#46
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Öèòàòà:
Unlearned. Part II: Methods to Reduce the Risk of Residual Weakness CONCLUSIONS Careful neuromuscular management may reduce the risk of postoperative residual weakness and its associated com- plications. Available data suggest that adherence to evidence-based practices related to NMBD dosing, moni- toring, and reversal may improve patient outcomes during the early recovery period from anesthesia and surgery. Based on the evidence presented, it seems reasonable to offer the following suggestions regarding the perioperative care of the surgical patient: 1. General Principles for Avoidance of Residual Paralysis • NMBDs should only be administered to patients who require this therapy. Dosing should be indi- vidualized based on surgical necessity, patient factors, and presence of coexisting disease. • Long-acting NMBDs (e.g., pancuronium) should be avoided. Intermediate-acting NMBDs should be used whenever feasible. • Clinical tests of muscle function (head lift, jaw clenching, grip strength, tidal volume, etc.) are unreliable predictors of recovery of neuromuscu- lar function. • To exclude with certainty the possibility of re- sidual paralysis in patients at risk, clinicians should use objective (quantitative) neuromuscu- lar monitoring tests. • Ideally, neuromuscular function should be moni- tored objectively (quantitatively) in all patients receiving NMBDs. 2. Principles of Monitoring in Clinical Practice • Objective (quantitative) monitoring of neuro- muscular function should be used. • Peripheral nerve stimulator units should display the delivered current output, which should be at least 30 mA. • Assessment of neuromuscular responses should take into consideration the musculature group that is monitored. The time course (onset, recov- ery) of muscle relaxants is different at peripheral muscles (adductor pollicis) than at central muscles (orbicularis oculi, corrugator supercilii). • Adequate spontaneous recovery (TOF count of 4) should be established before pharmacologic an- tagonism of NMBD block with anticholinester- ases. This requirement does not apply to reversal with sugammadex. • Tactile evaluation of TOF and DBS fade reduces (but does not eliminate) the incidence and degree of postoperative residual paralysis compared with the use of clinical criteria to assess readiness for tracheal extubation. 26,88,89 • The timing of tracheal extubation should be guided by quantitative monitoring tests such as TOF 0.9 or DBS3,3 0.9. 3. Principles for Pharmacologic Reversal with Anticholinesterases • During anesthetic techniques that do not en- hance the effects of muscle relaxants (such as total IV anesthesia), a minimal TOF count of 2 should be present before administration of anticholinesterases. 90 • During anesthetic techniques that enhance the ef- fects of muscle relaxants (such as inhaled volatile anesthesia), a TOF count of 4 should be present before administration of anticholinesterases. 19,90 • If recovery to TOF 0.90 is documented byMMG (quantitatively), neostigmine administration should be withheld. Administration of neostig- mine to fully recovered patients may decrease upper airway muscle activity and tidal volume. 