Determination of the timing of reversal for the rapid recovery from cisatracurium

Abstract

배경 : Neostigmine의 최대 효과는 근이완제 역전 후 10-20분 후에 나타난다. 이 기간 안에 cisatracurium에 의한 적절한 근이완의 역전 수준까지 도달하기 위한 neostigmine의 투여 시점을 알아보고자 한다. 방법 : 전향적 무작위 배정 임상 연구로 계획하였고 만성중이염 치료를 위한 수술을 받는 48명의 성인을 대상으로 하였다. 전신마취는 propofol과 remifentanil로 전정맥마취를 목표농도조절주입펌프를 이용하여 시행하였고, TOF-Watch SX® 과 기존의 신경자극기를 각각 양팔에 부착하고 TOF-Watch SX® 를 부착한 팔은 관찰자가 볼 수 없도록 가리개가 장착한 상태로 기저 TOF 비가 12초 간격으로 컴퓨터 프로그램을 통해 자동적으로 수집하였고 다른 팔은 신경자극기로 train-of-four (TOF) 또는 double-burst-stimulation (DBS) 자극한 후에 촉진하였다. 0.15mg/kg 의 cisatracurium을 마취 유도시에 투여하였고 TOF 4 군은 TOF 자극시 4번째 자극에 대한 반응이 있을 경우, DBSfade 군은 DBS에 대한 자극의 fade가 사라진 순간, TOFfade 군은 TOF에 대한 자극의 fade가 사라진 순간에 neostigmine 0.07mg/kg를 투여하였다. Neostigmine 투여후부터 TOF 비가 0.7, 0.8, 그리고 0.9가 되는 시간을 각각 측정하였다. 결과: Neostigmine 투여후부터 TOF 비가 0.9가 되는 시간은 12.6 ± 6.2, 10.1 ± 8.0, 그리고 9.1 ± 6.8분 (TOF4군, DBSfade군, 그리고 TOFfade군) 이었다. Neostigmine 투여후 10분에 TOF 비가 0.9이상이었던 환자는 50%, 63%, 그리고 69% 였고 근이완 역전제 투여 15분 후에는 81.3%, 87.5%, 그리고 81.3%였으며 각 군 간의 유의미한 통계학적인 차이는 없었다. Cisatracurium 투여 후 neostigmine 투여까지의 시간은 TOFfade군(69.3 ± 8.3 분)에서 TOF4군과 DBSfade군 (61.0 ± 8.3, 61.0 ± 7.3) 보다 유의미하게 길었다. (p=0.006). 결론: 결론적으로 적절한 시간 안에 TOF비 0.9이상 근이완을 역전하기 위해서는 TOF 자극시 4번 촉지될 때 또는 DBS시 fade가 사라진 순간 neostigmine을 투여하는 것을 추천한다.

Background: The maximal effect of neostigmine occurs within 10-20 min after intravenous administration, and adequate recovery from neuromuscular block within this period is recommended. We aimed to identify the appropriate time for neostigmine administration to achieve optimal recovery from a cisatracurium-induced neuromuscular block within this period. Methods: In this prospective randomized controlled study, forty-eight adults undergoing surgery for chronic otitis media were analyzed. Anesthesia was induced and maintained with a targeted and controlled infusion of propofol and remifentanil. TOF-Watch SX® and conventional nerve stimulators were applied to each arm. One arm was monitored for the evaluation of a tactile thumb response, and the other arm that was monitored to obtain train-of-four (TOF) ratios was shielded from the investigator whose data were collected using a laptop. Patients received 0.15 mg/kg of cisatracurium at induction and were randomized to receive neostigmine according to the following tactile responses: the appearance of a fourth TOF response (TOF4 group, n=16), absence of a fade to double burst stimulation (DBS) (DBSfade group, n=16), and absence of a fade to TOF stimulation (TOFfade group, n=16). The time from the administration of neostigmine to TOF ratios of 0.7, 0.8, and 0.9 were evaluated. Results: The demographic data were not different among the groups. The times from the administration of neostigmine to TOF ratios of 0.9 were 12.6 ± 6.2, 10.1 ± 8.0, and 9.1 ± 6.8 min in theTOF4, DBSfade, and TOFfade groups, respectively. At 10 min after the administration of neostigmine, the percentage of patients with a TOF ratio greater than 0.9 were 50%, 63%, and 69% in the TOF4, DBSfade, and TOFfade groups, respectively. At 15 min after reversal, 81.3%, 87.5%, and 81.3% of the patients in the TOF4, DBSfade, and TOFfade groups, respectively, had TOF ratio values greater than 0.9 (no intergroup differences). The time from the injection of cisatracurium to the administration of neostigmine (69.3 ± 8.3 min) was significantly longer in the TOFfade group compared with the DBSfade and TOF4 groups (61.0 ± 8.3 and 61.0 ± 7.3

p=0.006). Conclusion: We recommend administering neostigmine with the appearance of the fourth tactile response to TOF or the absence of a fade to DBS to recover from a cisatracurium-induced neuromuscular block to achieve a TOF ratio of 0.9 or more within a reasonable time.