Monitmiorisolcasertadefvers

Monitoraggio della
miorisoluzione in sala
operatoria( e oltre….).
by C.Melloni

Quando?Perchè? Come?

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Innervator Fisher & Paykel e TOfWatch Organon


Innervator (Fischer & Paykel)


Digistim


Metodiche di valutazione della funzione
neuromuscolare
Qualitativa:visiva….
Quali-quantitativa:tattile….
Quantitativa:misurazione della risposta
evocata:FORZA,Accelerazione,EMG,ecc.


Saitoh Y,Narumi Y, Fujii Y, Ueki M.
Tactile evaluation of fade of the train-of-four and doubleburst stimulation using the anaesthetist's non-dominant hand
Br. J. Anaesth. 1999; 83:275-278
We have studied detection of fade in response to train-of-four (TOF), double-burst
stimulation3,3 (DBS3,3) or DBS3,2, assessed tactilely by the anaesthetist using the
index finger of the non-dominant hand and the thumb of the patient, compared with
that assessed when the index finger of the dominant hand was used.
The probability of detection of any fade in response to TOF or DBS3,3 using the nondominant hand was significantly less than when the dominant hand was used
(P<0.05).
The probability of identification of fade in response to DBS3,2 assessed using the nondominant hand was comparable with that evaluated using the dominant hand when
TOF ratios were 0–0.9, but when TOF ratios reached 0.91–1.00,

Detection using the non-dominant hand was significantly
less common than with the dominant hand (12% vs 33%;
P<0.05). Using the non-dominant hand, the probability of detection of fade in

response to ulnar nerve stimulation was less than that with the dominant hand and
only the absence of DBS3,2 fade ensured sufficient recovery of neuromuscular block.

Curar test e apprezzamento tattile


Saitoh Y,Nakazawa K, Makita K,Tanaka H, Amaha K.Evaluation of
Residual Neuromuscular Block Using Train-of-Four and Double Burst
Stimulation at the Index Finger Anesth Analg 1997; 84:1354
% of tactile detection of fade in response to TOF,DBS 3,3 or DBS3,2 at the index
finger compared with that at the thumb during continuous infusion of vecuronium.
105 adult patients were studied. At TOF r (T4/T1) 0.41–0.70, fades in response to TOF
were more frequently identified by tactile means at the index finger than at the thumb
(58% vs 26%, P < 0.05). Similarly, at TOF ratios of 0.61–0.90, fades in

response to DBS3,3 were more frequently detected at the
index finger than at the thumb (55% vs 15%, P < 0.05),
and at TOF ratios of 0.81–1.00, the percentage of
detection of fade in response to DBS3,2 was higher at the
index finger than at the thumb (72% vs 40%, P < 0.05). In
addition, baseline displacement of the index finger or thumb during tactile assessment
of fade in response to neurostimulation was measured videographically.

baseline displacement of the index finger was
significantly less than that of the thumb (P < 0.05).
The

Servizio di Anestesia e Rianimazione
In summary, the percentageOspedale di Faenza(RA)
of tactile detection of fade in response to

GRASS S 79


GRASS ,Datex Relaxograph,Monitoraggio
sala op Cardiocap,Capnomac….


Ingombri in sala op….


RElaxograph Datex


SIU8 e FT10(Grass)


Valutazione della funzione
neuromuscolare
Risposta muscolare evocata…..
dalla stimolazione elettrica
sopramassimale …..
di un nervo periferico…..


Sedi di stimolazione del
n.ulnare


n.tibialis post. stimulation
Flexor hallucis brevis


Stimolazione del
n.peroneale(popliteo lat.)

Estensore hallucis
brevis

Stimolaz.n.ulnare e registraz
EMG dagli interossei dorsali


Sedi degli elettrodi per registrazione
EMG da stimolazione del n.ulnare
Registraz.n dall’eminenza
ipotenar.

Registraz.dall’eminenza tenar


Stimolazione del n.tibiale post
e registrazione EMG


Sedi per elettrodi per
stimolazione del n.faciale


Single twitch;stimolo singolo

onset
Mellonium

TOF,train of four,treno di 4


Tetano

PTP

PTC,post tetanic counting


TOF,DBS e Tetano


Single Twitch (ST)

Tetanic (TET)

Train-Of-Four (TOF)

Post Tetanic Count (PTC)


vocaboli e intervalli della
miorisoluzione
onset/offset
T1
T1/Tc
TOF
ratio
train
5-10-25-50-75-90%
recovery
recovery index:5-95% opp 10-95% opp 25-


T1
100
90
80
70
60
50
40
30
20
10
0

valori assoluti

T1 1
T 1 0,8
T 1 0,6
T1 0,5
T 1 0,2
T 1 0,1
T1

T1/Tc
100
90
80
70
60
50
40
30
20
10
0

T1 1-Tc 1
T 1 0,8-TC 1
T 1 0,6- Tc 1
T1 0,4-Tc 1
T1 0.2-Tc 1

T 1/TC

TOF o TOFr
100
90
80
70
60
50
40
30
20
10
0

I
II
III
IV

tof 1

tofr1


tof 0,5

tof 0,10

altri tof(r)
100
90
80
70
60
50
40
30
20
10
0

I
II
III
IV

tof 0,20

tof 0,05


tof 0

tof 0

valori utili dei tof
100
90
80
70
60
50
40
30
20
10
0

Valore del IV / valore del I

I
II
III
IV

tof
0,05

tof
0,1

tof
0,25


tof
0,50

tof
0,75

RI,ossia recovery index...
100
90
80
70
60
% 50
40
30
20
10
0

RI 5-95

RI 25-75

RI 5-25

T1/TC
5

T1/tc
25

T1/tc
75


T1/TC
95

Campo di applicazione delle differenti
Campo di applicazione delle differenti
modalità di stimolazione
modalità di stimolazione
intraoperatorio

induz iot

mancanza
mant:blocco blocco
di controllo
intenso
moderato antagonismo basale

ST

si

(si)

no

no

no

no

TOF

si

si

no

si

si

si

PTC

no

no

si

no

no

no

DBS no

no

si

no

si,dopo

si

Tet

no

si

no

si,dopo

si

no


Modalità di stimolazione
Modalità di stimolazione
RR
A
ST

no

TOF si
PTC no
DBS si
TET si

Consigli per il monitoraggio
Consigli per
sempre....
Pulizia e sgrassatura della sede scelta
evitare ipotermia sistemica e locale
valutazione tattile
valutare la differente sensibilità dei diversi gruppi muscolari

