Monitoria de la relajacion neuromuscular

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Monitoria de la relajacion neuromuscular

  1. 1. MONITORIA DE LA RELAJACION NEUROMUSCULARNANCY TATIANA RODRIGUEZ BETANCOURT ESTUDIANTE NIVEL I ANESTESIOLOGIA Y REANIMACION U DE C
  2. 2. Diagnostic Attributes of the Clinical Tests: Sensitivity, Specificity, Positive and NegativePredictive Values of an Individual Clinical Test for a Train-of-Four <90% Positive Negative Sensitivity Specificity predictive predictive value value Inability 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 0.19 0.88 0.51 0.64 5s Inability to lift leg for 5 0.25 0.84 0.50 0.64 s Inability to sustained 0.18 0.89 0.51 0.63 hand grip for 5 s Inability to perform sustained tongue 0.22 0.88 0.52 0.64 depressor testSorin 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
  3. 3. ESTIMULACIÓN ÚNICA Fcia >0,15 hz disminuye el nivel de la rta evocada para ser supramaximo. No comparables. DESPOLARIZANTES: fcia + alta, no desvanecimiento
  4. 4. TRAIN OF FOURALI 70 SEstímulossupramaximos cada0,5 seg (2.0hz)Repetir: 12-15 seg• control• Bloqueo parcial• radio TOF• fase II•Tof 0,7  rta aestímulo único
  5. 5. ESTIMULACIÓN TETÁNICA>30hz  50HZ 5 SEG >1-250-100-200 HZ 1 SEGNORMAL Y BNMD  SOSTENIDOBNMND Y FASE II  NOSOSTENIDOLiberación de acetilcolina(presináptico) equilibrioliberación/producción“márgen de seguridad”Receptores bloqueados =desvanecimiento“facilitación”: 60 seg PTC
  6. 6. CONTEO POSTETANICO 3 SEG
  7. 7. Figure 39-5 Relationship between the post-tetanic count(PTC) and time when onset of train-of-four (T1 )
  8. 8. Eliminarmovimientosindeseados(oftalmo)Fcia> 6minCarinaSevera: <2-3rtasTotal: leves +severas
  9. 9. DOBLE RÁFAGA • 50Hz • 750msec • 2 ráfagas de 3 impulsos • + sensible visual/tactilDBS3,3 ratio: 2da/1ra
  10. 10. EVALUACIÓN SUBJETIVA: DBS > TOF NINGUNO 100%
  11. 11. ESTIMULADOR: longitud pulso: 0,2- 0,3msec (>0,5=mm)corriente constante 60- 70mA (25-50 resistencia <2,5kΩ; frío 5kΩ
  12. 12. Área conducción 7-11mmLimpiar abrasivo
  13. 13. • Hipotenar: ulnar  flexor y aductor del 5to. Discrepancia tof 15-20%• Corrugado superciliar: >20-30 mA• Tibial posterior  flexor hallux• Peroneo dorsiflexión
  14. 14. 1 cm3-6 cm
  15. 15. Dosis – rta:Bajas: 1ro laringeosBloqueo 100%aductor: 1ro aductorBloqueo 100%laringeos: 1 rolaríngeos
  16. 16. • Tof > 0,3 : falla evaluación visual• DBS: hasta tof 0,6-0,7• Tetánico 100hz: desvanecimiento tof 0,8-0,9
  17. 17. VALORACIÓN OBJETIVA
  18. 18. MECANOMIOGRAFIA• Tension 200-300 gr de precarga  fuerza de contracción.• Control: 8-12 min, 2-5seg 50Hz
  19. 19. 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)
  20. 20. Cuerdas vocalesDiafragma: paravertebral t2l1derecho. Estímulo frénico encuello.Confiabilidad: posición deelectrodos, precarga, posiciónsobre el músculo, interferencia.No retorna a basal.
  21. 21. Figure 39-13 Evoked electromyographic printout from a Relaxograph. Initially, single-twitch stimulationwas given at0.1 Hz, and vecuronium (70 μg/kg) was given intravenously for tracheal intubation. After approximately 5minutes, themode of stimulation was changed to TOF stimulation every 60 seconds. At a twitch height (first twitch in TOFresponse)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 thecommonproblem of failure of the electromyographic response to return to control level. (Courtesy of Datex-Ohmeda,Helsinki,Finland.)
  22. 22. ACELEROMIOGRAFIA
  23. 23. Comparable mmg y emg. Radio>1.0
  24. 24. MONITOR PIEZOELECTRICO • Movimiento de banda = voltaje • No validado
  25. 25. FONOMIOGRAFIA
  26. 26. EVALUACION DE LAS RESPUESTAS EVOCADASTOF:1: 90-95% 3-64: 60-85%QX: 1-2
  27. 27. BLOQUEO RESIDUAL• <0,9 Train-of-Four Ratio 0.70-0.75 Signs and Symptoms Diplopia and visual disturbances• Alt esfinter Decreased handgrip strength esofágico y mm Inability to maintain apposition of the incisor faríngeos: teeth “Tongue depressor test” aspiración negative Inability to sit up without• Rta hipoxia assistance Severe facial weakness Speaking a major effort• Uso bnm Overall weakness and tiredness intermedios: 0.85-0.90 Diplopia and visual disturbances 3010% Generalized fatigue
  28. 28. Clinical Tests of Postoperative Neuromuscular RecoveryUnreliableSustained 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 H2OMost ReliableSustained 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
  29. 29. Anestesia: > sensibilidad abnm con disminución del VC y >CO2 esp
  30. 30. Complicaciones POPCx < 200 minNegra: TOF < 0.70 pancuronioRoja, atracurio y vecuronio: TOF ≥ 0.70pancuronio
  31. 31. Figure 39-19 Typical recording of themechanical response (Myograph 2000) toTOF nerve stimulation of the ulnarnerve after injection of 1 mg/kg ofsuccinylcholine (arrow) in a patient withgenetically determined abnormal plasmacholinesterase activity. The prolonged durationof action and the pronounced fade in theresponse indicate a phase IIblock.
  32. 32. UTILIDAD CLINICA
  33. 33. ALTERAN LA MONITORIA• Hipotermia central• Hipotermia de la extremidad• Lesión nervio, ME, SNC• Edad• Tipo de cx

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