围术期神经肌肉阻滞的管理:欧洲麻醉和重症监护学会临床指南  

Peri-operative management of neuromuscular blockade:a guideline from the European Society of Anaesthesiology and Intensive Care

作　　者：Thomas Fuchs-Buder Carolina S.Romero Heidrun Lewald Massimo Lamperti Arash Afshari Ana-Marjia Hristovska Denis Schmartz Jochen Hinkelbein Dan Longrois Maria Popp Hans Dde Boer Massimiliano Sorbello Radmilo Jankovic Peter Kranke Thomas Fuchs-Buder;Carolina S.Romero;Heidrun Lewald;Massimo Lamperti;Arash Afshari;Ana-Marjia Hristovska;Denis Schmartz;Jochen Hinkelbein;Dan Longrois;Maria Popp;Hans Dde Boer;Massimiliano Sorbello;Radmilo Jankovic;Peter Kranke(Department of Anaesthesiology,Intensive Care and Peri-operative Medicine,CHRU de Nancy,Nancy 54000,France;Department of Anesthesia and Critical Care,Consorcio Hospital General Universitario de Valencia,Methodology Department,Universidad Europea de Valencia,Valencia 46014,Spain;Department of Anesthesiology and Intensive Care,Technical University of Munich,Munich 80333,Germany;Anesthesiology Institute,Cleveland Clinic Abu Dhabi,Abu Dhabi 31250,United Arab Emirates;Department of Paediatric and Obstetric Anaesthesia,Copenhagen University Hospital,Rigshospitalet,Copenhagen 2100,Denmark;Department of Anaesthesiology&Intensive Care Medicine,Copenhagen University Hospital,Hvidovre 2650,Denmark;Department of Anesthesiology,CUB Ho^pital Erasme,Bruxelles 1070,Belgium;Department of Anaesthesiology and Intensive Care Medicine,University Hospital of Cologne,Cologne 50937,Germany;Department of Anesthesia and Intensive Care,Ho^pital Bichat-Claude Bernard,Universite de Paris,Paris 75018,France;Department of Anaesthesia,Critical Care Medicine,Emergency Medicine and Pain Medicine,University Hospitals of Wuerzburg,Wuerzburg 97080,Germany;Department of Anesthesiology Pain Medicine&Procedural Sedation and Analgesia Martini General Hospital Groningen,Groningen 9713 GZ,The Netherlands;Anesthesia and Intensive Care,AOU Policlinico-San Marco,Catania 95123,Italy;Clinic for Anesthesiology and Intensive Therapy,University Clinical Center Nis,School of Medicine,University of Nis,Nis 18000,Serbia)

机构地区：[1]法国南锡大学医学院附属医院麻醉学、重症监护与围术期医学科,法国南锡54000 [2]巴伦西亚大学综合医院麻醉与重症监护科,西班牙巴伦西亚46014 [3]慕尼黑工业大学麻醉学与重症监护科,德国慕尼黑80333 [4]克利夫兰阿布扎比诊所麻醉学研究所,阿联酋阿布扎比31250 [5]哥本哈根大学医院小儿和产科麻醉科,丹麦哥本哈根2100 [6]哥本哈根大学医院麻醉学与重症监护科,丹麦赫维德2650 [7]布鲁塞尔自由大学Erasme医院麻醉科,比利时布鲁塞尔1070 [8]科隆大学医院麻醉学与重症监护科,德国科隆50937 [9]巴黎大学附属比查特克劳德伯纳德医院麻醉学与重症监护医学科,法国巴黎75018 [10]维尔茨堡大学医院麻醉学、危重病医学、急诊医学和疼痛医学科,德国维尔茨堡97080 [11]格罗宁根大学医院麻醉学、疼痛医学与程序性镇静与镇痛科,荷兰格罗宁根9713 GZ [12]卡坦尼亚大学医院麻醉与重症监护科,意大利卡坦尼亚95123 [13]尼什大学医学院尼什临床中心麻醉学与重症治疗科,塞尔维亚尼什18000

