Atakan ERKILINÇ, Füsun GÜZELMERİÇ, Rezan YALTIRIK, Fahriye GÜLER, Halide OĞUŞ, Tuncer KOÇAK, Erdal TURAN, Fatma BİLGİN

Farklı hipotermik kardiyopulmoner bypass koşullarında rokuronyum ile rezidüel nöromusküler blok

Amaç: Bu çalışma, koroner bypass operasyonlarında orta etkili yeni bir nondepolarizan nöromusküler bloker olan rokuronyum ile oluşabilecek rezidüel nöromusküler blok düzeylerini araştırmak amacıyla prospektif, randomize olarak planlandı. Materyal ve Metod: Hastanemiz etik kurulu izniyle elektif koroner bypass operasyonu planlanan 30 olgu, kardiyopulmoner bypass sırasındaki hipotermi derecesine göre hafif (30-35°C) ve orta (25-30°C) hipotermik grup olarak (sırasıyla Grup l ve Grup 2) ikiye ayrıldı. Diazepam ile premedikasyon uygulanan olguların anestezi indüksiyonu diazepam, fentanil ve rokuronyum ile sağlandı. Nöromusküler monitorizasyonları TOP (train of four)-Guard cihazı ile yapılan olguların twitch (Tw) yüksekliği %0 olduğunda endotrakeal entübasyonları yapıldı. İndüksiyon sonrası, Tw yüksekliği %10'a ulaştığında 0.6 ıng/kg/lı dozunda rokuronyum infüzyonu başlandı ve Tw cevabı % 10 olacak şekilde doz ayarlandı. Hipotermik dönemde doz azaltıldı. Sternum kapatıldıktan sonra infüzyona son verildi. Postoperatif dönemde Tw %25 olduğu andan train-of-four (TOF) oranı (T4/Tı) > 0.7 değerine ulaşana kadar geçen süre kaydedildi. Bu süre 30 dakikanın üzerinde ise nöromusküler rezidüel blok olarak değerlendirildi. Spontan derlenme süreleri ve rezidüel nöromusküler blok saptanan olgular kaydedildi. Bulgular: Spontan derlenme süreleri ve rezidüel nöromusküler blok saptanan olgu yüzdeleri Grup 2'de Grup l'e göre daha yüksekti (p < 0.05). Sonuç: Uzun süreli ve 30°C'nin altında hipotermi uygulanan kardiyak operasyonlarda, spontan derlenme süresi ve postoperatif rezidüel nöromusküler bloğun bariz bir şekilde arttığım, hipotermi derinleştikçe gereken kas gevşetici miktarının azaldığını saptadık.

Residual neuromuscular block with rocuronium on different hypothermic cardiopulmonary bypass conditions

Background: This study was performed to investigate residual neuromuscular block levels of rocuronium, the new, nondepolarizing muscle relaxant with intermediate duration, in the variable hypothermic cardiopulmonary bypass conditions. Methods: After ethic committee's approval, 30 patients scheduled for an elective coronary artery bypass operation were randomised into two groups: Group I with mild hypothermia (30-35°C), and Group II with moderate hypothermia (25-30°C). After premedication with diazepam, anaesthesia was induced with diazepam, fentanyl and rocuronium. Patients' neuromuscular monitoring was evaluated with TOF (train of four)- Guard instruments. Endotracheal entubation was performed when the Twitch (Tw) height was 0%. After induction; when the Tw height reached 10%, muscle relaxation was maintained with infusion of rocuronium (0.6 mg/kg/h). The dose was adjusted to keep Tw response as 10%. The dosage of rocuronium was reduced in hypothermic periods. Infusion of rocuronium was stopped when the sternum was closed. In the postoperative period, time follow up was recorded when Tw height became 25% till the TOF ratio reached (T4/T1) > 0.7. When this time was over 30 minutes, that was assessed as residual neuromuscular block. Results: Group II had significantly higher spontaneus recovery times and residual neuromuscular block percentage than Group I. Conclusion: In patients undergoing coronary artery bypass with prolonged hypothermia under 30°C, spontaneus recovery times and postoperative residual neuromuscular block increase significantly, and the need for muscle relaxant decreases by deepening the hypothermia.