Indicazioni per il monitoraggio nm
Indicazioni per il monitoraggio nm
sempre???
Insuff renale
renale

possibilità anormalità farmacocinetica

insuff epatica
pazienti critici
estremi d'età

possibilità modificazioni farmacodinamiche

miastenia e sindr.miastenicheSub-points go to the right of
e sindr.miastenicheSub-points go to
right
the main points.
points.

asma bronchiale

per evitare l'antagonismo

quando la funzione nm deve essere assolutamente
normale nel postop

infusioni continue di nmb

cardiopatie severe
cardiopatie severe

ambulatoriali
ambulatoriali
obesi
insuff resp..
resp..

chir.prolungata

Indicazioni per il monitoraggio nm.
Indicazioni per il monitoraggio nm.
sempre?
Siringomielia
Siringomielia

Mal del motoneurone

poliomielite
poliomielite
SLA
SLA
Von Recklinghausen
Von Recklinghausen

malattie neurologiche
Miopatie
Collagenopatie
alterazioni elettrolitiche
interferenze farmacologiche

Sindr.miotoniche
Sindr.miotoniche

Tirotossicosi
Tirotossicosi
Distrofia muscolare
Distrofia muscolare

Problemi della valutazione visiva e/ o tattile
Problemi della valutazione visiva e/ o tattile
usando
usando

ST
ci
vuole
il
basale

TOF
esperienza nel valutare il fade
nel valutare il
sensibilità quando il IV
ricompare..quale è il rapporto
IV/I > 25-30%?

frequenza..


tetano
esperienza
nel valutare
il fade
non ripetibile
< 5 min..

Valutazione tattile
Valutazione tattile

Tetano
DBS
TOF

Relazione fra meccanomiografia e
Relazione fra meccanomiografia e
valutazione tattile
valutazione tattile
Drenck et al.Anesthesiology 79;578:1989.

valutazione
qualitativa del tof

48% di possibilità di non
discriminare un
esaurimento effettivo

valutazione
qualitativa del DBS

9% di possibilità di non
discriminare un
esaurimento reale


Dbs 3-3

Drenck NE, Ueda N, Olsen NV, et al. Manual evaluation of residual curarization using
double burst stimulation: A comparison with train-of-four. Anesthesiology 1989; 70:57881)

Absence of fade with tof implies a 52%
probability than tof>0.60
absence of fade with dbs implies a tof
>0.60 in 91% of cases
only tOFR<0.40 can be assessed manually
therefore,evaluation of DBS is relevant only
when there is no fade to tof


Conclusions:

Drenck NE, Ueda N, Olsen NV, et al. Manual evaluation of residual curarization using
double burst stimulation: A comparison with train-of-four. Anesthesiology 1989; 70:57881)

absence of fade to DBS normally
excludes severe residual nm
blockade(tofr<0.60) BUT DOES
NOT NECESSARILY INDICATE
ADEQUATE CLINICAL
RECOVERY.


Viby-Mogensen J, Jensen NH, Engbæk J, Ørding H,
Skovgaard LT, Chæmmer-Jørgensen B. Tactile and visual
evaluation of response to train-of-four nerve stimulation.
Anesthesiology 1985; 63:440-3.

Diaz/tps/N2O 66%/haloth 0.75-1.5%
IOT with SCC ,then panc
simult MMG in one arm & visual/tactile
evaluation in the opposite.
Experienced and (inexperienced)
anesthesiologists
6 different TOFR from every patient

Viby-Mogensen et al Tactile and visual evaluation of
response to train-of-four nerve stimulation. Anesthesiology
1985; 63:440-3.
100
90
80
70
60
fade
observed 50
40
%
30
20
10
0

true tofr <0.30
true tof 0.31-0.40
true tof 0.41-0.50
true tof 0.51-0.60
true tof 0.61-0.70
true tof>0.70

inexp.observers


exp.observers

Threshold fade by 3 very experienced observers ( VibyMogensen et al. Tactile and visual evaluation of response to train-of-four nerve
stimulation. Anesthesiology 1985; 63:440-3 )

0,7
0,6
0,5
0,4

onset
offset

0,3
0,2
0,1
0

visual

manual


Threshold fade by 3 very experienced observers (Viby-

TOFR

Mogensen et al. Tactile and visual evaluation of response to train-of-four nerve
stimulation. Anesthesiology 1985; 63:440-3.)

1
0,9
0,8
0,7
0,6
0,5

max
min
mean

0,4
0,3
0,2
0,1
0
visual onset

visual recovery

manual onset


manual recovery

Which is the TOFR level that can be reliably
detected visually by observing tetanic fade
of the AP in response to 100-Hz, 5-s tetanus
in anesthetized patients.?


