngay c khi c mt thuc m bay hi Booij LHDJ. Pharm World Sci. 1997; 19:112 15 Gii gin c Mc ch: Nhanh t T4/T1 > 0,9 Concensus 1990 (SFAR): Khuyn co dng thuc

gii gin c nu khng khng nh c ht phong b c hon ton Thc hnh lm sng M: Nu khng c bng chng cn phong b c + 4 na i sng ca thuc: khng gii gin c Nu vn cn bng chng phong b c: dng thuc gii gin cl Nu khng chc chn: dng thuc gii gin c 16 T1/2 loi tr, t 1/2 # of T1/2 % cn li % c loi tr

0 100 0 1 50 50 2 25 75 3 12.5 87.5 4

6.25 93.75 Time for conc to decrease by 1/2 Gim gin c tn d BAILLARD C. BJA 2005 ; 95 : 622-6 Cc yu t kt hp vi t l bin chng t vong Cc yu t OR Check list (bng kim) 0,61 Cng kp 0,44 + Y t gy m

0,41 Dng gii gin c 0,10 ARBOUS MS. Anesthesiology 2005 ; 102 : 257-68 18 0 p ng: gin c su 1-3: gin c ch 4: gin c thiu thm mc gin c mong mun mc gin c t c trong thc t bng thuc gin c ri bng gii gin c Thay i nhu cu gin c. Mc gin c tng dn t trn xung di vi cc gi tr twicht (T1) v t l chui bn (TOF). Donati F, Asean Journal of Anaesthesiology, p 18-22. 19 nh ngha giai on gii gin c Giai on gii gin c Khi u 25% ht gin c T1 (4 p ng vi TOF)

Kt thc? Ht gin c hon ton = T4/T1 > 0.9 ngn ci = Ht gin c tn d cc c ng h hp trn v c honh (v c khp ngn ci nhy hn) 21 iu kin gii gin c TOF (chui 4 p ng) Tc dng di (Pan, Pipe) Tc dng trung bnh (Roc, Vecu, Atra) c khp ngn ci Mc phong b t nhin cha nng gii gin c 0-3 p ng - Khng c dng gii gin c 0-1 p ng C th gii gin c

4 p ng 2 p ng Liu: Neostigmine + Atropine 40 mcg/kg + 15 mcg/kg 40 mcg/kg + 15 mcg/kg - Nu khng c TOF: i bt u ht tc dng gin c r rng (test nhc u, nhc chn, nh canule ming, ) 22 Anticholinesterases: neostigmine Neostigmine + glycopyrrolate t l 5/1 Hi phc hon ton khi dng 10-20 min trc

khi rt NKQ TOF count (2-) 4 Liu neostigmine cn c iu chnh theo mc hi phc: <<< 70 g/kg Type of monitoring nh tnh 2 - 3 twitches T4 with fade T4 without fade nh lng 2 - 3 twitches TOF ratio < 0,4 TOF ratio 0,4-0,9 TOF raio > 0,9 Liu neostigmin Cn nng l tng 50 g/kg 40 g/kg 20 g/kg Khng dng AchR nicotinic hu sinap 24

C ch tc dng ca khng cholinesterase (Neostigmin) Neostigmin gn vo enzym acetylchoninesterase: Ngn khng cho Ach gn vo enzym ny Bt hot enzym ny c ch enzym acetylchoninesterase Tng lng Ach khe sinp tng Ach n hot ho receptor t do hu sinp. 25 c im gii gin c ca Neostigmine Onset: (T2), lu 10-15 pht 90% s BN cn gin c tn d luc rt NKQ (11 7 pht sau tim) Tc dng trn: V ch nu tng liu cho gin c su hoc gii nhanh (40 mcg/kg Neos + 15 mcg/kg Atropin) Khng hiu qu khi dng gin c su

Yu t gy gim hiu qu gii gin c: Toan h hp, kim chuyn ho, h Ca++, h T0, halogen Gii gin c khi khng c gin c tn d: gy phong b thn kinh c (gii mn cm AchR?) 26 Chng ch nh ca neostigmine & Tc dng khng mong mun Chng ch nh (rt him): ri lon nhp hoc dn truyn, tng hot tnh ph qun Nn v bun nn sau m: 2 pha (bo v nu liu thp < 2 mg, nguy c nu liu cao hn) Neostigmin v bc r ming ni tiu ho? 1018 BN ct i trc trng vi 811 ming ni, bc r 3.8% 3 yu t nguy c bc r ming ni: ASA 3, m >3 h, bnh ti trc trng (OR =2.3; 3 & 3.75). Buchs NC et al, Int J Colorectal Dis 2008 27 Tc dng khng mong mun

