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For an ovarian cancer patient with muscle weakness, how to manage muscle relaxation under anesthesia?
What should be done with a patient undergoing endometrial cancer surgery who is still not satisfied with the results after using conventional muscle relaxation antagonism after surgery?
On November 16, in the "2022 Muscle Relaxation Science Popularization Week - Safety, Comfort and Health" series of live broadcasts held by "Physician Daily", experts discussed the common and difficult problems in gynecological anesthesia
.
Case 1: Muscle relaxation management
in patients with muscle weakness 01
Sulgen glucose sodium is a more ideal antagonist drug for patients with muscle weakness
The patient, 43 years old, underwent surgery for cervical squamous cell carcinoma and underwent "laparoscopic radical cervical cancer resection"
under general anesthesia.
General anesthesia was used for endotracheal intubation, rocuronium bromide was used for muscle relaxants, and sodium sulcoglulose was used to antagonize
it after surgery.
"Before the advent of muscle relaxant antagonists, muscle relaxants were recommended to be avoided during surgery in patients with muscle weakness, but this strategy changed
after the advent of muscle relaxant antagonists such as sulgamon sodium.
" Professor Sun Yu, a case sharer and professor of anesthesiology at the Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, said that the focus of anesthesia management in patients with muscle weakness is to prevent and treat respiratory crisis, and the principle
is to minimize the impact on neuromuscular conduction and respiratory function.
Professor Sun Yu
"For anesthesia in patients with muscle weakness, try to start with local anesthesia, neuraxial anesthesia, or low-dose regional block anesthesia
.
" Professor Yu Weifeng of the Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, emphasized that if you can do local anesthesia, do not use general anesthesia, if you must be general anesthesia, you need to pay attention to the fact that you can do intravenous anesthesia do not use inhalation anesthesia, if you can do shallow general anesthesia, do not use deep general anesthesia, try to use short-acting anesthesia with fast onset to recover as soon as possible, it is best to choose muscle relaxants
with antagonist drugs.
Professor Yu Weifeng
At present, the commonly used muscle relaxation antagonists are neostigmine and sugamoxamine sodium, what are the similarities and differences between the two drugs in clinical use? Professor Xu Haitao of Shanghai Changzheng Hospital said that neostigmine has a ceiling effect in the clinic, that is, increasing the use does not increase the antagonism, and if it is overdosed, it may also lead to cholinergic crisis, causing depolarization-like block and severe muscle weakness, manifested as hypoventilation, hypercapnia, inhalation hypoxia and postoperative pneumonia
.
Professor Xu Haitao
An observational study published in 2013 showed that patients undergoing thoracoscopic thymectomy were antagonized with 2 mg/kg of sugenglulose sodium after surgery.
The mean time for a TOF ratio greater than 0.
9 after dosing was 111 seconds (minimum 35 seconds, maximum 240 seconds), all patients were successfully extubated in the operating room, and none of the patients required re-intubation due to respiratory distress or myasthenic crisis.
Japan studied 798 adult patients with myasthenia who underwent thymectomy under general anesthesia, divided into the antagonist group using sulgamose sodium (506 cases) and the non-sugenglucosamine sodium antagonist group (289 cases), the analysis showed that the incidence of postoperative myasthenic crisis was significantly reduced in the use of sulgamose sodium group, and the researchers said that for patients with muscle weakness who need to antagonize the residual effect of postoperative muscle, sugenglulose sodium should be used instead of anticholinesterase drugs
.
"Sugamaglucosa sodium is a more ideal drug
for muscle relaxation antagonism in patients with muscle weakness.
" Professor Sun Yu emphasized that the anesthesia management of sulgamose sodium to reverse rocuronium bromide does not increase the risk of postoperative respiratory complications in patients with myasthenia, and avoiding the use of muscle relaxants just because of myasthenia gravis does not benefit patients, on the contrary, the total hospital stay of patients after the use of muscle relaxants is shorter, which may be related to
the use of muscle relaxants can reduce the dose of anesthetic drugs.
However, there are exceptions, and there are reports that a patient with muscle weakness has not recovered 1 hour after the use of sulgamose sodium antagonism, and the doctor gives another 2 mg of neostigmine, and the patient recovers
.
Professor Sun Yu emphasized that although the use of rocuronium bromide-sulgamose sodium is almost safe, it is necessary to be vigilant against unpredictability in patients with muscle weakness, respond flexibly clinically, and adjust medication strategies
in real time.
Case 2: Gynecological laparoscopic surgery patient
02
muscle relaxation residual Sugen glucose sodium to resolve
A 58-year-old patient with vaginal bleeding 5 months after menopause was diagnosed with endometrial cancer and needed surgery
.
During laparoscopic surgery, Trendelenburg position CO2 under the peritoneum has a great influence on breathing and circulation, and attention should be paid to strengthening the management
of intraoperative breathing, circulation, analgesia and muscle relaxation.
After the operation, the patient entered the PACU, and after 120 minutes of anesthesia induction, the patient had spontaneous breathing, and the airway pressure was also transiently increased, but the eye opening and nodding movements were not well coordinated, and the empirical antasis and atropine were antagonized
.