Baurain M,Hennart DA,Godschalx A,Huybrechts I,Nasrallah
G,d'Hollander AA., Cantraine F.Visual Evaluation of Residual
Curarization in Anesthetized Patients Using One HundredHertz, Five-Second Tetanic Stimulation at the Adductor Pollicis
We were looking for a clinical test to indicate a train-of-four (TOF) ratio of
Muscle .Anesth Analg 1998; 87:185–9
approximately 0.9. We compared the adductor pollicis muscle (AP) visually evaluated
response to ulnar nerve 100-Hz, 5-s tetanus (RF100 Hz) with the measured AP TOF
ratio in 30 ASA physical status I or II adult anesthetized (propofol, sufentanil, N2O/O2)
patients. After the induction of anesthesia, the left ulnar nerve was stimulated at the
wrist (single twitch and TOF) and the resultant isometric force was measured. When
TOF was assessed, the independent investigators, unaware of the left AP-measured

TOF ratios, visually evaluated the presence or absence of AP fading elicited by right
ulnar nerve 100-Hz, 5-s tetanus. The 30 patients were randomly allocated to receive
either 0.5 mg/kg atracurium (n = 15) or 0.1 mg/kg vecuronium (n = 15). The
neuromuscular blockade was allowed to resolve spontaneously. A multiple logistic
regression analysis was performed by computing the 771 visual observations. The
probabilities of success of 100-Hz, 5-s tetanus to detect TOF ratios of 0.8, 0.85, and
0.9 were 99%, 96%, and 67%, respectively. The sensitivity and specificity of 100-Hz,
5-s tetanus as an indicator of TOF ratios of 0.85 and 0.9 are 100% and 75%, 54% and
67%, respectively. We conclude that RF100 Hz visual assessment seems to be highly
sensitive in evaluating residual paralysis, as the absence of RF100 Hz visual fading at
the AP is compatibleRianimazione Ospedale di Faenza(RA) Implications: After the administration of
Servizio di Anestesia e with a TOF ratio >0.85.

Baurain et al.Visual Evaluation of Residual Curarization in
Anesthetized Patients Using One Hundred-Hertz, Five-Second
Tetanic Stimulation at the Adductor Pollicis Muscle .Anesth
Analg 1998; 87:185–9


Baurain et al.Visual Evaluation of Residual Curarization in
Anesthetized Patients Using One Hundred-Hertz, FiveSecond Tetanic Stimulation at the Adductor Pollicis
Muscle .Anesth Analg 1998; 87:185–9


Resistenza dei vari gruppi muscolari
Resistenza dei vari gruppi muscolari
Shows sequential relationships

Diaframma

mm.laringei


adduttore
del pollice

Segni clinici
Segni clinici
correlazione con forza residua

collaborazione del paziente!

stretta di un
stretta di un
depressore
depressore
linguale
linguale

sollevamento
sollevamento
testa > 5 sec
testa > 5 sec


sollevamento
sollevamento
arto> 5 sec
arto> 5 sec

stretta di
stretta di
mano
mano
sostenuta
sostenuta

segni clinici
segni clinici
affidabili vs non affidabili
TV normale
TV normale
Press neg < 25 mmHg
Press neg < 25 mmHg
Press neg < 50 mmHg
Press neg < 50 mmHg
tosse
tosse
apertura occhi
apertura occhi
protrusione lingua
protrusione lingua

inaffidabile
inaffidabile
inaffidabile
inaffidabile

affidabile
affidabile

inaffidabile
inaffidabile
inaffidabile
inaffidabile

inaffidabile
inaffidabile

prima che il paziente collabori....
prima che il paziente collabori....

Kopman et al.Relationship of the train of four fade ratio
to clinical signes and symptoms of residual paralysis in
awake volunteers.Anesthesioloogy,1997;86:765-71.

Volontari sani
infusione di mivacurium
monitoraggio Datex 221 NMT
valutazione;stretta di mano
sollev,testa & gamba per 5
sec.
Ritenzione di abbassalingua

Osservazioni cliniche sulla relazione fra
tof e correlati di forza:
disturbi visivi sempre con tof di
0.90(diplopia,diff.seguire oggetti in moto,ecc)
forza dei masseteri ridotta sempre
sollev.testa e gamba sempre possibile > 0.60
stretta di mano variabile,ma 83% del basale a tof
0.90
per tof < 0.75 tutti disturbati

Clinical signs of residual weakness vs tof
at the AP(Kopman,Anesthesiology,1997;86:765-71)

0,90
0,80
0,70
0,60
0,50
0,40
0,30
0,20
0,10
0,00

head lift
leg lift
retain tongue
depressor
lowest tof

highest tof

at which test passed or failed


Conclusioni delle correlazioni fra segni
clinici di forza muscolare e tof
Capacità di ritenzione dell’abbassalingua è
un test più sensibile del sollevamento del
capo
tof <1 ancora residuano disturbi visivi e
senso generalizzato di fatica
tof =1 (o altri monitoraggi) per dimissione
in chirurgia ambulatoriale??

FINE


Mivacurium/Atracurium:1 M.W.,F,63 a,68 kg,154 cm.ASA
2,TIVA Propof/fent/O2/aria. Prop.inf.cont.

Miva 9

Miva 1

Miva 2


Miva 4

Atrac 10

Mivacurium/Atracurium:2

Atrac 10


Miva 4

Atrac 10

Miva 4

Atrac 10


Mivacurium:MA,femm,37 a,75 kg,170 cm.ASA

1,colecistectomia.Prop/fent/isof et 1.0.Rash eritematoso diffuso con lieve
ipotens e bradic!

T1/Tc 90

Mivac 10

Mivac 2


T1/Tc
50

T1/Tc
75

Isof et 0.8:atracurium;ripr
spont.GP,m,56 a,66 kg,160 cm.ASA 2.Tiva prop/fent.TEA sn.