Tc dng neostigmin ln muscarinic: Tc dng Acetylcholin ln h muscarinic - chm nhp tim, tt huyt p, - co tht ph qun, tng m ri Cn dng thuc khng muscarinic (atropine & glycopyrrolate) - mch nhnh - kh ming - ri lon nhn - b tiu - lon thn sau m 28 Tc dng ca neostigmin Cisatracurium

Rocuronium TOF 5 min (%) 0,49 0,11 0,61 0,14 TOF 10 min (%) 0,72 0,10 0,76 0,11 TOF < 70 10 min (n) 9 9 TOF < 90 30 min (n) 2 5

neostigmine 50 mcg/kg ; n = 30/nhm KOPMAN AF. Anesth Analg 2004 ; 98 : 102-6 29 % s bnh nhn (TOF < 0,8) Loi thuc gin c: Din bin ca TOF sau khi gii gin c Pancuronium 50 40 Atracurium Vcuronium 30 20 10 0 0 5 10 15 20

30 40 50 Thi gian (min) sau ln o u tin BERG H. Acta Anaesthesiol Scand 1997 ; 41 : 1095-1103 30 Halogen nh hng n D50 ca Rocuronium 31 Tc dng ca halogen trn gii gin c TOF (%) 15 min sau neostigmine Sev duy tr TOF (%) TOF (%) ngng Sev 65,2 2,5 89,5 1,8 Iso duy tr

Ngng Iso 72,3 1,6 89,4 1,8 Vecuronium = 0,1 mg/kg ; n = 48/nhm ; trung binh SD Neostigmine = 40-55 mcg/kg ; T1 = 10% MORITA T. Anesth Analg 1995 MAC < 0.2 trc khi gii gin c ? 32 H thn nhit nh hng n gii gin c n Thi gian tc dng ca Vecuronium ng nhit 10 [24-36] H thn nhit 10

[45-74] TH 25-75 T 8-20 Neost T Neost 2-4 24-74* 2-4 T1 10% TOF = 75% 13-52 7-14 41-105 7-35* * : ng nhit (p < 0,05) Vecuronium = 0,1 mg/kg ; Neostigmin 40 mcg/kg ; T1 = 10% H thn nhit = 34,50C HEIER T. Anesthesiology 1991 ; 74 : 815-19 33 Neostigmin, th nhng, ..

Sugammadex Bom A et al. Angew Chem Int Ed Engl. 2002; 41:266270 35 Suggamadex (Org 25969): Cch an ton nht gii gin c Roc = + Org 25969 - cyclodextrin Bao bc roc, vec (dn xut steroides) Thc y phn b rocuronium ra khi AchR Khng ti gin c Gijsenbergh et al. Anesthesiology 2005;103:695

Sugammadex kh phong b thn kinh c: T4/T1 > 0,9: Roc + Sug: 13 ln nhanh hn Roc + Neostig Vec + Sug: 7 ln nhanh hn Vec + Neostigm Roc + Sug: 4 ln nhanh hn Cisatr + Neostig Ngay c gin c su Phc hi hon ton Nhanh: t Gijsenbergh F et al. Anesthesiology. 2005; 103:695703 37 Neostigmine hay Sugammadex? La nostigmine a-t-elle encore une place en 2009? (Neostigmin cn c vai tr nm 2009?) B. Plaud, J. Marty - D cn hn ch, neostigmin vn c vai tr, ch yu gii gin c khng kh cc loi benzylisoquinoleines: atra & cisatracurium - Sugammadex s ch c dng cho gin c khng kh cc loi steroides:

rocuronium & vecuronium. 38 Tnh chn lc v i tnh gn vi thuc gin c Neostigmin Ch c hiu qu gii atracurium v cisatracurium Liu qu t: 40% BN b gin c tn d Liu qu nhiu (> 60 g/kg): tng nguy c bin chng h hp sau m Liu (< 60 g/kg): liu ph hp vi phong b (TOF count 2+ p ng) Sugamamadex Nhanh t tc dng nh: khng b

gin c tn d khi ng liu Khng c tc dng muscarinic: khng cn thuc i khng muscarimic C kh nng i khng mc phong b su ca ro/vecuronium Cc tnh trng bnh khi quan ngi dng thuc gin c Gii hon ton cc thuc i khng tranh chp tm vn ng bng sugamamadex c th nh hng kt cc h hp ca bnh nhn KT LUN Gii gin c nn c tin hnh h thng tr khi c chng ch nh Sugammadex khc phc c mt s nhc im ca Neostigmin v nn c dng cho mt s tnh hung ring Neostigmin vn cn vai tr gii gin c, c bit nhm benzylisoquinoleines 40

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