Dr Dubois Philippe - · PDF fileDr Dubois Philippe. La jonction neuromusculaire

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Transcript of Dr Dubois Philippe - · PDF fileDr Dubois Philippe. La jonction neuromusculaire

  • Dr Dubois Philippe

  • La jonction neuromusculaire

    11K+

    11

    Fagerlund MJ, Eriksson LI. Current concepts in neuromuscular transmission. Br J Anaesth. 2009;103:108-14.

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    1

    1

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    32

  • Monitoring de la transmission neuromusculaire

    SingleTwitch

    TOF countTOF ratio

    DBS Ttanos50-100 Hz

    stimulation

    contraction

    curarisation

    PTCPTC

  • Profondeur du bloc

    Post-tetanic count

    TOF count

    TOF ratio

    Twitch height (T1)

    100

    0

    Onset

    Bloc intenseBloc profond

    Bloc modr

  • Dures daction

    Dure daction clinique

    Dure daction totale

    Onset

    Fin de curarisation

  • Occupation rsiduelle des rcepteurs

    Paton WDM, Waud DR. The margin of safety of neuromuscular transmission. J. physiol 1967;191:59-90Waud, B.E. and D.R. Waud,. Anesthesiology, 1972. 37(4): p. 413-6.

    100?

    70Tet 200 Hz

    50Tet 100 Hz

    20-25Tet 30 Hz

    25-30TOF ratio

    20-25Single Twitch

    % de rcepteur fonctionnels

    Rcupration de la valeur initiale

  • Curare dpolarisant

    Curares non-dpolarisants

    K1K1

    K2K2

    Rapport T4/T1= TOF ratio

    Rapport T1/T0Si calibration !

    100 %

  • Effets indsirables

    Fasciculations, hypertonie musculaire

    Hyperkalimie

    Bradycardie

    Hyperthermie maligne

    Pseudocholinestrases

    Histaminolibration

    Elimination organique

    Anaphylaxie

    Succinylcholine

    MivacuriumAtracurium

    Rocuronium

    TOUS

  • Doses dinduction et dures

    0 1 2 3 4 5 10 20 30 40 50 60 70 80 90 100 110 120 130

    Myoplgine 1 mg/kgMivacron 0.16 mg/kgEsmron 0.6 mg/kgTracrium 0.5 mg/kgNimbex 0.18 mg/kgPavulon 0.13 mg/kg

    Retour de la premire rponse au TOF

    Pente de rcupration du TOF ratio de 25 75%

  • 1. Cammu G. Interactions of neuromuscular blocking drugs. Acta Anaesth Belg 2001; 52: 357-363.2. Mencke T, Echternach M, Kleinschmidt S et al. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology 2003;98:1049-563. King M, Sujirattanawimol N, Danielson DR, Hall BA, Schroeder DR, Warner DO. Requirements for muscle relaxants during radical retropubic prostatectomy. Anesthesiology 2000; 93:1392-7

    Pharmacologie et dures daction : diffrences entre NMBA et variabilit interindividuelle

    Onset T1 25% TOFr 0.75

    PAC ASA 3n = 4 x 20

    Personnal data

    Bolus initial :Roc 0.6 mg/kgMiv 0.16 mg/kgAtr 0.5 mg/kgCis 0.18 mg/kg

    Prolongationpar :HalognsMagnsiumAmukinHypothermie

  • 1. Eriksson L.I.et al Attenuated ventilatory response to hypoxemia at vecuronium-induced partial neuromuscular block. Acta Anesthesiol Scand 1992;36:710-5.2. Eriksson L.I.et al Functionnal assessment of the pharynx at rest and during swallowing in partially paralysed humans. Anesthsiology 1997;87:1035-433. Debaene B et al.. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98:1042-84. Murphy GS et al. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008;107:130-75. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unleearned. Part 1: definitions, incidence, and adverse physiologic effects of residual neuromuscular block.

    Anesth Analg 2010;111:120-8

    Curarisation rsiduelle = TOF ratio < 0.9

    1.0

    0.9

    0.8

    0.7

    0.6

    0.5

    0.4

    0.3

    0.2

    0.1

    0.0

    0 50 100 150 200 250 300 350 400

    TO

    F R

    atio

    Time (min)

    All patients (n = 526)

    M. dilatateurs inspiratoires pharyngs

    Parois abdominale

    Adducteur du pouce

    Orbiculaire

    Diaphragme

    Muscles laryngs

    Sourcilier

    Dfinition: Rduction de la rponse ventilatoire lhypoxmie, tr dglutition, stress !!!

    Incidence: 40% jusque plus de 2 h aprs bolus

    Complications: Critical Respiratory Events 0.8 %112000 patients USA / an, or HTM 1300 cas / an

  • 1. Plaud B et al. Residual paralysis after emergence from anaesthesia. Anesthesiology 2010;112:1013-22. Viby-Mogensen Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth 2000;84:301-23. Cammu G. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg 2006;102:426-9

    Evaluation clinique et subjective ?