Atrac 50
Atrac
5+ 5


GL,62a,Kg68,169
cm.ASA1,plast.ern.sn.Fent,Prop,isof 0.9 et.

Typical Scc behavior

Scc
60 mg

1


4

6

min

ME,60,52,153,aSA1,mastect.Prop inf cont +
fent.

Pipec spont :long acting...

158


Tof 0.78

BF,68a,66kg,ASA1,colecistect.Fent/prop/isof 0.8 et.

Vecu long acting or potentiation?…….

Vecu 6

5

10

62

67
Vecu 1

Tailoring dosages


min

BF,68a,66kg,ASA1,colecistect..Fent/prop/isof
0.8 et.

Vecu long acting or potentiation?…….in every case,knowledge tailors dosage...

Vec 1

65


105

A1
P2

DPD,59a,90kg.colect con ileoretto..Propof/fent

Long acting...

Panc 0.8

Panc 8

10

15


115

120

125

min

M.A.,48a,65 kg,155 cm.ASA 3,(RAA+ valv.mitraort).VLC..Fent/prop/isof.

Long acting..

iot

PIP
3.2 mg

4


5

66

67

min

VGC,69 kg,iperparatir acuto,Ca+
+11.5.Ter:Clasteon,Lasix,calcitonin,..Fent/Prop

ED95:prudenza per insuff renale o ignoranza dell’ipercalcemia…?

Vecu 4

10

15


20

25

min

PF,69a,62kg,158
cm.ASA3(BPCO,ipertens);neopl
colecist.Hb10.2.Fent,tps,isof et 0.8.

Adjusting reversal...

Tof 0.90

PIP 3.1

3

62

65
A1+P2

70
A0,2+P1

How much reversal is enough?

80

86

R.M.59a,74 kg,160 cm,ASA
2,Quadrantect.,Tiva(fent/prop/O2/air).

At which depth ..?

Ptc 8

cis 8

10

20

Which is the nm blockade depth?

30

min

V.D:,84 a,65 Kg,160
cm.VLC.Tiva(prop/fent/O2/air)

which depth

Cis 6.5

9

14

19

29


?

min

V.D:,84 a,65 Kg,160
cm.VLC.Tiva(prop/fent/O2/air)

At which depth of nm blockade?

29

34

39

44


49

min

B.N.,78 a,76kg,165 cm,ASA
2.TIVA(prop/fent/O2/air).

min

5

10

15

20

Atrac 10

Miva 10

Does not function...?

30

D.A.L,61a,53 kg,ASA2.Stenosi antrale.TPS/Isof.
K+ 2.8-4.2;Hb9,Hct 28.

La prudenza non è mai troppa...

Vecu
3 mg


Vecu 0.5

Residual curarization
Is the main problem?


Frequency of residual
curarization
45
40
35
30
% of patients 25
postop
20
15
10
5
0


vecu
panc

Viby 1979
Beemer
Pedersen
Bevan
Ballard

Ballard et al.Residual curarization in the
recovery room after vecuronium.BJA
2000;84:394-

Incidence of residual block following
vecu evaluated in the RR in 565
patients:
nerve stimulator not used and block not
antagonized
RE:clinicallly significant residual block
found in 42% of patients;33% extubated
before the arrival in RR.

Is your practice
different?


POPC after pancuronium and atracurium(Pedersen AAS
1992;36;312-18)
12
10
8

1559
panc
atrac

% 6
4
2
0

1057
POPC


Viby Mogensen et al,AAS 1997
•
•
•
•

693 paz.randomizzati,cieco
chir elettiva
monitoraggio periop con Myotest e Tof
confronto fra 1-5-2 ED95 di
atrac,vecu,panc.
• Antagonismo se necessario;
• estubaz a tof eguale, tattile e resp adeguata.

Paralisi residua e % di tof<0.40 in RR,subito dopo
trasferimento
45
40
35
30
panc
atrac
vecu

25
20
15
10
5
0

Tof <0.70

tof<0.40


Residual neuromuscular block
and POPC
TOFR

Panc

Atrac &
vecu

>0.7

4,8%

5,4%

<0.7

16,9%*

4,2%


Andamento temporale del tof
<0.80 nella RR

% tof<0.80

50
40
panc
atrac
vecu

30
20
10
0
0

5

10

15

20
min


30

40

50

Risk of POPC following
abdominal surgery
70
60
50
%

40

panc
vecu & atra

30
20
10
0
20

30

40

50

60

age


70

80

Postoperative pulmonary
complications

20
15
10 %

atrac
vecu
panc

5
popc

popc con popc
blocco
senza
residuo blocco
residuo


0

panc
vecu
atrac

Popc secondo il tipo di
chirurgia
16
14
12
10

addom
ortop
ginecol

% 8
6
4
2
0

popc


Fattori di rischio per POPC nello studio
AAS 1997
Tipo di chirurgia;freq * 2-10(addominale)
età:ogni 10 anni * 1.68
durata di anestesia(> o < 200 min)*3.3
panc e tof<0.70:*5


Come evitare il blocco nm
residuo
Non usare miorilass. a lunga azione!
Monitoraggio !!
Come minimo misura il TOFR alla fine
dell’intervento o prima di antagonizzare
valuta sempre la risposta alla stimolazione
nm insieme ai segni clinici…

Clinical tests of postoperative
neuromuscular recovery
Unreliable

Reliable

» sustained eye
»
opening
» tongue protrusion
»
» arm lift to opposite
»
shoulder
» normal TV
»
» normal or near
normal VC
»
» max insp pressure <
= 25 cmH2O

sustained head lift for
5 sec
sustained arm lift for
5 sec
sustained hand grip
for 5 sec
sustained tongue
depressor test
max insp press > 50
cm H2O

Kirkegaard H,Heier T,Caldwell JE Efficacy of tactile guided
reversal from cisatracurium induced neuromuscular
block.Anesthesiology 2002;96:45-50

Anest with fent/prop/N2O
cisatrac 0.15 mg/kg
neostigmine 0.07 mg/kg administered at
reappearance of I,II,III,IV of TOF;tactile
vs Meccanomyography contralateral.


