idil TEKİN, Ahmet TUTAN, Nurettin LÜLECİ, Tuna ERİNÇLER

Endoskopik KBB operasyonlarında rokuronyum ile nöromuskuler blokaj ve intübasyon koşulları

Rokuronyum, etkisi kısa sürede oluşan non depolarizan yeni bir kas gevşeticidir. Bu çalışmanın amacı, rokuronyumun, endoskopik üst solunum yolu ameliyatları gibi orta süreli ameliyatlar için uygun bir kas gevşetici olma özelliklerine sahip olup olmadığının araştırılmasıdır. Ayrıca bu çalışmada, nöromuskuler blokajın zamanı ve seyri ile intübasyon için uygun koşulların sağlanabilme derecesi de araştırılmıştır. Endoskopik üst solunum yolu ameliyatları uygulanacak 1-3 risk gruplarında 30 hasta kendilerinin ve etik komitenin onayı ile araştırma kapsamına alınmışlardır. Güç intübasyon koşulları olasılığı, nöromuskuler hastalıklar ve son 24 saat içerisindeki aminoglikozit tedavisi dışlanma kriterleri sayılmıştır. Anestezi indüksiyonu, 500 ml Ringer laktat infüzyonu ve preoksijenasyondan sonra, 2 mg/kg propofol + 0,03 mg/kg. alfentanil ile yapılıp, anesteziye 5-8 mg/kg/saat propofol ve klinik gereksinime göre tekrarlanan alfentanil enjeksiyonlarıyla devam edilmiş, endotrakeal intübasyon deneyimli bir anestezisi tarafından 0,6 mg/kg (2 x EDgS) rokuronyum enjeksiyonundan 90 saniye sonra uygulanarak intübasyon şartları 1-4 puan ile ( 1:çok iyi, 2: iyi, 3: yeterli, 4: yetersiz) olmak üzere değerlendirilmiştir. Nöromuskuler monitorizasyon TOF-GUARD 00206 / 502.125 -Organon Teknika NV ile uygulanmıştır. Nöromuskuler blokajın seyrinde twitch eşiği ve TOF oranı saptanmıştır. Veriler, ortalama ± standart sapma olarak değerlendirilmiştir. 37-64 (ortalama 54+7) yaşlarındaki hastaların 17 sinde intübasyon koşulları çok iyi, 7'sinde iyi, 2 sinde yeterli ( hasta intübe edilebilmiş fakat intübasyon esnasında bariz diyafragm hareketleri izlenmiş) olarak kaydedilmiş, dört hastada, anatomik nedenlerle, glottis'in laringoskop ile görülmesi mümkün olmadığından, intübasyon koşulları belirlenememiştir. İntübasyon sırasındaki nöromuskuler blok % 78+22, başlangıç zamanı 152+62 saniye , klinik süre 30+8 dak ve geri dönüş indeksi 11+4 dakika, TOF oranının 0,7'ye dönüş süresi 51+14 dak. olarak saptanmıştır. Sonuç olarak; 0,6 mg/kg rokuronyumdan 90 saniye sonra iyi ve çok iyi intübasyon koşulları sağlanabilmiş, diyafragma hareketleri tamamen önlenememiştir. Endotrakeal intübasyon için adductor pollicis kasının tam paralizisi gerekli olmamıştır. 0,6 mg/kg rokuronyumun verilişinden belirli bir süre (ör 90 san. sonra) intübasyon gerçekleştirilebilmektedir. Kas tonusunun geri dönüşü, rokuronyumun orta süreli ameliyatlar için iyi bir kas gevşetici olduğunu göstermiştir. Ancak bloğun tamamen kayboluşunda kişisel farklar olabileceği göz önünde tutularak hastalar gözlenmelidir.

Intubating conditions, onset and recovery characteristics after rocuronium for anaesthesia in endoscopic upper airway surgery

Rocuronium is a new nondepolarizing muscle relasant, for which a fast onset has been described. The goal of this study was to examine whether the characteristics of rocuronium could make it an appropriate relaxant for the anaesthetic management of operations of intermediate duration such as endoscopie upper airway surgery. In addition, the time course of neuromuscular blockade and its relation to the quality of intubating conditions were analysed. The study was approved by the local ethic commitee; 30 patients (ASA status 1-3). scheduled for elective endoscopie upper airway surgery were included after written informed consent. Exclution criteria were suspected difficult intubating conditions , neuromuscular disease, or antibiotic therapy with aminoglycosides during the last 24 h. Anaesthesia was induced by propofol 2 mg/kg and alfentanil 1 mg after volume loading with 500 ml Ringer's lactate and preoxygenation, and was maintaned by propofol infusion 5-8mg/kg/h and repetitive alfentanil injections according to clinical needs. Endotracheal intubation was performed by senior anaesthesiologist 90 s after injection of rocuronium 0,6 mg/kg (2xEDgs ). Intubating conditions were graded 1 to 4 ( 1= excellent, 2= good, 3= sufficient, 4= inadequate). Electromyography was used lor neuromuscular monitoring by means of the TOP - guard ( 00206 / 502.125 - Organon Teknika NV) . Twitch height and TOF ratio were documented during the course of neuromuscular blockade. Data are presented as mean + standart deviation . Patients were aged 37 to 64 years (mean 54±7). Intubating conditions were excellent in 17 cases and good in 7. In 2 cases intubating conditions were graded sufficient, as patients could be easly intubated but showed clear diaphragmatic movements at intubation. In 4 patients intubating conditions could not be judged, as a laryngoscopic view of the glottic structures was impossible for anatomic reasons. Neuromuscular block at intubation was 78+22%, onset time 152+62 s. clinical duration 30±8 min., and recovery index 11+4 min. The TOF ratio required 51±14 min to return to 0,7. Good to exellent intubating conditions can be expected 90 s after injection of rocuronium 0,6 mg/kg. Diaphragmatic reactions cannot be excluded. Complete relaxation of the adductor pollicis muscle is not necessary for endotracheal intubation. Intubation at a certain time interval , for example, 90 s. after injection of rocuronium 0,6 mg/kg, can be recommended. Onset and recovery characteristics of rocuronium make it an appropriate relaxant for the anaesthetic management of operations of intermediate duration such as endoscopie upper airway surgery. Care should be given , however, to detect inadequate recovery of neuromuscular transmission, as there are considerable interindividual differences in recovery.

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