Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942004000400008
Brazilian Journal of Anesthesiology
Scientific Article

Avaliação do bloqueio neuromuscular residual e da recurarização tardia na sala de recuperação pós-anestésica

Evaluation of residual neuromuscular block and late recurarization in the post-anesthetic care unit

Maria Cristina Simões de Almeida; Dalto Rodrigues de Camargo; Saul Fernando Linhares; Sérgio Galluf Pederneiras

http://dx.doi.org/10.1590/S0034-70942004000400008 Braz J Anesthesiol, vol.54, n4, p.518-531, 2004
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Resumo

JUSTIFICATIVA E OBJETIVOS: O bloqueio neuromuscular residual altera a patência das vias aéreas aumentando o risco de graves complicações no pós-operatório. Nos pacientes que recebem o anticolinesterásico, a transmissão neuromuscular é incrementada pelo acúmulo de acetilcolina na placa motora, mas que, findo o efeito da neostigmina, teoricamente é possível uma "recurarização", visto que o agente antagonista não desloca o bloqueador neuromuscular do seu local de ação. Foi objetivo deste trabalho quantificar o grau de paralisia residual em Sala de Recuperação Pós-Anestésica (SRPA) e averiguar se os pacientes que receberam neostigmina apresentam fenômeno de "recurarização" tardia. MÉTODO: Foram estudados na SRPA 119 pacientes adultos que receberam bloqueadores neuromusculares para diferentes tipos de procedimentos. Ao chegarem na SRPA, a transmissão neuromuscular foi quantificada através de um monitor por método acelerográfico. Os eletrodos estimuladores foram instalados no trajeto do nervo ulnar no punho, e empregou-se a seqüência de 4 estímulos, com correntes de 30 mA, na periodicidade de 15 até 120 minutos. Nesta pesquisa considerou-se como resíduo de bloqueio neuromuscular uma relação T4/T1 abaixo de 0,9. No tempo de permanência da SRPA foram igualmente registrados os sintomas clínicos sugestivos de bloqueio neuromuscular residual e aferidos os sinais vitais. Para análise estatística foram empregadas medidas descritivas tais como média e freqüência absoluta. RESULTADOS: Os pacientes que receberam pancurônio apresentaram maior incidência de resíduo de bloqueio neuromuscular, principalmente os idosos. Nos pacientes que receberam neostigmina houve expressivo percentual de bloqueio neuromuscular residual. Em nenhum grupo observou-se o fenômeno de "recurarização" tardia. CONCLUSÕES: Constatou-se expressivo número de pacientes com resíduo de bloqueio neuromuscular, quando utilizado o pancurônio. A fase de recuperação, quando foi usada a neostigmina não se seguiu de "recurarização", sugerindo que esse fenômeno não tenha significado clínico quando o paciente não apresenta sinais de falência de órgãos ou comorbidades que alteram a transmissão neuromuscular.

Palavras-chave

BLOQUEADORES NEUROMUSCULARES, MONITORIZAÇÃO, MONITORIZAÇÃO, RECUPERAÇÃO PÓS-ANESTÉSICA

Abstract

BACKGROUND AND OBJECTIVES: Residual postoperative paralysis impairs airway patency increasing the risk for postoperative complications. Anti-cholinesterase agents improve neuromuscular transmission by acetylcholine build up in the endplate. However, when there is no longer neostigmine effect, "recurarization" is theoretically possible since the antagonist agent does not displace neuromuscular blocker from its action site. This study aimed at determining the degree of residual neuromuscular block in the Post Anesthetic Care Unit (PACU) and at observing whether patients receiving neostigmine presented the late "recurarization" phenomenon. METHODS: Participated in this study 119 adult patients who received neuromuscular blockers for different procedures. At PACU arrival, neuromuscular transmission has been quantified by acceleromyography, with stimulating electrodes placed over the ulnar nerve at the wrist, the train of four (TOF) was used with electrical current of 30mA at 15-minute intervals for a period of 120 minutes. Residual neuromuscular block was considered T4/T1 ratio below 0.9. Clinical symptoms suggesting residual neuromuscular block and vital signs were also recorded in the PACU. Descriptive measures, such as mean and absolute frequency were used for statistical analysis. RESULTS: Patients receiving pancuronium had a higher incidence of residual block, especially the elderly. Patients receiving neostigmine also presented an expressive percentage of residual curarization. There has been no late recurarization in both groups. CONCLUSIONS: The incidence of residual block was significantly higher in the pancuronium group. There has been no case of recurarization with neostigmine suggesting that this phenomenon has no clinical significance when patients have no signs of organ failure or co-morbidity impairing neuromuscular transmission.