Time from neostigmine
administration to TOFR 0.70
25,00
20,00
low
max
min
mediana

15,00
10,00
5,00
0,00
I twitch

II twitch

III twitch


IV twitch

Time from neostigmine administration
to TOFR 0.80
80
70
60
low
max
min
mediana

50
40
30
20
10
0
I twitch

II twitch

III twitch


IV twitch

Time from neostigmine administration
to TOFR 0.90
80
70
60
low
max
min
mediana

50
40
30
20
10
0
I twitch

II twitch

III twitch


IV twitch

MMG magnitude of the first TOF twitch(T1) measured at the
reappearance of each of the 4 tactile TOF responses.
80
70

T1 %

60
low
max
min
mediana

50
40
30
20
10
0
I twitch

II twitch

III twitch


IV twitch

Kirkegaard H,Heier T,Caldwell JE Efficacy of tactile guided
reversal from cisatracurium induced neuromuscular
block.Anesthesiology 2002;96:45-50

This study shows that achieving a TOFR
of 0.90 in <10 min following neostigmine
reversal is not a realistic goal;therefore
counting the number of tactile responses to tof stimulation
cannot be used as a guide for neostigmine admninistration if
the end point of reversal is a TOFR of 0.90 or higher within
10 min;but

is a good predictor of TOFR

0.70.

Assiomi della ripresa nm.
TOF > 0.70 sicuro indice della ripresa
nm……….. Ali HH, Wilson RS, Savarese JJ, Kitz RJ:
The effect of tubocurarine on indirectly elicited trainof-four muscle response and respiratory
measurements in humans. Br J Anaesth 47:570-4,

1975
Brand JB, Cullen DJ, Wilson NE, Ali HH:
Spontaneous recovery from nondepolarizing
neuromuscular blockade: Correlation between clinical
and evoked responses. Anesth Analg 56:55-8, 1977

Mutazioni occorse
Esplosione della chirurgia ambulatoriale
pressione per la diminuzione della
spesa sanitaria
aumento delle persone anziane e
debilitate anche in chir amb.
Disponibilità di nuovi farmaci


Rivalutazione della pratica
clinica
Età e stato di salute differiscono fra volontari sani e
pazienti!
La prassi clinica e l’utilizzo dei miorilassanti variano fra i
diversi centri ambulatoriali
il monitoraggio degli effetti nm non è praticato in
ospedale,figurarsi nei centri ambulatoriali!
I metodi di monitoraggio usati da Kopman et al si applico
ad una ampia gamma di situazioni cliniche.
Esistono pesanti pressioni economiche per la
diminuzione della spesa sanitaria.

Implicazioni del lavoro di
Kopman:1
I paz chirurgici sono in genere più anziani e ammalati dei
volontari sani dello studio di Kopman/( ASA 1, entro il 15%
del peso ideale,tra 23—33 anni….)
gli effetti residui dei miorilassanti è probabile possano essere
+ significativi nella pratica ambulatoriale con pazienti +
anziani e debilitati.
Si potrebbe arguire che i paz.con sedazione residua siano
meno attenti a disturbi visivi e
debolezza dei muscoli facciali;ma è anche vero che dal punto
di vista della sicurezza i paz postop siano esposti a rischio
maggiore di aumento della morbilità,poichè la debolezza

Implicazioni del lavoro di
Kopman:2
mivacurium non è rappresentativo dei miorilassanti usati in
chir amb;il mercato è dominato dai miorilassanti ad azione
intermedia quali vecuronium, atracurium, rocuronium,
cisatracurium
se una paralisi residua permane per un’ora dopo interruzione
del mivac,caratterizzato da un RI di pochi min,che succede
dopo la somministrazione dei mioril a durata intermedia(RI
20-30 min )?

Conclusions form
Kopman,Brull,Erikkson…..
gli indicatori della ripresa della funzione nm devono
essere modificati.
TOFR <0.9 è sempre accompagnato da disturbi
funzionale del faringe e dei muscoli delle prime vie aeree
e si accompagna a sintomi soggettivi di paralisi parziale
residua
L’assenza di effetti clinici significativi indotti dai
miorilassanti può essere definita come un TOFR = o >
0.90 all’ AP.


Eriksson LI, Sato M, Severinghaus JW. Effect of a vecuronium-induced
partial block on hypoxic ventilatory response. Anesthesiology 1993;
78:693-9.
Eriksson LI. Reduced hypoxic chemosensitivity in partially paralysed
man: a new property of muscle relaxants? Acta Anaesthesiol Scand 1996;
40:520-3.
When awake volunteers received vecuronium, atracurium, and
pancuronium in small doses to stabilize the adductor pollicis (AP)
mechanical train-of-four (TOF) ratio at 0.7, reflex hyperventilation
induced by hypoxemia was depressed, whereas the ventilatory
response to hypercapnia was entirely normal. Absence of
hypoxemia-induced reflex hyperventilation was observed when the
TOF ratio returned to 0.9 .


nmb

Sito nicotinico

ipossia

Corpi carotidei
Sito
muscari
nico

atropina


Ipossia

Chemorecet perif

ipercapnia
Chemrecett.centr SNC


iperventilazione

Conclusioni
Esiste evidenza sperimentale e
clinica che i nmb nondepolarizzanti
inteferiscano con il controllo della
ventilazione in condizioni di
ipossia,verosimilmente attraverso
una depressione reversibile della
attività chemorecettoriale dei corpi
carotidei
implicazioneclinica

Problems of tactile or visual assesment
using
ST
basal

TOF
fade assessment needs
experience

frequence..
sensibility when IV reappears:which
is the IV/I ratio > 25-30%?


tetanic
fade assessment
needs experience
do not repeat < 5
min..

