Impact On Grafted raum Function Of Rocuronium-sugammadex Vs Cisatracurium neostigmine Strategy Rau Neuromuscular Block Management.

AbstractKeeb kwm:Qhov cuam tshuam ntawm sugammadex hauv cov neeg mob nrogkab mob raum kawgnyob rau hauvhloov raumtseem nyob deb ntawm kev txhais. Txoj kev tshawb no tsom los sib piv sugammadex rau neostigmine rau kev thim rov qab ntawm rocuronium- thiab cisatracurium-induced neuromuscular block (NMB), feem, hauv cov neeg mob hloov lub raum.

Txoj kev:Ib qhov chaw ib-chaw, 2014-2017 kev tshawb nrhiav kev tswj xyuas cov ntaub ntawv rov qab tau ua tiav. Tag nrho ntawm 350 tus neeg mob tau hloov lub raum, sib npaug ntawm pawg sugammadex (175 tus neeg mob) thiab pawg neostigmine (175 tus neeg mob), tau txiav txim siab. Tom qab lub raum ua haujlwm, ntsuas los ntawm kev saib xyuas cov ntshav creatinine thiab urea thiabkwv yees glomerular filtration rate(eGFR), yog qhov kawg. Lwm cov ntsiab lus kawg yog cov tshuaj loog thiab lub sijhawm phais, tom qab siv tshuaj loog qhov chaw zov me nyuam ntev ntawm kev nyob, tsev kho mob tom qab mob hnyav, thiab rov muaj NMB lossis teeb meem. Cov txiaj ntsig: Tsis muaj qhov sib txawv tseem ceeb hauv tus neeg mob lossis, tshwj tsis yog cov tshuaj koom nrog hauv kev tswj hwm NMB, tshuaj loog, thiab cov yam ntxwv ntawm kev phais, tau pom ntawm ob pawg.Cov tshuaj creatinine( nruab nrab [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.{{9} }] μmol/L, p {{10}}.0128) thiab ntshav urea (14.9 [10.8-21.6] vs 17.1 [13 .{2{{30}}}}. {48}} [6.0-11. pawg neostigmine tom qab phais. Cov pab pawg sugammadex tau pom qhov tshwm sim qis dua ntawm kev mob ntshav qab zib hnyav hypoxemia (0.6% vs 6.3%, p=0.006), luv PACU nyob (70 [60-90] min vs 90 [60-105} ] min, p < 0.001), thiab txo ICU nkag (0.6% vs 8.0%, p=0.001).

Nws yuav siv sij hawm ntev npaum li cas rau CISTANCHE ua haujlwm?

Cov lus xaus:Piv rau cisatracurium-neostigmine, rocuronium-sugammadex lub tswv yim rau kev thim rov qab ntawm NMB tau pom tias muaj kev rov qab zoo dua hauv cov neeg mob hloov lub raum.

Ntsiab lus:Tshuaj loog, Neuromuscular thaiv, Rocuronium, Cisatracurium, Sugammadex, Neostigmine, Kab mob kawg raum,Hloov pauv raum

