医療倫理の進歩
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概要

甲状腺手術、IONM、スガマデクスナトリウムの関係：IONMに使用するスガマデクスナトリウムの利点

トゥルグト・ドンメズ

抽象的な

はじめに：甲状腺手術における最も重要な合併症の1つは、反回神経（RLN）損傷の結果として生じる声帯麻痺です。神経の片側損傷は患者が耐えることができますが、両側の神経麻痺は死亡のような重篤な合併症を引き起こす可能性があります。外科医は、RLNの損傷を防ぎその機能を保護するために、厳密に標準化された術中神経モニタリング技術（IONM）を使用して、良好で高品質のモニタリングと安全な手術を成功させる必要があります。しかし、手術中に使用される神経筋遮断効果のある全身麻酔薬の半減期は、IONMの有効性と信頼性に密接に関連しています。私たちは、TOF-Guard神経筋伝達モニターを使用して神経伝導を検出し、麻酔薬の神経筋遮断に拮抗するスガマデクスナトリウム（ブリディオン）を投与した後、より信頼性の高いIONMを提供することを目的としました。

 

背景：鎮静後、患者は2分間換気され、スリーブより2cm上に固定された表面陰極（Dr. Langer喉頭シリンダー陽極）を備えた保護された気管内チューブ（内径7～7.5mm）で挿管された。セメント陰極（サイズ6～7または7.7～9mm）は、スリーブ（拡大）より10～20mm上に気管内チューブ上に円形に折り畳まれ、声帯に近づいた。麻酔科医は、喉頭鏡を使用して、陰極が正確に配置されているかどうかを確認した（図1、AC）。ショートや電流の悪影響を防ぐため、接地陽極を肩に設置し、喉頭シリンダーに接続した。喉頭神経への電気刺激に対する首の運動反応を記録することで、声帯周囲の陽極の適切な配置を確認した。

 

Method:- 20 patients who underwent total thyroidectomy operation in our surgery department between January 2017 and March 2017 were involved into the study. All the patients were intubated following anesthesia induction with propofol 1.5 mg/kg; rocuronium 0.6 mg/kg; remifentanil 0.25 microgram/kg/min and mechanically ventilated at Vc mode. Anesthesia maintenance was provided with remifentanil of 0.25 microgram/min, sevoflurane of 0.8 mac, and air-o2 combination of 4 lt/min. Following the intubation, the TOF-Guard neuromuscular transmission monitor was placed on left hand and TOF was measured and recorded. 100 mg of bridion was administered intravenously just before the surgeon start thyroid gland resection. Following bridion injection, TOF response at 1st, 2nd, 3rd and 4th minutes were measured and recorded. If the response was over 90%, then the surgeon was let to use neuromuscular monitoring device. Vocal cord examinations were done in all the patients by an ear-nose-throat specialist on the 1st post-operative day. Age, gender, recurrent laryngeal nerve conduction speed before and after excision, BMI, surgery time, hospital stay duration, nerve conduction response duration following drug injection and complications were analyzed. A 3-to 4-cm Kocher entry point was made and the platysma with subplatysmal folds were raised superiorly and poorly with the assistance of the electrocautery. The lash muscles were withdrawn for sidelong presentation of the center thyroid vein, if present, to be partitioned. Every little vessel were blocked with a vessel-fixing gadget. The electrocautery was utilized to dismember the pyramidal projection and the isthmus. During complete thyroidectomy, the vagal nerve was found on the left side first. The vagus nerve was found by dismembering the region between carotid conduit and jugular vein. The vagus nerve (VN) was distinguished under direct vision and the nonappearance of the sign was watched. At that point, a sugammadex sodium (2mg/kg) bolus was controlled intravenously. Following sugammadex sodium infusion, TOF records of first, second, third and fourth minutes were estimated and at where the reaction was greater than 90%, the neuromuscular checking gadget was begun to be utilized.

 

Results: None of the patients developed nerve-related complications. The mean age was 47.6±11.82 years and mean BMI was 28.745±3.20. The mean operation time was 52.65±5.51 min. There wasn’t any significant difference in neither right nor left RLN monitoring values before and after surgery. Following the drug injection, the TOF guard nerve conduction response values were found 23.5±4.90; 69.5±6.86; 88±4.1 and 100, on 1st, 2nd, 3rd and 4th minutes, respectively. The use of an anti-muscle relaxant drug and detecting the presence of nerve conduction with TOF-guard nerve monitor can provide a more reliable IONM and more safe surgery.

 

経歴:トゥルグット・ドンメズは1997年にイスタンブール大学チェラパシャ医学部を卒業し、2003年に同学部の病院で一般外科の研修を修了しました。彼はルトフィエ・ヌリ・ブラート国立病院で働いています。彼は腹腔鏡手術と甲状腺手術の専門家です。