Cemal ELMAS, Yasemin ELMAS, Ertan ÖZTÜRK

Laringeal maske ile pozitif basınçlı ventilasyon: Kas gevşetici kullanımı gerekli mi?

Bu çalışma laringeal maske yerleştirilmesi ve laringeal maske ile pozitif basınçlı mekanik ventilasyon uygulanması sırasında kas gevşetici ajan kullanımının etkilerini araştırmak üzere planlandı. Cerrahi olarak kas gevşetici ajan kullanımı gerekli olmayan 45 olgu rasgele üç eşit gruba ayrıldı. Anestezi indüksiyonu propofol ile gerçekleştirildikten sonra; Grup I'de kas gevşetici ajan verilmedi, Grup II'de 0.3 mg kg-1 ve Grup III'de 0.6 mg kg-1 rokuronyum iv uygulandı. Propofol injeksiyonunun tamamlanmasından 2 dk sonra olgulara LMA yerleştirildi. Anestezi idamesi ve ventilasyon %1.7 sevofluran içeren %60 N2O-O2 gaz karışımı ile gerçekleştirildi. Pozitif basınçlı mekanik ventilasyon parametreleri; İ:E = 1:2, tidal volüm 8 mL kg-1 ve solunum frekansı dakikada 10 olacak şekilde başlatıldı. Maksimum inspirasyon pik basıncı 15 cmH2O'yu geçmeyecek ve ETCO2 değeri 32-36 mmHg arasında tutulacak şekilde tidal volüm ve solunum frekansında gerekli değişiklikler yapıldı. Operasyon sonunda rokuronyum verilen ve TOF oranı

Anahtar Kelimeler:

Nöromüsküler blokaj ajanları, Kas gevşemesi, Larinks maskeleri, Ventilatörler, mekanik, Solunum, yapay

Positive pressure ventilation with laryngeal mask airway: Is neuromuscular blocking agent a necessity?

The aim of this study was to evaluate the effects of a neuromuscular blocking agent on the insertion of and on the positive pressure ventilation with laryngeal mask airway. Forty-five patients undergoing elective surgery in which muscular relaxation was not required were studied. After the anesthesia was induced with propofol; no neuromuscular blocking agent was used in Group I, and 0.3 and 0.6 mg kg-1 rocuronium were given in Group II and III, respectively. The laryngeal mask airway was inserted 2 minutes after completion of the induction dose of propofol. Anesthesia was maintained by mechanic ventilation with 1.7% sevoflurane and 60% nitrous oxide in oxygen. The initial positive pressure ventilation parameters were; I:E =1:2, tidal volume = 8 mL kg-1, ventilatory frequency = 10 min-1. Respiratory rates and tidal volumes were adjusted to maintain the ETCO2 between 32-36 mmHg and to limit the peak airway pressures up to15 cmH2O. At the end of operation, neuromuscular block was antagonized with neostigmine 1 mg and atropin 0.5 mg in the patients who received rocuronium and who had a TOF ratio >0.7. There were no failed insertion attempts. Maximum peak inspiratory pressures were not different among the three groups; their range was 11-14 cmH2O in Group I and II, and 11-15 cmH2O in Group III. In Group I, adequate ventilation was achieved by the mean tidal volume of 8.3 mL kg-1 and the mean respiratory rate of 9.9 min-1; these values were 8.4 mL kg-1 and 9.9 min-1 in Group II, and 8.1 mL kg-1 and 9.7 min-1 in Group III, respectively. None of the patients had any complications.In conclusion,neuromuscular blocking agent does not facilitate the laryngeal mask airway insertion and is not a necessity for the positive pressure ventilation.

Keywords:

Neuromuscular Blocking Agents, Muscle Relaxation, Laryngeal Masks, Ventilators, Mechanical, Respiration, Artificial,

___

1. Fassoulaki A, Paraskeva A, Karabinis G, Melemeni A. Ventilatory adequacy and respiratory mechanics with laryngeal mask versus tracheal intubation during positive pressure ventilation. Acta Anaesthesiol Belg 1999; 50: 113-7.
2. Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth 1998; 45: 564-7.
3. Smith I, White PF. Use of the laryngeal mask airway as an alternative to a face mask during outpatient arthroscopy. Anesthesiology 1992; 77: 850-5.
4. Fisher JA, Ananthanarayan C, Edelist G. Role of the laryngeal mask in airway management. Can J Anaesth 1992; 39:1-3.
5. Van Vlymen JM, Fu W, White PF, Klein KW, Griffin JD. Use of the cuffed oropharyngeal airway as an alternative to the laryngeal mask airway with positive-pressure ventilation. Anesthesiology 1999; 90: 1306-10.
6. Chui PT, Cheam EW. The use of low-dose mivacurium to facilitate of the laryngeal mask airway. Anaesthesia 1998; 53:491-5.
7. Keller C, Sparr HJ, Brimacombe JR. Positive pressure ventilation with the laryngeal mask airway in non-paralysed patients: comparison of sevoflurane and propofol maintenance techniques. Br J Anaesth 1998; 80: 332-6.
8. Valentine J, Stakes AF, Bellamy MC. Reflux during positive pressure ventilation through the laryngeal mask. Br J Anaesth 1994; 73: 543-4.
9. Devitt JH, Wenstohe R, Noel AG, O'Donnell MR Laryngeal mask airway and positive-pressure ventilation. Anesthesiology 1994; 80: 550-5.
10. Brimacombe JR. Positive pressure ventilation with the size 5 laryngeal mask. J Clin Anesth 1997; 9: 113-7.
11. Verghese C, Brimacombe JR. Survey of laryngeal mask airway usage in 11,919 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996; 82: 129-33.
12. Wailer N, Latorre F, Eberle B, Goedecke R, Heinrichs W. Respiratory mechanics, gastric insufflation pressure, and air leakage of the laryngeal mask airway. Anesth Analg 1997; 84: 1025-8.
13. Keller C, Brimacombe J. Bronchial mucus transport velocity in paralyzed anesthetized patients: a comparison of the laryngeal mask airway and cuffed tracheal tube. Anesth Analg 1998; 86: 1280-2.
14. Maltby JR, Beriault MT, Watson NC, Fick GH. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth 2000; 47: 622-6.
15. Bapat PP, Verghese C. Laryngeal mask airway and the incidence of regurgitation during gynecological laparoscopies. Anesth Analg 1997; 85: 139-43.
16. Ho BY, Skinner HJ, Mahajan RP. Gastro-oesophageal reflux during day case gynaecological laparoscopy under positive pressure ventilation: laryngeal mask vs. tracheal intubation. Anaesthesia 1998; 53: 921-4.