围术期神经肌肉阻滞的管理:欧洲麻醉和重症监护学会临床指南

Peri-operative management of neuromuscular blockade:a guideline from the European Society of Anaesthesiology and Intensive Care

近来的研究表明,由于围术期神经肌肉阻滞管理不当,肌肉松弛药(肌松药)残留阻滞及其术后并发症的发生率居高不下。需要重视神经肌肉功能监测仪、肌松药及其拮抗剂的合理应用,以利于改善神经肌肉阻滞管理。欧洲麻醉和重症监护学会(European Society of Anaesthesiology and Intensive Care,ESAIC)首次发布围术期神经肌肉阻滞管理临床指南,旨在为临床医生提供最佳医疗管理的循证建议,以提高围术期患者安全。本指南主要聚焦在3个临床问题:肌松药是否有助于成人气管插管?神经肌肉阻滞深度是否影响腹部手术患者的预后?肌松药残留阻滞的诊断和治疗策略有哪些?根据PICO原则(患者、干预、对照、结局;patient,intervention,comparator,outcome;PICO)构建临床问题并进行文献检索。初始纳入的临床研究为24 000篇,采用逐步筛选策略,最终临床研究88篇纳入指南分析。应用GRADE方法学(Grading of Recommendations,Assessment,Development and Evaluation,GRADE)对结局指标证据、质量等级进行评价。运用两轮德尔菲法收集专家组建议并形成统一推荐:R1推荐应用肌松药辅助气管插管(1A)。R2推荐应用肌松药以减少气管插管导致的咽部和(或)喉部损伤(1C)。R3推荐在快速顺序诱导插管(rapid sequence induction intubation,RSII)时使用短效肌松药,例如琥珀胆碱1 mg/kg或罗库溴铵0.9~1.2 mg/kg(1B)。R4推荐在需要改善外科手术条件时,加深神经肌肉阻滞深度(1B)。R5尚无足够的证据推荐深度神经肌肉阻滞可减轻术后疼痛或降低围术期并发症的发生率(2C)。R6推荐在拇内收肌处刺激尺神经,定量监测神经肌肉阻滞深度以排除肌松药残留阻滞(1B)。R7推荐应用舒更葡糖钠逆转甾体类肌松药(罗库溴铵、维库溴铵)诱导的深、中及浅度神经肌肉阻滞(1A)。R8推荐在使用新斯的明前,TOFr自行恢复至>0.2,并继续定量监测神经肌肉功能,直至TOFr超过0.9(1C)。

Recent data indicated a high incidence of inappropriate management of neuromuscular block,with a high rate of residual paralysis and relaxant-associated postoperative complications.These data are alarming in that the available neuromuscular monitoring,as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade.In this first European Society of Anaesthesiology and Intensive Care(ESAIC)guideline on peri-operative management of neuromuscular block,we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety.We identified three main clinical questions:Are myorelaxants necessary to facilitate tracheal intubation in adults?Does the intensity of neuromuscular blockade influence a patient′s outcome in abdominal surgery?What are the strategies for the diagnosis and treatment of residual paralysis?On the basis of this,PICO(patient,intervention,comparator,outcome)questions were derived that guided a structured literature search.A stepwise approach was used to reduce the number of trials of the initial research(n=24000)to the finally relevant clinical studies(n=88).GRADE methodology(Grading of Recommendations,Assessment,Development and Evaluation)was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality.A two-step Delphi process was used to determine the agreement of the panel members with the recommendations:R1 We recommend using a muscle relaxant to facilitate tracheal intubation(1A).R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation(1C).R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation(RSII)such as succinylcholine 1 mg/kg or rocuronium 0.9 to 1.2 mg/kg(1B).R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved(1B).R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications(2C).R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis(1B).R7 We recommend using sugammadex to antagonise deep,moderate and shallow neuromuscular blockade induced by aminosteroidal agents(rocuronium,vecuronium)(1A).R8 We recommend advanced spontaneous recovery(i.e.TOF ratio>0.2)before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained(1C).