Keywords

MONITORING, MONITORING, NEUROMUSCULAR BLOCKERS, POSTANESTHETIC RECOVERY

References

Ali HH, Utting JE, Gray TC. Quantitative assessment of residual antidepolarizing block: I. Br J Anaesth. 1971;43:473-477.

Debaene B, Plaud B, Dilly MP. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98:1042-1048.

Eriksson LI, Sundman E, Olsson R. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology. 1997;87:1035-1043.

Kopman AF, Ng J, Zank LM. Residual postoperative paralysis: Pancuronium versus mivacurium, does it matter?. Anesthesiology. 1996;85:1253-1259.

Berg H, Roed J, Viby-Mogensen J. Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomized, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095-1103.

Feldman A, Fauvel N. Recovery from a Neuromuscular Block. Applied Neuromuscular Pharmacology. 1994:107-122.

Bevan D. Post-operative Sequelae of Neuromuscular Blocking Agents. Applied Neuromuscular Pharmacology. 1994:143-159.

Bowman WC. Prejunctional and postjunctional cholinoceptors at the neuromuscular junction. Anesth Analg. 1980;59:935-943.

Pearce AC, Casson WR, Jones RM. Factors affecting train-of-four fade. Br J Anaesth. 1985;57:602-606.

Williams NE, Webb SN, Calvey TN. Differential effects of myoneural blocking drugs on neuromuscular transmission. Br J Anaesth. 1980;52:1111-1115.

McCoy EP, Connolly FM, Mirakhur RK. Nondepolarizing neuromuscular blocking drugs and train-of-four fade. Can J Anaesth. 1995;42:213-216.

Flood P, Ramirez-Latorre J, Role L. Alpha 4 beta 2 neuronal nicotinic acethylcholine receptors in the central nervous system are inhibited by isoflurane and propofol, but alpha 7-type nicotinic acethylcholine receptors are unaffected. Anesthesiology. 1997;86:859-865.

Violet JM, Downie DL, Nakisa RC. Differential sensitivities of mammalian neuronal and muscle nicotinic acethylcholine receptors to general anesthetics. Anesthesiology. 1997;86:866-874.

Sivilotti L, Colquhoun D. Acethylcholine receptors: too many channels, too few functions. Science. 1995;269:1681-1682.

Role LW, Berg DK. Nicotinic receptors in the development and modulation of CNS synapses. Neuron. 1996;16:1077-1085.

McGehee DS, Heath MJ, Gelber S. Nicotine enhancement of fast excitatory synaptic transmission in CNS by presynaptic receptors. Science. 1995;269:1692-1696.

Bohnen N, Warner MA, Kokmen E. Early and midlife exposure to anesthesia and age of onset of Alzheimer's disease. Int J Neurosci. 1994;77:181-185.

Fletcher JE, Sebel PS, Mick SA. Comparison of the train-of-four fade profiles produced by vecuronium and atracurium. Br J Anaesth. 1992;68:207-208.

Walts LF, Levin N, Dillon JB. Assessment of recovery from curare. JAMA. 1970;213:1894-1896.

Engbaek J, Ostergaard D, Viby-Mogensen J. Clinical recovery and train-of-four ratio measured mechanically and electromyographically following atracurium. Anesthesiology. 1989;71:391-395.

Beemer GH, Rozental P. Postoperative neuromuscular function. Anaesth Intensive Care. 1986;14:41-45.

Hutton P, Burchett KR, Madden AP. Comparison of recovery after neuromuscular blockade by atracurium or pancuronium. Br J Anaesth. 1988;60:36-42.

Fezing AK, d'Hollander A, Boogaerts JG. Assessment of the postoperative residual curarisation using the train of four stimulation with acceleromyography. Acta Anaesthesiol Belg. 1999;50:83-86.

Ali HH, Utting JE, Gray TC. Quantitative assessment of residual antidepolarizing block: II. Br J Anaesth. 1971;43:478-485.

Ali HH, Kitz RJ. Evaluation of recovery from nondepolarizing neuromuscular block, using a digital neuromuscular transmission analyzer: preliminary report. Anesth Analg. 1973;52:740-745.

Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86:765-771.

Meistelman C, Bevan DF. The Action of Relaxants on Different Muscles of The Body. Applied Neuromuscular Pharmacology. 1994:411-429.

Eriksson LI, Nilsson L, Witt et al. Videographical computerized manometry in assessment of pharyngeal function in partially paralyzed humans. Anesthesiology. 1995;83:A886.

Eriksson LI, Lennmarken C, Wyon N. Attenuated ventilatory response to hypoxaemia at vecuronium-induced partial neuromuscular block. Acta Anaesthesiol Scand. 1992;36:710-715.

