Update: Muskelrelaxierung in der Anästhesie

Der korrekte Einsatz von Muskelrelaxanzien und deren Monitoring im Rahmen der Anästhesie ist seit Jahrzehnten Gegenstand von kontroversen Diskussionen. Insbesondere die Identifikation und das Management von neuromuskulären Restblockaden und die damit assoziierten Komplikationen stehen dabei im Fokus. Weder die Einführung von kurzwirksamen Muskelrelaxanzien in den 1980er-Jahren („intermediate Duration Neuromuscular Blocking Drugs“, NMBD) noch die Einführung des spezifischen Antagonisten Sugammadex im Jahr 2008 sowie die sich im Rahmen der klinischen Versorgung stetig erhöhende Verfügbarkeit von quantitativem neuromuskulärem Monitoring konnten hier abschließende Antworten liefern [1].

Abstract

The correct use of muscle relaxants and neuromuscular monitoring during anesthesia has been subject of controversial discussions for decades. Particularly important in clinical practice are identification and management of residual neuromuscular blockages and avoidance of associated complications. Despite the differences in the molecular mechanisms of action between depolarizing and non-depolarizing muscle relaxants the blockade of the postsynaptic nicotinic acetylcholine receptor remains a common ending pathway. Due to its unfavorable side effect profile, succinylcholine should only be used in justified exceptional cases. The use of muscle relaxants generally reduces the complication rate in airway management. However, even the single use of muscle relaxants increases the likelihood of postoperative pulmonary complications. These complications associated with the use of muscle relaxants, such as residual neuromuscular blockade, must be anticipated. The application of guideline-based approaches, including continuous neuromuscular monitoring and the application of muscle relaxant reversal agents, may significantly reduce the rate of adverse events associated with the use of muscle relaxants.

Kernaussagen

• Muskelrelaxanzien bleiben in der Anästhesie unverzichtbar, um

  • Intubationsbedingungen zu verbessern,

  • das Risiko für Intubationsverletzungen zu verringern und

  • in Notfallsituationen die Maskenbeatmung zu vereinfachen.

• Succinylcholin sollte nur noch als Reservemedikament vorgehalten werden.

• Jede Anwendung von Muskelrelaxanzien sollte kontinuierlich mit quantitativem neuromuskulärem Monitoring überwacht werden.

• Zur Extubation sollte eine TOF-Ratio von (TOF = Train of Four) > 0,95 angestrebt werden.

