Nöromusküler Blok Monitörizasyonu
Özet
Nöromusküler bloke edici ajanlar (NMBA), genel anestezi sırasında endotrakeal entübasyonu kolaylaştırmak ve cerrahi koşulları iyileştirmek amacıyla uygulanır; bloğun derinliğini ayarlamak ve derlenmeyi değerlendirmek için nöromusküler izlem zorunludur. Derlenmenin izlenmesinde akseleromiyografi, elektromiyografi veya kinemiyografi gibi kantitatif (objektif) monitörizasyon yöntemlerinin kullanılması ve TOF oranının 0.9 veya üzerinde olduğunun dokümante edilmesi önerilmektedir. Kantitatif monitör bulunmadığı durumlarda periferik sinir stimülatörü ile gerçekleştirilen subjektif TOF değerlendirmesi kullanılabilse de, bu yöntem rezidüel kürarizasyon açısından yeterli derlenmeyi garanti etmemektedir. Baş kaldırma veya kavrama gücü gibi geleneksel klinik testler rezidüel bloğun tespitinde hassas ve spesifik değildir. Monitörizasyonda tercih edilen öncelikli bölge ulnar sinir ve adduktor pollicis kasıdır; erişim kısıtlılığında fasiyal ve posterior tibial sinirler de değerlendirilebilir. Nörostimülasyon kalıpları arasında TOF, tetani, post-tetanik sayım (PTC) ve çift patlama stimülasyonu (DBS) yer almaktadır. En sık kullanılan kantitatif yöntem, Newton'un İkinci Hareket Yasası'na dayanarak başparmağın ivmesini ölçen akseleromiyografidir (AMG). Kas gruplarının blokaj yanıtı ve derlenme hızları farklılık gösterir; diyafram ve larinks kasları en hızlı derlenirken, adduktor pollicis kası en geç derlenir. Bu nedenle adduktor pollicis kasında TOF oranının 0.9 seviyesine ulaşması, hava yolu kaslarının ve diyaframın da tamamen iyileştiğini ve güvenli ekstübasyonu temsil eder.
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