Taw qhia

Hloov pauv raumsawv cev rau qhov kev xaiv zoo tshaj plaws los txhim kho kev ciaj sia thiab kev ua neej zoo nyob rau hauv cov neeg mob uas muaj kab mob raum kawg (ESRD) (Kellar, 2015). Txoj kev phais ntawm lub raum hloov pauv feem ntau yog ua raws li kev siv tshuaj loog thiab nthuav tawm cov teeb meem tseem ceeb rau tus kws tshuaj loog (Martinez li al. 2013). Kev ua tib zoo tshuaj loog yog pom zoo kom txhim kho cov txiaj ntsig (Martinez li al. 2013; De Gasperi li al. 2014; Mittel thiab Wagener, 2017; Wagener li al. 2020). Kev tswj hwm ntawm neuromuscular block (NMB) tsim nyog tau txais kev saib xyuas tshwj xeeb (Martinez li al. 2013; Mittel thiab Wagener, 2017) kom txo tau qhov tshwm sim ntawm cov teeb meem vim kev ua haujlwm tom qab NMB (De Gasperi li al. 2014; Miskovic thiab Lumb, 2017). Cov neeg mob tau txais, piv rau cov tsis tau txais, cov tshuaj tiv thaiv kab mob neuromuscular blocking (NMBAs) thaum lub sij hawm siv tshuaj loog yog qhov muaj feem yuav muaj feem cuam tshuam txog kev ua pa tom qab ua pa nyuaj (kho qhov tsis sib xws [aOR]: 1.86) (Kirmeier li al. 2019) . Benzylisoquinolinium compounds, xws li cisatracurium, thiab aminosteroid NMBAs, xws li rocuronium, feem ntau siv thaum lub sij hawm tshuaj loog rau lub raum hloov. Tsis muaj pov thawj txhawb nqa qhov zoo tshaj plaws ntawm NMBA tshwj xeeb. Cisatracurium zoo li tau txais txiaj ntsig los ntawm qee qhov kev nyiam ntawm cov tshuaj loog vim tias nws tsis ua haujlwm los ntawm Hofmann tshem tawm thiab hydrolysis los ntawm esterases ywj pheej ntawm lub raum ua haujlwm, thaum rocuronium yog tus cwj pwm los ntawm kev tshem tawm hauv nruab nrog cev. Txawm li cas los xij, ob qho tib si cuam tshuam nrog lub sijhawm ntev me ntsis ntawm kev ua haujlwm thiab yuav tsum tau ua tib zoo saib xyuas kev ua haujlwm neuromuscular kom muaj kev nyab xeeb thaum kawg ntawm kev phais (Della Rocca li al. 2003; Martinez li al. 2013; Mittel thiab Wagener, 2017). Thaum kev saib xyuas cov paj hlwb kom zoo yog qhov tseem ceeb hauv kev zam kom tsis txhob muaj teeb meem tom qab kev phais, tshwj xeeb yog mob ua pa (Blobner li al. 2020), kev xaiv cov tshuaj thim rov qab zoo li tsis muaj qhov tseem ceeb (Kheterpal li al. 2020). Piv rau neostigmine, ib qho acetylcholinesterase inhibitor ib txwm siv rau kev thim rov qab ntawm NMB, kev siv sugammadex, hloov kho -cyclodextrin tsim rau kev thim rov qab ntawm NMB vim los ntawm aminosteroid NMBAs, tshwj xeeb tshaj yog rocuronium, tau cuam tshuam nrog qhov tshwm sim ntawm qhov mob ntsws loj heev ( Kheterpal thiab 2020).

Sugammadex yog cov tshuaj hydrophilic heev thiab ua haujlwm hauv cov ntshav los ntawm kev encapsulating thiab inactivating unbound rocuronium los ua ib qho 1: 1 dej-soluble complex. Kev tso zis tso zis yog txoj hauv kev tseem ceeb ntawm kev tshem tawm sugammadex thiab sugammadex-rocuronium complex. Lub sijhawm no, kev tswj hwm sugammadex tsis pom zoo los ntawm cov chaw tsim khoom rau cov neeg mob lub raum tsis zoo (creatinine clearance [CrCl] < 30 mL / min), suav nrog cov qauv kev lim ntshav (EMA 2021). Cov ntaub ntawv kev nyab xeeb ntawm sugammadex tau pom nyob rau hauv kev tshawb fawb soj ntsuam nrog rau cov neeg mob lub raum tsis zoo (Staals li al. 2008; de Souza li al. 2015) tau txhawb kom nws siv hauv kev kho mob hauv cov neeg mob ESRD (Adams li al. 2020; Paredes li al. ., 2020), tshwj xeeb tshaj yog nyob rau hauv lub raum hloov pauv (Unterbuchner, 2016; Ono et al. 2018; Arslantas thiab Cevik, 2019; Adams li al. 2020; Vargas li al. 2020). Txawm li cas los xij, tsuas yog rov qab txheeb xyuas suav nrog cov ntawv ceeb toom (Unterbuchner, 2016) lossis cov neeg mob me me muaj nyob hauv cov ntaub ntawv (Ono li al. 2018; Arslantas thiab Cevik, 2019; Adams et al. 2020; Vargas et al. 2020). Tsis tas li ntawd, tsis muaj cov ntaub ntawv muaj nyob rau ntawm kev siv sugammadex rau kev thim rov qab ntawm NMB tob hauv cov neeg mob hloov lub raum. Yog li, peb txoj kev tshawb fawb tsom los ntsuas qhov cuam tshuam ntawm sugammadex, muab ntawm cov koob tshuaj pom zoo rau kev thim rov qab ntawm qhov nruab nrab lossis sib sib zog nqus rocuronium-induced NMB, piv rau neostigmine, tswj hwm rau kev thim rov qab ntawm qhov nruab nrab cisatracurium-induced NMB, ntawm lub raum ua haujlwm hauv pawg loj ntawm cov neeg mob tau hloov lub raum.