Correlazione soggettiva-oggettiva(palpazionemeccanomiografia)

1 Twitch= T110%
3 twitches=T1 25%


tactile assessment
tactile assessment

Tetanus
DBS
TOF

Clinical signs
Clinical signs
correlation with residual force

patient cooperation!

tongue
tongue
depressor
depressor
clenching
clenching

head lift
head lift
> 5 sec
> 5 sec


arm or leg
arm or leg
lift> 5 sec
lift> 5 sec

sustained
sustained
hand grip
hand grip
strenght
strenght

clinical signs
reliable vs not reliable
reliable vs not reliable

TV normal
TV normal

Neg Press < 25 mmHg
Neg Press < 25 mmHg

Neg press < 50 mmHg
Neg press < 50 mmHg

cough
cough

eye opening
eye opening

tongue protrusion
tongue protrusion

unreliable
unreliable
unreliable
unreliable

reliable
reliable

unreliable
unreliable

unreliable
unreliable

unreliable
unreliable

before patient cooperationri....
before patient cooperationri....

Special neuromuscular
monitoring
Mantiene quello che
promette?

TOF,DBS , Tetanus


Percentage of tactile detection of fade in response to TOF at the index
finger compared with that at the thumb during continuous infusion of
vecuronium (Saitoh Y,Nakazawa K, Makita K,Tanaka H, Amaha K.Evaluation of Residual

Neuromuscular Block Using Train-of-Four and Double Burst Stimulation at the Index Finger Anesth
Analg 1997; 84:1354)

True tof

100
90

<0,20
0,21--0.30
0,31-0,40
0,41-0,50
0,51-0,60
0,61-0,70
0,71-0,80
0,81-0,90
>0,90

80
70
60
true TOFR 50
40
30
20
10
0

index


thumb

finger compared with that at the thumb during continuous infusion of
vecuronium (Saitoh Y,Nakazawa K, Makita K,Tanaka H, Amaha K.Evaluation of Residual
Neuromuscular Block Using Train-of-Four and Double Burst Stimulation at the Index Finger
Anesth Analg 1997; 84:1354)

100
90
80

0-0,40
0,41-0,50
0,51-0.60
0,61-0,70
0,71-0,80
0,81-0,90
>0,90

70

true
TOFR

60
50
40
30
20
10
0

index

thumb

At TOFR>0.60 fade at index 55% vs thumb 15%


burst stimulation decreases, but not eliminates, the
problem of postoperative residual paralysis. Acta
Anaesthesiol Scand 1998; 42:1168-74
BACKGROUND: Routine perioperative monitoring with accelero-myography might
prevent residual block, whereas routine tactile evaluation of the response to train-offour (TOF) nerve stimulation does not. The purpose of this prospective, randomised
and blinded study was to evaluate the effect of manual evaluation of the response to
double burst stimulation (DBS3.3) upon the incidence of residual block. METHODS:
Sixty adult patients scheduled for elective abdominal surgery were included in the
study. Pancuronium 0.08 to 0.1 mg kg-1 was given for relaxation and tracheal
intubation. For maintenance of neuromuscular block, pancuronium 1-2 mg was
administered. The patients were randomly allocated into two groups. In group DBS
(double burst stimulation) the degree of block during anaesthesia was assessed by
manual evaluation of the response to TOF nerve stimulation. During reversal, when no
fade was detectable in the TOF response, the stimulation pattern was changed to
DBS3.3. The trachea was extubated when the anaesthetist judged the neuromuscular
function to have recovered adequately and no fade in the DBS3.3 response could be
felt. In group CC (clinical criteria) patients were managed without the use of a nerve
stimulator, and the level of neuromuscular block and reversal were evaluated solely on
the basis of clinical criteria. In both groups, the TOF ratio was measured by
mechanomyography immediately after tracheal extubation. Also, the ability to sustain
Servizio
Anestesia e Rianimazione Ospedale di Faenza(RA)
head lift fordi5 s, to protrude the tongue, to open the eyes, and to lift one arm to the

Shorten GD, Merk H, Sieber T. Perioperative
train-of-four monitoring and residual
curarization. Can J Anaesth 1995; 42:711-15
It has been suggested that perioperative train-of-four (TOF) monitoring
does not reduce the incidence of postoperative residual curarization
(PORC). The purpose of this study was to examine whether the use of
tactile assessment of the response of the adductor pollicis to
supramaximal TOF stimulation of the ulnar nerve at the wrist during
anaesthesia affected the incidence of PORC. Thirty-nine ASA I or II
surgical patients were studied during thiopentone/fentanyl
N2O/enflurane anaesthesia. Pancuronium (70-100 micrograms.kg-1)
was used to facilitate tracheal intubation and additional pancuronium
increments used to maintain surgical relaxation. The requirement for
incremental doses of pancuronium and adequacy of recovery following
reversal were assessed according to random allocation, either with
(Group A; n = 20) or without (Group B; n = 19) access to TOF
monitoring. Patients in the two groups received neostigmine in similar
doses (Group A: 53 micrograms.kg-1 (5.9); Group B: 55
micrograms.kg-1 (5.4)). On arrival of the patient to the recovery area,
neuromuscular function was assessed electromyographically (using
the Datex NMT 221 Rianimazione Ospedale di Faenza(RA)and clinically. The incidence
to measure TOF ratio)
Servizio di Anestesia e
of PORC (TOF ratio < 70%) was greater in Group B (47%) than in