    TOF count 0

    TOF count 1

    TOF count 4

    TOF ratio 0.4

    TOF ratio 0.6

    TOF ratio 0.8

    TOF ratio 0.9

    TOF visuel =

    Vent spontaneMouvements

    DBS tactile =

    Ttanos 50 Hz =TOF tactile =

    Ttanos 100 Hz 5s =

    Head liftTongue depressor test

    1. Mauvaise qualit des tests cliniques, difficile raliser2. Mauvaise sensibilit du monitoring subjectif

    pour exclure la prsence de curarisation rsiduelle

    Volume ok, ouvrir yeux, serrer main, tirer la langue

  • Solution 1: monitoring objectif quantitatif

    1. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010;111:129-40

    MMG

    EMG

    KMG

    AMG

    Hand adapter TOF-tube

  • Efficace pour assurer de bonnes conditions dintubation et de bonnes conditions opratoire, aprs bolus ou infusion continue

    Efficace pour prvenir la curarisation rsiduelle

    Prouv dans les tudes, vivement recommand

    et dmontr en pratique clinique !

    Malheureusement trs sous-utilis !! Peu disponible, rarement utilis (pas cher) Anesthsistes pas encore convaincus !?

    1. Mortensen C.R., et al Perioperative monitoring of NM transmission using acceleromyography preventsprevents residual NM block following pancuronium. Acta Anesthesiol Scand 1995;39:797-8012. Viby-Mogensen Br J Anaesth 2000;84:301-2 : The clinician should always monitor the extend of neuromuscular recovery using objective objective meansmeans3. Eriksson L.I. Evidence-based practice and neuromuscular monitoring. Anesthesiology 2003;98:1037-94. Murphy et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neurom. blockade and adverse respiratory events in the PACU. Anesthesiology 2008;109:389-995. Baillard et al. Postoperative residual neuromuscular block : a survey of management. Br J Anaesth 2005; 95: 622-6.6. Naguib M et al. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg 2010;111:110-9

    MMG

    EMG

    KMG

    AMG

    Solution 1: monitoring objectif quantitatif

  • 1. Arbous et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102: 257-68

    Solution 2: NostigmineCholine

    +acetate

    AChE

    NeostigmineChE inhibitors

    Inhibition des cholinestrases:

    bloc comptitif en faveur de l Actylcholine

    Dose 0.05 mg/kg

    Effets muscariniques: besoin danticholinergique

    (Robinul 0.2 mg/mg)

    Efficace: Lantagonisation des curares en fin dintervention est associe une rduction de la mortalit 24 h.

  • 1. Kirkegaard H. et al. Efficacy of tactile-guided reversal from cisatracurium-induced neuromuscular block. Anesthesiology 2002; 96: 45-502. Kim et al. Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockade during propofol or sevoflurane anesthesia. Anesth Analg 2004;99:1080-5.3. Murphy et al. Residual paralysis at the time of tracheal extubation. Anesth Analg 2005; 100: 1840-5 : TOF ratio < 0.9 est observ aprs extubation chez 88 % des patients !4. Eikermann et al. Unwarranted administration of Ach inhibitors can impair genioglossus and diaphragm muscle function. Anesthesiology 2007; 107: 621-95. Dubois P.E.. Delayed reversal of a potentiated rocuronium neuromuscular block. EJA 2009;26:350-52.

    Solution 2: Nostigmine: limitations

    Concentration (m)

    TO

    F R

    atio

    0 0.01 0.1 1 10 100

    1.0

    0.8

    0.6

    0.2

    0.0

    0.4

    15>15

  • Bom AT. Anesthesiology 2003;99:632-7.

    Solution 3: Sugammadex Choline+acetate

    AChE

    HostmoleculeLes charges ngatives prsentes en surface du Sugammadex interagissent

    avec les charges positives lies la prsence damonium quaternaire sur les curares strodiensqui sont alors fortement et durablement capturs au centre de la molcule de cyclodextrine.

  • 1. Mirakhur RK. Sugammadex in clinical practice. Anaesthesia 2009, 64:45-542. Blobner M et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia. Eur J A 2010;27:874-81

    Solution 3: Sugammadex

    Bridion 2 mg/kg NEO 50 g/kg

    Recovery of TOF Ratio to 0.9

    1,4

    17,6

    0

    2

    4

    6

    810

    12

    14

    16

    18

    20

    Med

    ian

    Tim

    e to

    Rec

    ove

    ry(m

    in)

    NEO 70 g/kgBridion 4 mg/kg

    Recovery of TOF Ratio to 0.9

    2,7

    49

    0

    10

    20

    30

    40

    50

    60

    Med

    ian

    Tim

    e to

    Rec

    ove

    ry(m

    in) Rocuronium 0.6 mg/kg Neostigmine 50 g/kg(%)

    100

    50

    7:49:34 7:59:34 8:09:34 8:19:34 8:29:49 8:39:49 8:50:03 9:00:19 9:10:19 9:20:34 9:30:49 9:41:04

    Rocuronium 0.6 mg/kg Bridion 2 mg/kg(%)

    100

    50

    10:21:06 10:32:38 10:44:08 10:55:38 11:07:08 11:18:53 11:30:38 11:42:08 11:53:5312:04:3912:13:56

    T1 to 90%

    3.2

    10.9

    3

    Rocuronium 1.2 mg/