PDF

___

1. Bevan DR. Newer neuromuscular blocking agents. Pharmacol Toxicol 1994;74:3-9.
2. Eriksson LI, Sato M, Sevoringhous JW. Effect of a rocuronium-induced partial neuromuscular block on hypoxic vantilatory response. Anesthesiology 1993;78:693-9.
3. Thornton RJ, Blakeney C, Feldman SA. The effect of hypotermia on neuromuscular conduction. Br J Anaesth 1976;48:264-6.
4. Matteo RS, Ornstein E, Schwartz AE, et al. Pharmacokinetics and pharmacodynamics of rocuronium (ORG 9426) in elderly surgical patients. Anesth Analg 1993;77:1193-7.
5. Alvarez-Gamez JA, Estellas ME, Fabregat J, Perez F, Bruggert AJ. Pharmacokinetics and pharmacodynamics of rocuronium bromide in adult patients. Eur Anaesth 1994;11:53-6.
6. Baurain MJ, Dernovoi BS, d'Hollander AA, Bloon PC. Comparison between spontaneous recoveries of rocuronium (ORG 9426) and vecuronium paralysis in thiopental, fentanyl, N2O/O2 adult anesthetized patients. Anesthesiology 1992;77:932-5.
7. Fawcett WJ, Fauvel NJ, Feldman SA. Comparison of recovery index of rocuronium or vecuronium with simultaneously administered pancuronium in the isolated forearm. Anaesthesia 1993;48:200-1.
8. Crofts SL, Aberdeen R, Huchison GL. Clinical monitoring of neuromuscular function. Br J Hosp Medic 1992;48:633-40.
9. Mogensen JV. Neuromuscular monitoring. In: Miller RD, ed. Anesthesia. Churchill Livinstone: New York, 1994:1345-61.
10. Kayhan Z, ed. Klinik Anestezi. Logos Yayıncılık: İstanbul, 1997:135-62.
11. Morgan GE, Michail MS, eds. Clinical Anesthesiology. Appleton & Lange: Stamford, 1996:149-64.
12. Nitschmann P, Oberkoglene W, Hertsig M, Schwarz S. Comparison of haemodynamic effects of rocuronium bromide with thos of vecuronium in patients undergoing CABG surgery. Eur J Anaesthesiol 1994;9:113-5.
13. Bevan DR, Smith CE, Donati F. Postoperative neuromuscular blockade: A comparison between atracurium, vecuronium and pancuronium. Anesthesiology 1988;69:272-6.
14. Bevan DR, Kahwaji R, Ansermino JM. Residual block after mivacurium with or without edrophonium reversal in adults and children. Anesthesiology 1996;84:362-7.
15. Muir AW, Anderson KA, Pow E. Interaction between rocuronium bromide and some drugs used during anaesthesia. Eur J Anaesthesiol 1994;9:93-8.
16. Smeulers NJ, Wierda JM, Van den Broek L. Hypotermia cardiopulmonary bypass influences the concentrationesponse relationship and the biodisposition of rocuronium. Eur J Anesthesiol 1995;11:91-4.
17. Shanks CA, Fragan RJ, Ling D. Continuous intravenous infusion of rocuronium (org 9426) in patients receiving balanced enflurane or isoflurane anesthesia. Anesthesiology 1993;78:649-51.
18. Denny NM, Kneeshaw JD. Vecuronium and atracurium infusions during hyothermic cardiopulmonary bypass. Anaesthesia 1986;41:919-22.
19. Feldman SA, Englan AJ, Margarþon MP. Tracheal intubation conditions after one minute: Rocuronium and vecuronium alone and in combination. Anaesthesia 1997;52:336-40.
20. Beaufort AM, Wierda JM, Belapavlovic M, Nederveen PJ, Kleef WW, Agoston S. The influence of hypotermia (surface cooling) on the time-course of action and the pharmacokinetics of rocuronium in humans. Eur J Anaesthesiol 1995;11:95-106.
21. Flynn PJ, Hughes R, Waltson B. Use of atracurium in cardiac surcery involving cardiopulmonary bypass with induced hypothermia. Br J Anesth 1984;56:967-72.
22. Buzello W, Schluermann D, Pollmaecher T, Spillner G. Unequal effects of cardiopulmonary bypass induced hypothermia on neuromuscular blockade from constant infusion of alcuronium, d-tubocurarine, pancuronium and vecuronium. Anesthesiology 1987;66:842-6.
23. Buzello W, Schuermann D, Schindler M, Spillner G. Hypothermic cardiopulmonary bypass and neuromuscular blockade by pancuronium and vecuronium. Anesthesiology 1985;62:201-4.
24. Heier T, Caldwell JE, Sessler DI, Miller RD. Mild intraoperative hypothermia increases duration of action and spontaneus recovery of vecuronium blockade during nitrous oxide isoflurane anesthesia in humans. Anesthesiology 1991;74:815-9.