MONITORIA DE LA RELAJACION

NEUROMUSCULAR

NANCY TATIANA RODRIGUEZ BETANCOURTESTUDIANTE NIVEL I

ANESTESIOLOGIA Y REANIMACIONU DE C

SUBJETIV

A

Sensitivity Specificity

Positive predictive

value

Negative predictive

valueInability to smile 0.29 0.80 0.47 0.64

Inability to swallow 0.21 0.85 0.47 0.63

Inability to speak 0.29 0.80 0.47 0.64

General weakness 0.35 0.78 0.51 0.66

Inability to lift head for 5 s 0.19 0.88 0.51 0.64

Inability to lift leg for 5 s 0.25 0.84 0.50 0.64

Inability to sustained hand grip for 5 s

0.18 0.89 0.51 0.63

Inability to perform sustained tongue depressor test

0.22 0.88 0.52 0.64

Diagnostic Attributes of the Clinical Tests: Sensitivity, Specificity, Positive and Negative Predictive Values of an Individual Clinical Test for a Train-of-Four <90%

Sorin J. Brull, MD, Glenn S. Murphy. Residual Neuromuscular Block: Lessons Unlearned. Part II: Methods to Reduce the Risk of Residual Weakness. A & A July 2010 vol. 111 no. 1 129-140

OBJETIVA

Fibra = todo o nada

Músculo = sumatoria de fibras

Estímulo supramáximo 20-25% (dolor)

ESTIMULACIÓN ÚNICA

Fcia >0,15 hz disminuye el nivel de la rta evocada para ser supramaximo. No comparables.

DESPOLARIZANTES: fcia + alta, no desvanecimiento

TRAIN OF FOURALI 70´S

Estímulos supramaximos cada 0,5 seg (2.0hz)

Repetir: 12-15 seg

• control• Bloqueo parcial• radio TOF• fase II

• Tof 0,7 rta a estímulo único

ESTIMULACIÓN TETÁNICA>30hz 50HZ 5 SEG >1-2´

50-100-200 HZ 1 SEG

NORMAL Y BNMD SOSTENIDO

BNMND Y FASE II NO SOSTENIDO

Liberación de acetilcolina (presináptico) equilibrio liberación/producción “márgen de seguridad” Receptores bloqueados = desvanecimiento“facilitación”: 60 seg PTC

CONTEO POSTETANICO

3 SEG

Figure 39-5 Relationship between the post-tetanic count (PTC) and time when onset of train-of-four (T1 )

Eliminar movimientos indeseados (oftalmo)

Fcia> 6min

Carina

Severa: <2-3rtasTotal: leves + severas

DOBLE RÁFAGA• 50Hz• 750msec• 2 ráfagas de

3 impulsos• + sensible

visual/tactil

DBS3,3 ratio: 2da/1ra

EVALUACIÓN SUBJETIVA: DBS > TOFNINGUNO 100%

ESTIMULADOR:longitud pulso: 0,2-

0,3msec (>0,5=mm)

corriente constante 60-70mA (25-50

resistencia <2,5kΩ; frío 5kΩ

Área conducción 7-11 mmLimpiar abrasivo

• Hipotenar: ulnar flexor y aductor del 5to. Discrepancia tof 15-20%

• Corrugado superciliar: >20-30 mA• Tibial posterior flexor hallux• Peroneo dorsiflexión

1 cm

3-6 cm

Dosis – rta: Bajas: 1ro laringeos

Bloqueo 100% aductor: 1ro aductor

Bloqueo 100% laringeos: 1 ro laríngeos

• Tof > 0,3 : falla evaluación visual• DBS: hasta tof 0,6-0,7• Tetánico 100hz: desvanecimiento tof

0,8-0,9

VALORACIÓN OBJETIVA

MECANOMIOGRAFIA

• Tension 200-300 gr de precarga fuerza de contracción.

• Control: 8-12 min, 2-5seg 50Hz

ELECTROMIOGRAFIA

• Potenciales de acción: placa (1/3 medio mm), inserción y uno neutro

• Osciloscopio• % control o radio tof• Mediano y ulnar• Interoseo, hipotenar (< artefactos,

sobreestimar)

Cuerdas vocalesDiafragma: paravertebral t2l1 derecho. Estímulo frénico en cuello.

Confiabilidad: posición de electrodos, precarga, posición sobre el músculo, interferencia. No retorna a basal.

Figure 39-13 Evoked electromyographic printout from a Relaxograph. Initially, single-twitch stimulation was given at0.1 Hz, and vecuronium (70 μg/kg) was given intravenously for tracheal intubation. After approximately 5 minutes, themode of stimulation was changed to TOF stimulation every 60 seconds. At a twitch height (first twitch in TOF response)of approximately 30% of control (marker 1), 1 mg of vecuronium was given intravenously. At marker 2, 1 mg ofneostigmine was given intravenously, preceded by 2 mg of glycopyrrolate. The printout also illustrates the commonproblem of failure of the electromyographic response to return to control level. (Courtesy of Datex-Ohmeda, Helsinki,Finland.)

ACELEROMIOGRAFIA

Comparable mmg y emg. Radio >1.0

MONITOR PIEZOELECTRICO

• Movimiento de banda = voltaje

• No validado

FONOMIOGRAFIA

EVALUACION DE LAS RESPUESTAS EVOCADAS

3-6´

• TOF:• 1: 90-95%• 4: 60-85%• QX: 1-2

BLOQUEO RESIDUAL

• <0,9• Alt esfinter

esofágico y mm faríngeos: aspiración

• Rta hipoxia• Uso bnm

intermedios: 3010%

Train-of-Four Ratio Signs and Symptoms

0.70-0.75 Diplopia and visual disturbancesDecreased handgrip strengthInability to maintain apposition of the incisor teeth“Tongue depressor test” negativeInability to sit up without assistanceSevere facial weaknessSpeaking a major effortOverall weakness and tiredness

0.85-0.90 Diplopia and visual disturbancesGeneralized fatigue

Clinical Tests of Postoperative Neuromuscular Recovery

Unreliable Sustained eye openingProtrusion of the tongueArm lift to the opposite shoulderNormal tidal volumeNormal or nearly normal vital capacityMaximum inspiratory pressure less than 40 to 50 cm H2O

Most Reliable Sustained head lift for 5 secondsSustained leg lift for 5 secondsSustained handgrip for 5 secondsSustained “tongue depressor test”

Maximum inspiratory pressure 40 to 50 cm H2O or greater

Anestesia: > sensibilidad a bnm con disminución del

VC y >CO2 esp

Complicaciones POPCx < 200 minNegra: TOF < 0.70 pancuronioRoja, atracurio y vecuronio: TOF ≥ 0.70 pancuronio

Figure 39-19 Typical recording of the mechanical response (Myograph 2000) to TOF nerve stimulation of the ulnarnerve after injection of 1 mg/kg of succinylcholine (arrow) in a patient with genetically determined abnormal plasmacholinesterase activity. The prolonged duration of action and the pronounced fade in the response indicate a phase IIblock.

Antagonizar?

UTILIDAD CLINICA

ALTERAN LA MONITORIA

• Hipotermia central• Hipotermia de la extremidad• Lesión nervio, ME, SNC• Edad• Tipo de cx