64 4. Reversal Considerations in Clinical Practice A. No neuromuscular monitor or peripheral nerve stimulator used. i. Clinical tests of adequacy of reversal are unreliable—pharmacologic reversal should be administered routinely and only when spon- taneous muscle activity is present. B. Peripheral nerve stimulator—subjective (visual, tactile) assessment i. TOF count 1 or no TOF response—delay reversal. ii. TOF count 2 or 3—administer pharmaco- logic reversal. iii. TOF with fade (TOF 0.40)—administer pharmacologic reversal. iv. TOF with no perceived fade (TOF 0.40)—administer pharmacologic reversal, consider low dose (20 g/kg) of neostig- mine. 91 C. Quantitative evoked response monitor (e.g., AMG, KMG, and EMG) i. No TOF response or TOF count of 1—delay reversal. ii. TOF count 2 or 3—administer pharmaco- logic reversal. iii. TOF 0.40—administer pharmacologic versal. iv. TOF 0.40 to 0.90—administer pharma logic reversal, consider low dose (20 g/ of neostigmine. v. TOF 0.90—no reversal recommended. |
#47
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Öèòàòà:
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#48
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Èìåþ æåëàíèå êóïèòü êî... ïîëüçîâàòüñÿ èíãàëÿöèîííûìè àíåñòåòèêàìè, íî íå èìåþ âîçìîæíîñòè
Âñïîìèíàþ êàðòèíêè èç ïðîñïåêòîâ äèïðèâàíà â æóðíàëå "Àíåñòåçèîëîãèÿ è ðåàíèìàòîëîãèÿ" (âûïèñûâàë â äîèíòåðíåòíóþ ýïîõó) - äîâîëüíîå ëèöî ïàöèåíòà, "êîìôîðò ïàöèåíòà, ýêîíîìèÿ ðåñóðñîâ è âðåìåíè ïåðñîíàëà çà ñ÷åò áûñòðîãî âîññòàíîâëåíèÿ". Ëè÷íî ÿ íà ýòó íåõèòðóþ ðåêëàìíóþ óäî÷êó ïîïàëñÿ. Ïðåäïî÷èòàþ èç äîñòóïíûõ âèäîâ îáùåé àíåñòåçèè ÒÂÂÀ - ôåíòàíèë, ïðîïîôîë. Íî ïðåèìóùåñòâà òàêîé êîìáèíàöèè ðåàëèçóþòñÿ òîëüêî ïðè äîñòàòî÷íî áûñòðîé ýêñòóáàöèè. Èíà÷å íåò ðàçíèöû ñ òèîïåíòàëîì-äèàçåïàìîì, åñëè åùå ÷àñ âåíòèëèðîâàòü-ñåäèðîâàòü. Âîò è âûõîäèò, áåç ïðîçåðèíà íèêóäà Ýòî, êîíå÷íî, ïîêà íå ïîäâåçëè ýñìåðîí-ñóãàììàäåêñ |
#49
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Îáðàùàÿñü åùå ðàç ê Valeriy, íå ìîãó íå ñîãëàñèòüñÿ, ÷òî âåñòè áîëüíîãî ÷àñ íà ïðîïîôîëå à ïîòîì 2 ÷àñà â ÎÈÒ íà ñèáàçîíå äåéñòâèòåëüíî ãëóïî. È âñå-òàêè, áîëüøèíñòâî àïïåíäèöèòîâ, ïîëó÷èâøèõ íà "ñòàðòå" 4 ìã àðäóàíà (èëè ïðåäëîæåííûå óæå 6) ìîãóò â ñëó÷àå êðàéíåé íåîáõîäèìîñòè â ñòðàíàõ ïîñòñîâåòñêîãî ïåðèîäà äîïîëó÷èòü ïî õîäó 1-2 àìïóëû äèòèëèíà (íå ìåíåå íàó÷íî, ÷åì 4ìë êîðäèàìèíà)è áûòü ýêñòóáèðîâàííûìè âñêîðå ïîñëå ïîñëåäíåãî øâà. Áîëüíîé òî "âñòàë" íå ïîòîìó, ÷òî ðåëàêñàíòà íå õâàòèëî - ýòî îí ñìîã ñäåëàòü, ïîòîìó ÷òî ðåëàêñàíòà, à âñòàë, ïîòîìó ÷òî ïðîñíóëñÿ. À ñïàë áû, è íå óçíàë áû, ÷òî àðäóàíà ìàëîâàòî, íå áîã âåñòü êàêàÿ îïåðàöèÿ ñ íèì ïðîèñõîäèò. Äëÿ áîëüøèíñòâà àïïåíäèöèòîâ äåêóðàðèçàöèÿ íå íóæíà. À äëÿ áîëüøèíñòâà ðåçåêöèé æåëóäêà îíà òîæå íå íóæíà, ïîòîìó ÷òî íàó÷íî îáîñíîâàòü ôàðìàêîäèíàìèêó àðäóàíà â êîíöå 3-÷àñîâîé îïåðàöèè, êîãäà åùå õèðóðãè ïàðó ðàç ïîïðîñèëè "äîáàâèòü", óæå âðÿä ëè âîçìîæíî, êàê è ïðîãíîçèðîâàòü õîä "äåêóðàðèçàöèè". Áåçîïàñíî ýêñòóáèðîâàòü ïîñëå äëèòåëüíûõ îïåðàöèé "ñ ïîñëåäíèì øâîì" ìîæíî ïðè ïðèìåíåíèè ðåëàêñàíòîâ ìåíåå äëèòåëüíîãî äåéñòâèÿ, æåëàòåëüíî â âèäå "öåëåâîé" èíôóçèè, îñòàëüíîå - òâîð÷åñòâî ( â õîðîøåì ñìûñëå ýòîãî ñëîâà) â âûáîðå ïðîñòðàíñòâåííî-âðåìåííîãî ñîîòíîøåíèÿ ïîñëåäíèõ äîç ãèïíîòèêîâ è ðåëàêñàíòîâ . Íó ðàçâå íå òàê?
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#51
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Ñêàæó ïî ñåêðåòó, Valery, íàñ òàê íåêîòîðûå íàøè àíåñòåçèîëîãè ðàçâëåêàþò. Ââîäÿò 16ìã àðäóàíà â èíäóêöèè, ïðîâîäÿò îïåðàöèþ íà ñåðäöå êðóòî, íà èçîôëþðàíå (äàæå íà ýòàïå ÀÈÊà, çàìåòüòå, íå íà âíóòðèâåííûå ïåðåõîäÿò, à èìåííî ïîäà÷ó ãàçà â ÀÈÊ îñóùåñòâëÿþò), à ìû ïîòîì â ÎÈÒ ñåäèðóåì ÷àñîâ 8-10, ïîòîìó ÷òî áîëüíîé ñåáÿ ñîáðàòü íå ìîæåò. Âîïðîñ íàïðàøèâàåòñÿ ñàì ñîáîé.