Pedersen T, Viby-Mogensen J, Bang U, Olsen NV, Jensen E, Engbæk J.
Does perioperative tactile evaluation of the train-of-four response
influence the frequency of postoperative residual neuromuscular
blockade? Anesthesiology 1990; 73:8359
The authors conducted a randomized controlled clinical trial to evaluate the
usefulness of perioperative manual evaluation of the response to train-of-four (TOF)
nerve stimulation. A total of 80 patients were divided into four groups of 20 each. For
two groups (one given vecuronium and one pancuronium), the anesthetists assessed
the degree of neuromuscular blockade during operation and during recovery from
neuromuscular blockade by manual evaluation of the response to TOF nerve
stimulation. In the other two groups, one of which received vecuronium and the other
pancuronium, the anesthetists evaluated the degree of neuromuscular blockade solely
by clinical criteria. The use of a nerve stimulator was found to have no effect on the
dose of relaxant given during anesthesia, on the need for supplementary doses of
anticholinesterase in the recovery room, on the time from end of surgery to end of
anesthesia, or on the incidence of postoperative residual neuromuscular blockade
evaluated clinically. The median (and range of) TOF ratios recorded in the recovery
room were 0.75 (0.33-0.96) and 0.79 (0.10-0.97) in the vecuronium groups monitored
with and without a nerve stimulator, respectively. These ratios were significantly higher
than those found in the pancuronium groups, which wre 0.66 (0.06-0.90) and 0.63
(0.29-0.95), respectively. However, no difference was found between the vecuronium
and pancuronium groups in the number of patients showing clinical signs of residual
neuromuscular blockade, as evaluated by the 5-s head-lift test.(ABSTRACT

Recovery from neuromuscular blockade: residual curarisation
following atracurium or vecuronium by bolus dosing or
infusions. Acta Anaesthesiol Scand 1995; 39:288-93.
AB - We conducted a survey of the incidence of Postoperative Residual Curarisation
(PORC) in two groups of patients following the use of atracurium or vecuronium. In the
first group (B) the neuromuscular blocking drugs were administered by bolus dosing,
and in the second group (I) by continuous fusion. On arrival in the recovery room,
neuromuscular function was assessed both by compound evoked electromyogram
(EMG) in a train of four pattern and also clinically, by the ability to sustain a headlift for
> 5 seconds, and to cough. Results were obtained from 150 patients (100 in group B
and 50 in group I). The incidence of PORC, as defined by a train of four ratio of < 0.7,
on arrival in the recovery room was 12% in group B, and 24% in group I. Clinical
criteria of adequate neuromuscular reversal revealed different results, with the majority
of patients being unable to perform either clinical test on arrival in recovery. Those
patients in whom a peripheral nerve stimulator was used intra-operatively did not have
a reduced incidence of PORC. We have demonstrated that PORC is still a common
occurrence even with intermediate duration of action neuromuscular blocking drugs.


Baillard C, Gehan G, Reboul-Marty J,
Larmignat P, Samama CM, Cupa M. Residual
curarization in the recovery room after
vecuronium. Br J Anaesth 394-5; 2000:84.
2: Viby-Mogensen J, Jørgensen BC, Ørding
M. Residual curarization in the recovery room.
Anesthesiology 1979; 50:539-41.
3: Bevan DR, Smith CE, Donati F.
Postoperative neuromuscular blockade: a
comparison between atracurium, vecuronium,
and pancuronium. Anesthesiology 1988;
69:272-6.


Reboul-Marty, J.2; Larmignat, P.1; Samama, C.
M.1; Cupa, M.1
Br. J. Anaesth. 2000; 84
residual block after
anaesthesia(propof/fent/isof)
only vecuronium but no anticholinesterase
568 consecutive patients
on admission to the recovery room. The ulnar
nerve was stimulated submaximally using
TOF stimulation (30 mA). Postoperative
residual curarization was defined as a TOF
ratio <0.7

Reboul-Marty, J.2; Larmignat,
P.1; Samama, C. M.1; Cupa, M
. Of the 568 patients, 239 (42%) had a TOF
<0.7 in the recovery room. These patients had
received a larger cumulative dose of
vecuronium than patients who had full
recovery (mean 7.7 (SD 3.6) mg vs 6.2 (2.7)
mg; P<0.05) and a shorter time had elapsed
since the last vecuronium dose (117 (70) min
vs 131 (80) min; P<0.05). Of 435 patients
whose trachea was extubated, 145 (33%)
exhibited inadequate recovery from
neuromuscular block. Six of these had one or
no response to TOF stimulation and were


Reboul-Marty, J.2; Larmignat,
P.1; Samama, C. M.1; Cupa, M


Inadequate recovery from nm
block:lieteraure data
author

year

Nm
blocker

Adm
mode

Baillard

200 BJA

Vecu

intermitte
nt


Assessm
ent:intrao
p/RR
Clinical/ac
cel

% of
inadeq
reversal
42%

Residual block after mivacurium with or
without edrophonium reversal in adults and
children. Anesthesiology 1996; 84:362-7.
AB - BACKGROUND: The rapid recovery
from mivacurium- induced neuromuscular
block has encouraged omission of its reversal.
The purpose of this study was to determine, in
children and in adults, whether failure to
reverse mivacurium neuromuscular block was
associated with residual neuromuscular block
on arrival in the postanesthesia care unit.
METHODS: In 50 children, aged 2-12 yr, and
50 adults, aged 20-60 yr, anesthesia was
induced and maintained with propofol and
fentanyl, and neuromuscular block was