Cov ntaub ntawv thiab cov txheej txheem

Cov lus hais txog kev coj ncaj ncees thiab kev pom zoo rau kev kawm Tag nrho cov txheej txheem ua nyob rau hauv txoj kev tshawb no yog los ntawm cov qauv kev ncaj ncees ntawm lub koom haum thiab/los yog lub teb chaws tshawb fawb committee thiab nrog rau 1964 Helsinki tshaj tawm thiab nws tom qab hloov kho los yog sib piv cov qauv kev coj ncaj ncees. STROBE cov lus pom zoo rau kev tshawb nrhiav cov ntaub ntawv tswj xyuas pawg tau ua raws. Qhov kev soj ntsuam rov qab no tau pom zoo los ntawm peb Pawg Saib Xyuas Kev Tshawb Fawb (Ethics Committee hauv Kev Tshawb Fawb Kev Tshawb Fawb-CESC ntawm Padova, Ltalis, prot.n.42587, 16 Lub Xya Hli 2020), uas zam qhov yuav tsum tau txais cov neeg mob daim ntawv tso cai (cov ntaub ntawv yog txheeb xyuas rov qab thiab tsis qhia npe).

Cov neeg mob

Tag nrho ntawm 350 tus neeg mob nrog ESRD tab tom hloov lub raum ntawm peb lub tsev kho mob tau soj ntsuam. Cov neeg mob tau raug xaiv ua ntu zus mus txog thaum ua tiav cov qauv loj. Cov tshuaj loog thiab cov ntaub ntawv kho mob thiab cov ntaub ntawv xov xwm hauv computer database tau siv los khaws cov ntaub ntawv hais txog txhua tus neeg mob (hnub nyoog siab dua lossis sib npaug li 18 xyoo) nrog ESRD uas tau txais sugammadex lossis neostigmine rau thim rov qab rocuronium- lossis cisatracurium-induced NMB, raws li, thaum nqus tau. los yog intravenous anesthesia rau lub raum transplantation. Txhua qhov tshuaj loog thiab cov ntaub ntawv kho mob tau raug tshuaj xyuas rau cov ntaub ntawv ua ntej, kev ua haujlwm, thiab kev ua haujlwm tom qab txog li 5 hnub tom qab kev phais. Cov neeg mob cov pej xeem, comorbidities (piv txwv li, keeb kwm ntawm neurological, ua pa, plawv, plab, thiab kab mob metabolic), cov ntaub ntawv perioperative nrog rau lub raum ua haujlwm (cov ntshav creatinine thiab urea, kwv yees glomerular filtration rate [eGFR]), thiab cov xwm txheej tom qab raug txiav txim siab.

Ob lub sijhawm sib txawv uas txhais tau tias cov pab pawg kis tau raug suav tias yog: lub sijhawm ua ntej sugammadex, 2014-2015 (los ntawm cov neeg mob uas cisatracurium-neostigmine-kho tau txheeb xyuas), thiab lub sijhawm sugammadex, 2016-2017 (los ntawm qhov twg rocuronium -sugammadex-kho cov neeg mob tau txheeb xyuas). Sugammadex tau qhia hauv Padua University Tsev Kho Mob thaum Lub Ib Hlis 2013 thiab tau pib txwv rau kev thim rov qab thaum muaj xwm txheej ceev thiab niaj hnub thim rov qab ntawm rocuronium-induced NMB hauv cov neeg mob uas muaj kev pheej hmoo siab uas tau txhaj tshuaj loog (Carron M, Baratto F 2016). Thaum Lub Ib Hlis 2016, kev siv sugammadex tau tso cai rau kev hloov pauv niaj hnub. Qhov no ua rau muaj kev hloov pauv los ntawm kev siv cisatracurium-neostigmine mus rau rocuronium sugammadex lub tswv yim. Neostigmine tau tswj hwm kom thim rov qab tsuas yog nruab nrab cisatracurium-induced NMB, thaum sugammadex tau siv rau ob qho tib si sib sib zog nqus thiab nruab nrab rocuronium-induced NMB thaum kawg ntawm kev phais. Kev saib xyuas tus qauv tau txais, suav nrog kev siv tshuaj loog sib sib zog nqus thiab kev saib xyuas kev ua haujlwm neuromuscular. Lub tsheb ciav hlau-ntawm-plaub qhov piv (TOFR) Ntau dua lossis sib npaug ntawm 0.90 tau txais los ua tus qauv rau tracheal extubation (Brull thiab Kopman, 2017). Txhua tus neeg mob tau txais tshuaj tua kab mob tiv thaiv kab mob (piperacillin 2 g) ua ntej kev phais, kev tiv thaiv kab mob (thyroglobulin 1-1.5 mg / kg lossis basiliximab 20 mg, thiab methylprednisolone 500 mg) thaum pib ntawm txoj kev phais, thiab diuretics (furosemide 100 mg. thiab mannitol 18% 80 mL) thaum phais tom qab anastomosis ntawm lub raum hlab ntsha.

