Klinička procena neuromišićne blokade intraoperativnim neurofiziološkim monitoringom

Abstract

Ciljevi: U kliničkoj praksi se rutinski upotrebljava vizuelna metoda evaluacije TOF testa, koja ne pruža u potpunosti precizne podatke u periodu oporavka neuromišićne blockade. Neophodno je ispitati mogućnost upotrebe specifičnije i preciznije metode u TOF monitoring, kao što je kvantitativna TOF metoda. Određivanje razlike između vrednosti T1 i T4 mišićnih kontrakcija, dobijenih kvantitativnom TOF metodom, može biti precizan pokazatelj prisustva neuromišićne blokade na testiranom mišiću. Takođe, aplikacijom kvantitativne TOF metode, neophodno je utvrditi da li kod različitih mišića postoji različit period oporavka od prisustva neuromišićne blokade. Upotreba kvantitativne TOF metode, i poređenje T4 / T1 odnosa između različitih mišića, može biti pokazatelj postojanja razlika u oporavku od prisustva neuromišićne blokade. Materijal i metode: U istraživanju je analiziran oporavak od prisustva neromišićne blokade na m.abductor hallucis i m. interosseus dorsalis primus aplikacijom kvantitativnog TOF testa u toku ortopedskih hirurških procedura na kičmenom stubu uz upotrebu intraoperativnog neurofiziološkog monitoring kod 147 bolesnika. T4/T1 odnos je određen na testiranom mišiću stopala i šake, obavljena je klasifikacija ispitanika u odnosu na dozu neuromišićnog blokatora i proteklo vreme od apilikacije. Poređenjem T4/T1 odnosa između testiranih mišića utvrđene su razlike u oporavku od prisustva neuromišićne blokade. Vizuelnom TOF metodom je vršena procena neuromišićne blokade od strane anesteziologa, stimulacijom n.ulnaris i praćenjem kontrakcije m.adductor pollicis. Rezultati dobijeni vizuelnom TOF metodom su upoređeni sa rezultatima dobijenim kvantitativnom TOF metodom na m. interosseus dorsalis primus. Rezultati: Postoje značajne razlike u T4/T1 odnosu između testiranih mišića na stopalu i šaci (p<0.05). T4/T1 odnos određen na m.abductor hallucis ima niže vrednosti, odnosno brži oporavak, u odnosu na m. interosseus dorsalis primus (p<0.05). Kvantitativnom TOF metodom dobijeni su pouzdani rezultati o proceni neuromišićne blokade kod svih testiranih bolesnika, dok su vizuelnom TOF metodom dobijeni kod 40 % testiranih bolesnika. Rezultati pokazuju da postoje značajne razlike u pouzdanosti i preciznosti između kvantitativne i vizuelne TOF metode. Zaključak: Kvantitativna TOF metoda je klinički prihvatljiva i pouzdana metoda u proceni prisustva neuromišićne blokade. Razlike u oporavku od neuromišićne blokade uočene kod različitih mišića, ukazuju da je TOF monitoring neophodan na određenoj mišićnoj regiji koja pruža pouzdane i precizne podatke o neuromišićnoj blokadi regije na kojoj se hirurška procedura obavlja. Kvantitativna TOF metoda pruža preciznije podatke o stepenu prisustva neuromišićne blokade u odnosu na vizuelnu subjektivnu TOF metodu.

Purpose: In clinical practice routinely used method of TOF test is visual method of interpretation. This method does not provide completely reliable data in period of spontaneous recovery from neuromuscular blockade. It is necessary to investigate possibility of application of more specific and more accurate method in TOF monitoring, such as quantitative TOF method. Determination of difference between the values of T1 and T4 muscle contraction, obtained by quantitative TOF method, may indicate the presence of neuromuscular blockade on tested muscle. In addition to this, by application of quantitative TOF method, it is necessary to determine is there a difference in period of recovery from neuromuscular blockade between defferent muscles. Comparison of T4/T1 ratios between different muscles may indicate presence of different period of recovery from neuromuscular blockade. Methods: Study analyzed differences between recovery of foot - abductor hallucis muscle and hand - first dorsal interosseous muscle by application of quantitative TOF test on 147 patients undergoing lumbar spine surgery. T1 to T4 decrements on hand and foot TOF were determined and classified into different groups, depending of neuromuscular blocking agents (NMBA) dose and elapsed time after administration. T1 - T4 decrements were compared between hand and foot TOF and differences between muscle recovery were determined. Visual method of TOF test was performed by anesthesiologists, by using peripheral nerve stimulator and stimulating ulnar nerve. Quantitative TOF test was measured on first dorsal interosseous muscle, and compared with visual TOF results obtained on adductor pollicis muscle. Results: There are significant differences between T1 - T4 decrements obtained on tested muscles of hand and foot (p<0.05). T1-T4 decrement determined on abductor hallucis muscle had lower values, respectively more rapid recovery, than first dorsal interosseous muscle (p<0.05). Quantitative method of TOF test had reliable and correct results in all tested subjects, while visual interpretation of TOF method showed accurate results in 40 % of all cases. Results indicated that significant difference was present between quantitative and visual method of TOF interpretation. Conclusions: Difference between observed recovery of hand and foot muscles is indicating that quantitative TOF test should be performed on specific site for which accurate data about the level of neuromuscular blockade is needed. During lumbar spine surgery, in addition to hand TOF, foot TOF should be included as it provides more accurate data needed for neurophysiological intraoperative monitoring. Quantitative TOF method provides more accurate data about level of neuromuscular blockade if compared with subjective visual TOF method.