Dubois PE,Broka S,Joucken KL. TOF-Tube
Anesth Analg 2000; 90:232
We would like to present a hand and forearm protection device that
optimizes the monitoring of neuromuscular function by acceleromyography in a maximum of surgical procedures while reducing spatial
obstructions and offering maximal protection to the patient. In our
opinion, this constitutes an evolution compared with the setting systems
currently used for this purpose.
The structure is tubular () and made out of rigid composite materials.
Its limited length (35 cm) prevents any compression lesion around the
elbow. Its large diameter ovoid section (13 cm ´ 11 cm) allows the
inserting of hands of any size and insures total thumb mobility. Two of
the extremities on this apparatus are cut off in order to permit the
fingers and the fore-arm to be set, whereas an internal fixation insures
the stability of the wrist. A groove located on the upper part of the tube
allows for the adaptation of an elastic preload of the thumb, thereby

Dubois, Philippe E., MD; Broka, Serge M.,
MD; Joucken, Kurt L., MD
Anesth Analg 2000; 90:232


Biblio da cercare
Fawcett WJ, Dash A, Francis GA, Liban JB, Cashman JN. Recovery from neuromuscular
blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions.
Acta Anaesthesiol Scand 1995; 39:288-93.
Fruergaard K, Viby-Mogensen J, Berg H, El-Mahdy AM. Tactile evaluation of the response to
double burst stimulation decreases, but not eliminates, the problem of postoperative residual
paralysis. Acta Anaesthesiol Scand 1998; 42:1168-74
Beemer GH, Reeves JH, Bjorksten AR. Accurate monitoring of neuromuscuiar blockade using a
peripheral nerve stimulator: a review. Anaesth Intensive Care 1990; 18A90‑496.
Hayes AH, Mirakhur RK, Breslin DS, at al. Postoperative residual block after intermediate‑acting
neuromuscular blocking drugs. Anaesthesia 2001; 56:312‑318.


Different muscle groups resistance
Different muscle groups resistance
Shows sequential relationships

Diaphragm

mm.larinx


adductor
pollicis

Comparison of double-burst and train-of-four stimulation to
assess neuromuscular blockade in children. Anesthesiology
1990; 73:401-3
Double-burst stimulation (DBS), a new technique to evaluate neuromuscular function,
consists of two 50-Hz trains of 60-ms duration and 750 ms apart. DBS was compared
with train-of-four (TOF) stimulation in 21 children aged 3-10 yr, during halothane
anesthesia. On one arm the ulnar nerve was stimulated supramaximally with TOF
stimulation every 12 s and the force of the evoked contraction of the adductor pollicis
measured with an FTO3 force transducer and recorded on paper. Atracurium (0.4-0.5
mg.kg-1) was administered. During recovery from neuromuscular blockade, TOF
stimulation was interrupted periodically and DBS substituted. The same stimulation
patterns were applied to the ulnar nerve of the other arm simultaneously, and the
clinical anesthesiologist was asked to estimate the degree of fade with both. There
was good correlation between the measured TOF ratio (ratio of fourth to first
response) and DBS ratio (ratio of second to first response). The TOF and DBS ratios
above which fade could no longer be appreciated manually were (mean +/- SEM) 0.44
+/- 0.03 and 0.67 +/- 0.04 (P = 0.0002). Corresponding ranges were 0.3-0.8 for TOF
and 0.4-0.9 for DBS, but DBS fade was always apparent if TOF fade could be
detected. Therefore, in children, DBS is more sensitive than is TOF stimulation for the
clinical assessment of recovery from neuromuscular blockade.

Saddler et al Comparison of double-burst and train-of-four
stimulation to assess neuromuscular blockade in children.
Anesthesiology 1990; 73:401-3

Children 3-10 years
TPS/N2O/haloth
atracurium 0.4-0.5 mg/kg
MMG
TOF vs DBS,MMG vs tactile.visual


Saddler et al Comparison of double-burst and train-of-four
stimulation to assess neuromuscular blockade in children.
Anesthesiology 1990; 73:401-3

TOF & DBS linearly related close to 1
anesthesioogist tended to overestimate
recovery with tof and DBS
fade could no longer be detected at a
value of TOF 0.44+/-0.03
with DBS fade detected until tof 0,67+/0.04

17 O'Hara DA, Fragen RJ, Shanks CA.
Comparison of visual and measured
train‑of‑four recovery after
vecuronium‑induced neuromuscular blockade
using two anaesthetic techniques. Br J
Anaesth 1986; 58:1300‑1302.
18 Kopman AF. Tactile evaluation of
train‑of‑four count as an indicator of reliability
of antagonism of vecuronium ‑ or
atracurium‑induced neuromuscular blockade.
Anesthesiology 1991; 75:588‑593.
19 Lien CA, Belmont MR, Abalos A, at al. The


Corrispondenza(approx)fra blocco %
Corrispondenza(approx)fra blocco %
recettoriale,ST,TOF durante blocco
recettoriale,ST,TOF durante blocco
competitivo
competitivo
blocco recettoriale T1 % T4%

TOFr

100

0

0 0

90-95

0

0 T1 perd

10

5

T O FR

0
I

II

I II

IV

20
15

85-90

10

0 T2 perd

10

TOFR

5
0

80-85

20-25

0 T3 perd

I

II

III

IV

30

75-80
75

80-90
100

48-58 0.60-0.70
75-100 0.75-1

20
T O FR

10
0
I

II

III

IV

1 00

50

100

100 1

50

T OFR

0


I

II

III

IV

Monitmiorisolcasertadefvers

Recommended

Recommended

More Related Content

What's hot

What's hot (6)

Viewers also liked

Viewers also liked (7)

Similar to Monitmiorisolcasertadefvers

Similar to Monitmiorisolcasertadefvers (20)

More from Claudio Melloni

More from Claudio Melloni (20)

Monitmiorisolcasertadefvers

Editor's Notes