Eriksson LI. Reduced hypoxic chemosensitivity in partially paralyzed man: A new property of muscle relaxants?. Acta Anaesthesiol Scand. 1996;40:520-523.

Eriksson LI, Sato M, Severinghaus JW. Effect of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. Anesthesiology. 1993;78:693-699.

Viby-Mogensen J, Jorgensen BC, Ording H. Residual curarization in the recovery room. Anesthesiology. 1979;50:539-541.

Lennmarken C, Lofstrom JB. Partial curarization in the postoperative period. Acta Anaesthesiol Scand. 1984;28:260-262.

Bevan DR, Smith CE, Donati F. Postoperative neuromuscular blockade: a comparison between atracurium, vecuronium, and pancuronium. Anesthesiology. 1988;69:272-276.

Howardy-Hansen P, Rasmussen JA, Jensen BN. Residual curarization in the recovery room: atracurium versus gallamine. Acta Anaesthesiol Scand. 1989;33:167-169.

Oliveira AS, Bastos CO, Serafim MM. Avaliação do bloqueio neuromuscular residual na sala de recuperação pós-anestésica. Rev Bras Anestesiol. 1997;47:502-511.

Baxter MR, Bevan JC, Samuel J. Postoperative neuromuscular function in pediatric day-care patients. Anesth Analg. 1991;72:504-508.

Feldman S. Explanations of Clinical Events Based on Biophase Binding. The Neuromuscular Junction. 1996:61-71.

Feldman S. Second thoughts on the train-of-four. Anaesthesia. 1993;48:1-2.

Savarese JJ. Reversal of nondepolarizing blocks: more controversial than ever?. IARS Review Couse Lectures. 1993:77-82.

Gill RS, Scott RP. Etomidate shortens the onset time of neuromuscular block. Br J Anaesth. 1992;69:444-446.

Gill SS, Bevan DR, Donati F. Edrophonium antagonism of atracurium during enflurane anaesthesia. Br J Anaesth. 1990;64:300-305.

Harper NJN. Reversal of Neuromuscular Blockade. Muscle Relaxants in Anaesthesia. 1995:135-155.

Payne JP, Hughes R, Al Azawi S. Neuromuscular blockade by neostigmine in anaesthetized man. Br J Anaesth. 1980;52:69-76.

Furuya R, Oka K, Watanabe I. The effects of ketamine and propofol on neuronal nicotinic acethylcholine receptors and P2x purinoceptors in PC12 cells. Anesth Analg. 1999;88:174-180.

Eriksson LI. The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation. Anesth Analg. 1999;89:243-251.

D'Honneur G, Lofaso F, Drummond GB. Susceptibility to upper airway obstruction during partial neuromuscular block. Anesthesiology. 1998;88:371-378.

Isono S, Ide T, Kochi T. Effects of partial paralysis on the swallowing reflex in conscious humans. Anesthesiology. 1991;75:980-984.

Meistelman C, Plaud B, Donati F. Neuromuscular effects of succinylcholine on the vocal cords and adductor pollicis muscles. Anesth Analg. 1991;73:278-282.

Donati F, Meistelman C, Plaud B. Vecuronium neuromuscular blockade at the diaphragm, the orbicularis oculi, and adductor pollicis muscles. Anesthesiology. 1990;73:870-875.

Meistelman C, Donati F. The Action of Relaxants on Different Muscles of The Body. Applied Neuromuscular Pharmacology. 1994:411-429.

Ansermino JM, Sanderson PM, Bevan JC. Acceleromyography improves detection of residual neuromuscular blockade in children. Can J Anaesth. 1996;43:589-594.

Donati F. Neuromuscular monitoring: useless, optional or mandatory?. Can J Anaesth. 1998;45:R106-R116.

Silverman DG, Connelly NR, O'Connor TZ et al. Accelographic train-of-four at near-threshold currents. Anesthesiology. 1992;76:34-38.

Saitoh Y, Nakazawa K, Toyooka H et al. Optimal stimulating current for train-of-four stimulation in conscious subjects. Can J Anaesth. 1995;42:992-995.

Brull SJ, Silverman DG. Visual assessment of train-of-four and double burst-induced fade at submaximal stimulating currents. Anesth Analg. 1991;73:627-632.

Brull SJ. Use of submaximal stimulation. .

Martin R, Bourdua I, Theriault S. Neuromuscular monitoring: does it make a difference?. Can J Anaesth. 1996;43:585-588.

Bevan D. Post-operative Sequelae of Neuromuscular Blocking Agents. Applied Neuromuscular Pharmacology. 1994:143-159.

Bevan DR, Donati F, Kopman AF. Reversal of neuromuscular blockade. Anesthesiology. 1992;77:785-805.

Bom AH. New Approaches to Reversal of Neuromuscular Block. .

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