After 2~3 minutes, the patient's heart rate increased significantly, and the blood pressure increased significantly, but within 20 minutes, the tidal volume of the patient's spontaneous breathing was still not satisfactory, the respiratory rate was unstable, the patient showed consciousness but poor coordination of command movements, strenuous eye opening, limb movements were still uncoordinated, TOFr value was only 0.
67, and there were still muscle relaxation remnants
after the diagnosis of muscle relaxation antagonism.
At 145 minutes of anesthesia induction, the muscle relaxation residual antagonism protocol was adjusted: sugamose sodium 2mg/kg
intravenously.
At 147 minutes, the patient's consciousness was clear, his eyes could be opened voluntarily to cooperate with commanding movements, his limb movements could be coordinated and his head could be raised, the tidal volume of spontaneous breathing reached 650 mL, and muscle relaxation monitoring showed TOFr0.
96, SPO2: 99%.
After 20 minutes, arterial blood gas is rechecked and the endotracheal tube
is removed.
Professor Huang Shaoqiang of the Department of Anesthesiology of the Obstetrics and Gynecology Hospital of Fudan University said that this is a common scenario encountered by anesthesiologists in the clinic, and it is necessary to wait for the results of the intraoperative frozen pathology report during the operation, and the amount
of anesthesia and muscle relaxant needs to be reduced.
If the freezing report is malignant, the operation needs to continue, anesthesia and muscle relaxants have to be added, and the operation is nearing the end and is quickly over
.
At this time, the patient's resuscitation and muscle relaxation management require caution by the anesthesiologist
.
Professor Huang Shaoqiang
"Given the well-documented risk of postoperative muscle relaxation residue, muscle relaxation should be routinely antagonized
.
" Dr.
Lu Yaojun, a case sharer and anesthesiology department of Fudan University Obstetrics and Gynecology Hospital, said that under the monitoring of muscle relaxation, reasonable muscle relaxation antagonism, rapid and accurate reversal of muscle relaxation residual effect, can avoid the occurrence of long-term respiratory support and related respiratory complications of patients, and Sugen glucosamine sodium can allow patients to quickly recover from deep muscle relaxation, reduce muscle relaxation residue, and escort patients with deep muscle relaxation
.
Dr.
Lu Yaojun
The residual risk avoidance program of muscle relaxation is to standardize the application of muscle relaxants, and do a good job of muscle relaxation monitoring and muscle relaxation antagonism
in high-risk patients.
As early as 2015, the British guidelines on muscle relaxation emphasized that the use of muscle relaxants should be monitored for muscle relaxation, from anesthesia induction to anesthesia awakening stage, muscle relaxation monitoring should be carried out, TOFr > 0.
9 can only be extubated, not subjective judgment, quantitative monitoring techniques
are required.
Summary:
Professor Yu Weifeng emphasized that in clinical anesthesia, the influencing factors
of patients' interdisciplinary diseases should be considered.
The pathology of many diseases has synergistic or antagonistic effects with medication and muscle relaxants, such as acidosis, low potassium, low calcium, or the use of β receptor blockers, calcium channel blockers, etc.
, which have a synergistic effect on muscle relaxants; High potassium, high calcium, burns, or the use of vasoactive drugs, hormones, etc.
, have antagonistic effects
on muscle relaxants.
Therefore, anesthesiologists must always tighten a string, and must fully understand the patient's disease history and medication before surgery, which has a good guiding effect
on judging the recovery of muscle relaxation.
"The use of muscle relaxants should be as simple as
possible.
" Professor Yu Weifeng believes that if a single drug can be used without combining drugs, if it must be combined drugs, the following points should be paid attention to: First, the combination of depolarization and non-depolarizing muscle relaxants is not advocated; Second, it is not advocated to use long-acting and short-acting muscle relaxants in two consecutive periods; Third, the combination of two drugs with similar structures is added to 1+1=2; the combination of two drugs with different structures is synergistic, 1+1>2
.
Professor Yu Weifeng emphasized that the combination application of drugs is very complicated, and under the action of multiple drugs, the management of muscle relaxation becomes more complicated, and it is even more impossible to accurately judge the time and state
of muscle relaxation recovery.
Therefore, he advocated that the application of muscle relaxants should be simplified as much as possible, and the simpler the better
.
Deep muscle relaxation has many advantages, which can not only improve the surgical field and operating space, reduce the pressure of artificial pneumoperitoneum, reduce ischemia-reperfusion injury of abdominal organs, but also reduce systemic inflammation, reduce or avoid abdominal wall pressure injury, reduce postoperative pain and accelerate postoperative recovery
.
Professor Huang Shaoqiang said that for gynecological patients who need laparoscopic and robotic surgery, deep muscle relaxation management is more needed, which puts forward higher requirements for postoperative muscle relaxation antagonism, and the treatment of muscle relaxation residue is a skill
that every anesthesiologist must master.
Typesetting: Huang Jing
Editor: Huang Jing
Reviewed: Hsu Bongyan
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