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Cirurgia da tireoide, İONM e relações de sugamadex sódico: Benefícios do uso de sugamadex sódico para IONM

Turgut Donmez

Introdução: Uma das complicações mais importantes na cirurgia da tireoide é a paralisia das cordas vocais como resultado de lesão do nervo laríngeo recorrente (RLN). Enquanto a lesão unilateral do nervo pode ser tolerada pelos pacientes, a paralisia bilateral do nervo pode resultar em complicações tão graves quanto a morte. O cirurgião deve usar uma técnica de monitoramento neurológico intraoperatório (IONM) estritamente padronizada para ter sucesso em um monitoramento bom e de boa qualidade e cirurgia segura, a fim de prevenir lesões no RLN e salvar suas funções. Mas, a meia-vida dos medicamentos anestésicos gerais com efeito de bloqueio neuromuscular que são usados ​​durante a operação está intimamente relacionada à afetividade e confiabilidade do IONM. Nosso objetivo foi detectar a condução nervosa usando o monitor de transmissão neuromuscular TOF-Guard e fornecer um IONM mais confiável após a administração de sugamadex sódico (bridion), que antagoniza o bloqueio neuromuscular do medicamento anestésico.

Histórico: Após a sedação, o paciente foi ventilado por dois minutos e intubado com um tubo endotraqueal protegido (medição interna de 7 a 7,5 mm) com um cátodo de superfície fixado 2 cm melhor que a manga (ânodo do cilindro laríngeo Dr. Langer). Os cátodos de cimento, de 6-7 ou 7,7-9 mm de tamanho, foram dobrados circularmente sobre o tubo endotraqueal, 10-20 mm sobre a manga (expandir), aproximando as cordas vocais. O anestesiologista verificou se ele estava posicionado com precisão utilizando um laringoscópio (Fig. 1, AC). Para evitar um curto-circuito e um impacto hostil do fluxo elétrico, um ânodo de aterramento foi colocado no ombro e associado ao cilindro laríngeo. O assentamento correto dos ânodos ao redor das cordas vocais foi verificado registrando a atividade do motor, possível reação no pescoço à motivação elétrica no nervo laríngeo.

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.

Biografia: Turgut Donmez se formou na Faculdade de Medicina da Universidade de Istambul Cerrahpasa em 1997 e concluiu sua Residência em Cirurgia Geral em 2003 no mesmo hospital da faculdade. Ele tem trabalhado no Hospital Estadual Lutfiye Nuri Burat. Ele tem experiência em cirurgia laparoscópica e de tireoide