Ññûëêà íà Monitoring and Pharmacologic Reversal of a Nondepolarizing Neuromuscular Blockade Should Be Routine ïðèêîëüíàÿ, òîëüêî îíà äåíåã õî÷åò. To Cactus: ÿ ñðàçó óêàçàëà, ÷òî ýòî èç ñåðèè " à ÿ òàêîå âèäåë, è íè÷åãî". À åùå ÿ âèäåëà íàðêîçû íà ÷èñòîì äèòèëèíå, íàïðèìåð - õîëåöèñòýêòîìèè, òðàâìàòîëîãèè, óðîëîãèè... Óäèâèòåëüíî, íî èç îñîáåííîñòåé ó ýòèõ ïàöèåíòîâ ó êàæäîãî 4-5 ðàçâèâàëñÿ íàñòîÿùèé ëàðèíãîñïàçì ïîñëå ýêñòóáàöèè, à òàê íè÷åãî...(( |
#52
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Íå ðåøàþñü ýêñòóáèðîâàòü ÷åðåç ÷àñ ïîñëå 4 ìã àðäóàíà áåç ïðîçåðèíà.
80% àïïåíäèöèòîâ äåêóðàðèçèðóþ, äàæå ïîñëå àòðàêóðèóìà. Ïîñëå ðåçåêöèè æåëóäêà, åñëè áûñòðî ïðîñíóëñÿ - ïðîçåðèí è â ðåàíèìàöèþ, ïîä ìîíèòîð. (Íàñ÷åò äâîéíîãî áëîêà - ãðåøåí, î÷åíü ðåäêî ââîæó äèòèëèí â êîíöå, è áîþñü íå "äâîéíîãî áëîêà", à òîãî, ÷òî íå ñìîãó òåïåðü ââåñòè ïðîçåðèí ) À ïðî òâîð÷åñòâî - áîëüíàÿ òåìà, âñå òâîðèì, ïîñëå òîãî êàê óïðàâëåíöû çàêóïÿò íàì ïî ñâîåìó ðàçóìåíèþ õîëñò, êðàñêè è êèñòè. |
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#53
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"À Âû íîêòþðí ñûãðàòü ñìîãëè áû
íà ôëåéòàõ âîäîñòî÷íûõ òðóá?.." (Â.Ìàÿêîâñêèé) |
#54
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Âèäèòå ëè, ïðè ïðî÷òåíèè ïîñòà ó ìåíÿ ñëîæèëîñü âïå÷àòëåíèå, ÷òî
Âû òàêóþ ìåòîäèêó ðåêîìåíäóåòå (èëè íå ñ÷èòàåòå ÷åì-òî "êðèìèíàëüíûì"). Öèòàòà:
È ÷òî, â íàðêîçíûõ êàðòàõ åñòü çàïèñè î ââåäåíèè äåïîëÿðèçóþùèõ ðåëàêñàíòîâ íà ôîíå àðäóàíà? |
#55
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Öèòàòà:
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#56
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Ïðî ðàçâëåêàþò - ýòî îòâåò íà ïîñò Valery, à òî ïóòàíèöà ïîëó÷èëàñü. ß òàêîãî íå ðåêîìåíäóþ íèêîìó.
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#57
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Êîãäà êîíêðåòíî è êóäà ââîäèëñÿ äèàçåïàì? È ÷åì îïðåäåëÿëàñü èìåííî ýòà äîçà?
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#58
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Öèòàòà:
Ñîâñåì äðóãîå äåëî - àïïåíäýêòîìèÿ. 99% àïïåíäýêòîìèé ýêñòóáèðóþòñÿ íà ñòîëå. Çà÷åì íóæíû äîëãîèãðàþøèå ðåëàêñàíòû, ëîøàäèííûå äîçû ôåíòàíèëà è äèàçåïàì, äëÿ ìàëåíüêîãî ðàçðåçà è áûñòðîé îïåðàöèè ? Ìû äëÿ àïïåíäýêòîìèè è äðóãèõ îïåðàöèé, íà êîòîðûõ ïðåäïîëàãàåòñÿ ýêñòóáàöèÿ íà ñòîëå, èñïîëüçóåì ïðåèìóøåñòâåííî äâà ðåëàêñàíòà - àòðàêóðèé è ðîêóðîíèé. Ïîñëå ðîêóðîíèÿ ëè÷íî ÿ èñïîëüçóþ äåêóðàðèçàöèþ âñåãäà, ïîñëå àòðàêóðèÿ, åñëè ïðîøëî áîëüøå 40 ìèí - ÷àñà ñ ïîñëåäíåé (íåèíòóáàöèîííîé) äîçû, ìîæíî íå èñïîëüçîâàòü âðîäå. |
#59
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Öèòàòà:
Íå íóæíû. Íî ó ðÿäà êîëëåã, ó÷àñòâóþùèõ â îáñóæäåíèè, äðóãèõ íåò. À âîïðîñû ñíàáæåíèÿ ëåæàò çà ïðåäåëàìè êîìïåòåíöèè âðà÷åé-àíåñòåçèîëîãîâ. |
#60
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