出　　处：《中华麻醉学杂志》2024年第6期641-656,共16页Chinese Journal of Anesthesiology

摘　　要：近来的研究表明,由于围术期神经肌肉阻滞管理不当,肌肉松弛药(肌松药)残留阻滞及其术后并发症的发生率居高不下。需要重视神经肌肉功能监测仪、肌松药及其拮抗剂的合理应用,以利于改善神经肌肉阻滞管理。欧洲麻醉和重症监护学会(European Society of Anaesthesiology and Intensive Care,ESAIC)首次发布围术期神经肌肉阻滞管理临床指南,旨在为临床医生提供最佳医疗管理的循证建议,以提高围术期患者安全。本指南主要聚焦在3个临床问题:肌松药是否有助于成人气管插管?神经肌肉阻滞深度是否影响腹部手术患者的预后?肌松药残留阻滞的诊断和治疗策略有哪些?根据PICO原则(患者、干预、对照、结局;patient,intervention,comparator,outcome;PICO)构建临床问题并进行文献检索。初始纳入的临床研究为24 000篇,采用逐步筛选策略,最终临床研究88篇纳入指南分析。应用GRADE方法学(Grading of Recommendations,Assessment,Development and Evaluation,GRADE)对结局指标证据、质量等级进行评价。运用两轮德尔菲法收集专家组建议并形成统一推荐:R1推荐应用肌松药辅助气管插管(1A)。R2推荐应用肌松药以减少气管插管导致的咽部和(或)喉部损伤(1C)。R3推荐在快速顺序诱导插管(rapid sequence induction intubation,RSII)时使用短效肌松药,例如琥珀胆碱1 mg/kg或罗库溴铵0.9~1.2 mg/kg(1B)。R4推荐在需要改善外科手术条件时,加深神经肌肉阻滞深度(1B)。R5尚无足够的证据推荐深度神经肌肉阻滞可减轻术后疼痛或降低围术期并发症的发生率(2C)。R6推荐在拇内收肌处刺激尺神经,定量监测神经肌肉阻滞深度以排除肌松药残留阻滞(1B)。R7推荐应用舒更葡糖钠逆转甾体类肌松药(罗库溴铵、维库溴铵)诱导的深、中及浅度神经肌肉阻滞(1A)。R8推荐在使用新斯的明前,TOFr自行恢复至>0.2,并继续定量监测神经肌肉功能,直至TOFr超过0.9Recent data indicated a high incidence of inappropriate management of neuromuscular block,with a high rate of residual paralysis and relaxant-associated postoperative complications.These data are alarming in that the available neuromuscular monitoring,as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade.In this first European Society of Anaesthesiology and Intensive Care(ESAIC)guideline on peri-operative management of neuromuscular block,we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety.We identified three main clinical questions:Are myorelaxants necessary to facilitate tracheal intubation in adults?Does the intensity of neuromuscular blockade influence a patient′s outcome in abdominal surgery?What are the strategies for the diagnosis and treatment of residual paralysis?On the basis of this,PICO(patient,intervention,comparator,outcome)questions were derived that guided a structured literature search.A stepwise approach was used to reduce the number of trials of the initial research(n=24000)to the finally relevant clinical studies(n=88).GRADE methodology(Grading of Recommendations,Assessment,Development and Evaluation)was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality.A two-step Delphi process was used to determine the agreement of the panel members with the recommendations:R1 We recommend using a muscle relaxant to facilitate tracheal intubation(1A).R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation(1C).R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation(RSII)such as succinylcholine 1 mg/kg or rocuronium 0.9 to 1.2 mg/kg(1B).R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved(1B).R5 There is insufficient evidence to recommen

关 键 词：神经肌肉阻滞 神经肌肉功能 肌松药 临床指南 罗库溴铵 琥珀胆碱 外科手术 定量监测 

分 类 号：R614[医药卫生—麻醉学]