Schlüsselwörter

neuromuskuläre Blockade - neuromuskuläres Monitoring - Sugammadex

Keywords

sugammadex - muscle relaxant - neuromuscular monitoring

Publication History

Article published online:
28 August 2024

• Literatur

• 1 Rodney G, Raju P, Brull SJ. Neuromuscular block management: evidence-based principles and practice. BJA Education 2024; 24: 13-22
• 2 Fuchs-Buder T, Romero CS, Lewald H. et al. Peri-operative management of neuromuscular blockade: a guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2023; 40: 82-94
• 3 Thilen SR, Weigel WA, Todd MM. et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138: 13-41
• 4 Dhonneur G, Kirov K, Slavov V. et al. Effects of an intubating dose of succinylcholine and rocuronium on the larynx and diaphragm: an electromyographic study in humans. Anesthesiology 1999; 90: 951-955
• 5 Kopman Aaron F, Zhaku B, Lai Kane S. The “intubating dose” of succinylcholine: the effect of decreasing doses on recovery time. Anesthesiology 2003; 99: 1050-1054
• 6 Lundstrøm LH, Møller AM, Rosenstock C. et al. Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103,812 consecutive adult patients recorded in the Danish Anaesthesia Database. Br J Anaesth 2009; 103: 283-290
• 7 Tran DTT, Newton EK, Mount VAH. et al. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia 2017; 72: 765-777
• 8 Sørensen MK, Bretlau C, Gätke MR. et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth 2012; 108: 682-689
• 9 Murphy GS, Szokol JW, Avram MJ. et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology 2011; 115: 946-954
• 10 Khandkar C, Liang S, Phillips S. et al. Comparison of kinemyography and electromyography during spontaneous recovery from non-depolarising neuromuscular blockade. Anaesth Intensive Care 2016; 44: 745-751
• 11 Stewart PA, Freelander N, Liang S. et al. Comparison of electromyography and kinemyography during recovery from non-depolarising neuromuscular blockade. Anaesth Intensive Care 2014; 42: 378-384
• 12 Colegrave N, Billard V, Motamed C. et al. Comparison of the TOF-Scan™ acceleromyograph to TOF-Watch SX™: Influence of calibration. Anaesth Crit Care Pain Med 2016; 35: 223-227
• 13 Tacquard C, Collange O, Gomis P. et al. Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey. Acta Anaesthesiol Scand 2017; 61: 290-299
• 14 Reddy JI, Cooke PJ, van Schalkwyk JM. et al. Anaphylaxis is more common with rocuronium and succinylcholine than with atracurium. Anesthesiology 2015; 122: 39-45
• 15 Tacquard C, Iba T, Levy JH. Perioperative anaphylaxis. Anesthesiology 2023; 138: 100-110
• 16 Rose M, Fisher M. Rocuronium: high risk for anaphylaxis?. Br J Anaesth 2001; 86: 678-682
• 17 Pandit JJ, Andrade J, Bogod DG. et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014; 113: 549-559
• 18 Samet A, Capron F, Alla F. et al. Single acceleromyographic train-of-four, 100-Hertz tetanus or double-burst stimulation: which test performs better to detect residual paralysis?. Anesthesiology 2005; 102: 51-56
• 19 Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology 2009; 110: 1253-1260
• 20 Eikermann M, Vogt FM, Herbstreit F. et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med 2007; 175: 9-15
• 21 Raval AD, Anupindi VR, Ferrufino CP. et al. Epidemiology and outcomes of residual neuromuscular blockade: a systematic review of observational studies. J Clin Anesth 2020; 66: 109962
• 22 Kirmeier E, Eriksson LI, Lewald H. et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med 2019; 7: 129-140
• 23 Blobner M, Hunter JM, Meistelman C. et al. Use of a train-of-four ratio of 0.95 versus 0.9 for tracheal extubation: an exploratory analysis of POPULAR data. Br J Anaesth 2020; 124: 63-72
• 24 Nair VP, Hunter JM. Anticholinesterases and anticholinergic drugs. Continuing Education in Anaesthesia Critical Care & Pain 2004; 4: 164-168
• 25 Arslan B, Sahin T, Ozdogan H. Sugammadex and anaphylaxis: an analysis of 33 published cases. J Anaesthesiol Clin Pharmacol 2021; 37: 153-159
• 26 Burbridge MA. Incidence of anaphylaxis to sugammadex in a single-center cohort of 19,821 patients. Anesth Analg 2021; 132: 93-97
• 27 Miyazaki Y, Sunaga H, Kida K. et al. Incidence of anaphylaxis associated with sugammadex. Anesth Analg 2018; 126: 1505-1508
• 28 Orihara M, Takazawa T, Horiuchi T. et al. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. Br J Anaesth 2020; 124: 154-163
• 29 Harper NJN, Cook TM, Garcez T. et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth 2018; 121: 159-171
• 30 Zwiers A, van den Heuvel M, Smeets J. et al. Assessment of the potential for displacement interactions with sugammadex: a pharmacokinetic-pharmacodynamic modelling approach. Clin Drug Investig 2011; 31: 101-111
• 31 Piepho T, Kriege M, Byhahn G. et al. S1-Leitlinie Atemwegsmanagement 2023. Anästh Intensivmed 2024; 65: 69-96
• 32 Taha SK, El-Khatib MF, Baraka AS. et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia 2010; 65: 358-361
• 33 Cammu G, de Kam PJ, De Graeve K. et al. Repeat dosing of rocuronium 1.2 mg kg-1 after reversal of neuromuscular block by sugammadex 4.0 mg kg-1 in anaesthetized healthy volunteers: a modelling-based pilot study. Br J Anaesth 2010; 105: 487-492