“反转还是不反转?”答案很清楚!

G. Murphy, A. Kopman
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引用次数: 28

摘要

在20世纪80年代末,人们普遍认为,在大多数麻醉后护理单位(pacu)中,未发现的术后残留神经肌肉阻滞(PRNB)是常见的。1-4然而,1989年的一篇社论指出,几乎没有客观证据证实PRNB与长期甚至短暂的不良呼吸结果相关的假设自Miller5的社论发表以来的25年里,关于这一重要的患者安全问题的结果数据慢慢积累起来,但相关数据库仍然相当稀少。在本期的《麻醉学》杂志上,Bulka等人6为试图检查PRNB长期后果的少量研究提供了重要的补充。他们报告了两个主要发现:(1)与未接受松弛剂的患者相比,使用神经肌肉阻滞剂(nmba)与术后肺炎(PoP)的绝对发生率较高相关;(2)手术结束时未能逆转nmba与PoP发生率增加2.25倍相关。为什么这些发现不足为奇呢?Bulka等人6指出,接受nmba治疗的患者的PoP发病率比(1.79)明显更高。这一观察结果与几项大型数据库调查的结果一致,这些调查描述了术中使用NMBA与主要发病率和死亡率之间的关联。60多年前,Beecher和todd7报道,接受nmba的患者与未使用肌肉松弛剂的患者相比,与麻醉相关的死亡风险高6倍。对10年间(1967年至1976年)240,483种麻醉药收集的数据的分析显示,“肌神经阻滞后呼吸功能不全”是手术后死亡的第二大常见原因。类似地,英国的一项研究报告称,nmba剂量引起的术后呼吸衰竭是导致死亡的主要原因在一项大型前瞻性研究中,使用长效NMBA泮库溴铵会增加术后肺部并发症的风险最近的研究报道,给予NMBAs的患者术后发生去饱和的风险更高,需要重新插管,并且给予高剂量NMBAs的患者术后发生呼吸系统并发症的风险更高据报道,服用nmba的患者发病率和死亡率的增加可能是继发于PRNB。术后脆弱期(从气管拔管到PACU中toF小于0.9之间)神经肌肉恢复不完全可能损害上气道通畅、气道保护性反射、呼吸、吞咽和咳嗽,导致重大呼吸事件(如PoP)和死亡的风险增加。数据显示神经肌肉阻滞逆转失败与术后不良结果之间的关联不太确定。一项大型病例对照数据库调查显示,与降低死亡率和昏迷相关的初级麻醉管理特点是nmbas效果的逆转在"倒车还是不倒车? "
本文章由计算机程序翻译,如有差异,请以英文原文为准。
"To Reverse or Not To Reverse?": The Answer Is Clear!
Anesthesiology, V 125 • No 4 611 October 2016 B y the late 1980s, it was well recognized that undetected postoperative residual neuromuscular block (PRNB) was a common occurrence in most postanesthesia care units (PACUs).1–4 However, an editorial in 1989 noted that there was little, if any, objective evidence to validate the hypothesis that PRNB was associated with long-term or even transient adverse respiratory outcomes.5 In the two and a half decades since the editorial by Miller5 was published, outcome data regarding this important patient safety issue have slowly accumulated, but the relevant database remains quite sparse. In this issue of ANestHesIology, Bulka et al.6 provide an important addition to the small list of studies that attempt to examine the long-term consequences of PRNB. They report two main findings: (1) the use of neuromuscular blocking agents (NMBAs) was associated with a higher absolute rate of postoperative pneumonia (PoP) when compared to matched cases where patients did not receive relaxants and (2) failure to reverse NMBAs at the end of surgery was associated with a 2.25-fold increase in the incidence of PoP. Why should these findings be less than surprising? Bulka et al.6 noted that the incidence rate ratio (1.79) for PoP was significantly higher in patients who received NMBAs. This observation is consistent with the findings from several large database investigations, which have described an association between intraoperative NMBA use and major morbidity and mortality. More than 60 yr ago, Beecher and todd7 reported that the risk of death related to anesthesia was six times higher in patients receiving NMBAs compared to those administered no muscle relaxants. An analysis of data collected over a 10-yr period (1967 to 1976) involving 240,483 anesthetics revealed that “respiratory inadequacy after myoneural blockade” was the second most common cause of death after surgery.8 similarly, a study from great Britain reported that postoperative respiratory failure secondary to dosing of NMBAs was a primary cause of mortality.9 In a large prospective study, the use of the long-acting NMBA pancuronium entailed a higher risk of postoperative pulmonary complications.10 More recent studies reported that patients administered NMBAs had a higher risk of postoperative desaturations and need for reintubation11 and that those given high doses of NMBAs had an increased risk of postoperative respiratory complications.12 The increased incidence of morbidity and mortality reported in patients administered NMBAs is likely secondary to PRNB. Incomplete neuromuscular recovery during a vulnerable postoperative period (between tracheal extubation and achieving a train-of-four [toF] ratio of less than 0.9 in the PACU) may impair upper airway patency, protective airway reflexes, breathing, swallowing, and coughing, resulting in an increased risk of significant respiratory events (like PoP) and death. Data demonstrating an association between failure to reverse neuromuscular blockade and adverse postoperative outcomes are less certain. A large case–control database investigation revealed that the primary anesthetic management characteristic associated with a reduction in mortality and coma was reversal of the effects of NMBAs.13 In a “To Reverse or Not To Reverse?”
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