Tom qab kev phais, cov neeg mob raug xa mus rau tom tsev kho mob tshuaj loog (PACU). Qib ntawm kev nco qab, tus nqi ua pa, pulse oximetry, lub plawv dhia, thiab cov ntshav siab tau raug saib xyuas kom txog thaum tso tawm mus rau chav kho mob phais. Mob thiab tom qab phais xeev siab thiab ntuav (PONV) raug soj ntsuam siv tus lej ntsuas ntsuas (NRS) los ntawm 0=tsis muaj mob lossis xeev siab mus rau 10=qhov mob hnyav tshaj plaws lossis xeev siab. Cov neeg mob kuj tau raug soj ntsuam rau cov pov thawj kho mob ntawm qhov seem lossis rov tshwm sim NMB (xws li cov leeg tsis muaj zog, oxygen desaturation, hypoventilation, qhov tshwm sim ua pa tseem ceeb). Cov neeg mob uas muaj qhov mob NRS qhov qhab nia> 3 hauv PACU tau txais kev cawm dim (paracetamol 1 g thiab tramadol 1 mg / kg intravenously). Cov neeg mob uas tau qhab nia PONV NRS ntawm > 3 tau txais kev cawmdim koob tshuaj dro peridol 0.625-1.25 mg intravenously. Endpoints Serum creatinine (primary endpoint) thiab serum urea thiab eGFR (secondary endpoints) rau kev saib xyuas lub raum ua haujlwm ntev txog 5 hnub tom qab kev phais yog cov ntsiab lus tseem ceeb ntawm txoj kev tshawb no. Lwm cov ntsiab lus kawg yog tshuaj loog thiab lub sijhawm phais, qhov ntev ntawm PACU nyob, chav saib xyuas mob hnyav (ICU) nkag, cov ntaub ntawv pov thawj ntawm kev ua pa tom qab ua pa nyuaj (xws li, hypoxemia nrog peripheral arterial ntshav oxygen saturation [SaO2] < 90%, kev ua pa tseem ceeb) lossis mob plawv. Kev tshwm sim (xws li mob stroke, myocardial ischemia, plawv tsis ua hauj lwm, kub siab, arrhythmia), PONV NRS tus qhab nia ntawm> 3, mob NRS tus qhab nia ntawm> 3, residual los yog recurrent NMB, thiab muaj lwm yam teeb meem postoperative nyob rau hauv 24 teev tom qab kev phais uas yuav tsum tau. kev kho mob. Rau kev ua pa ua pa, kev ntsuam xyuas roj pa ntawm cov ntshav hlab ntsha (pH, cov hlab ntsha ib feem ntawm cov pa oxygen [PaO2] thiab carbon dioxide [PaCO2]) tau ua 15-20 min tom qab tracheal extubation tau txiav txim siab. Rau kev ua haujlwm ntawm lub plawv, lub plawv dhia (HR) thiab systolic (SBP), thiab diastolic (DBP) cov ntshav siab ntsuas tau ntsuas 15-20 min tom qab tracheal extubation tau txiav txim siab. Cov ntaub ntawv tau sau los ntawm cov kws tshawb fawb yam tsis muaj kev koom tes hauv kev tswj cov neeg mob. Lawv tsim cov ntaub ntawv nrog cov ntaub ntawv tsis qhia npe rau kev txheeb xyuas kev txheeb xyuas los ntawm cov kws tshawb fawb tsis koom nrog kev sau cov ntaub ntawv.

Kev txheeb cais

Cov qauv loj yog raws li cov kev xav hauv qab no: qhov sib txawv nruab nrab ntawm 44.2 μmol / L ntawm cov ntshav creatinine hauv thawj hnub tom qab kev phais ntawm pawg sugammadex thiab pawg neostigmine raws li kev kho mob hauv lub sijhawm tom qab phais (Kork li al. 2{{4 }}15; Gameiro li al. 9}.8). Xav txog cov kev xav no, cov qauv piv txwv tau suav tias yog 350 tus neeg mob, sib npaug ntawm pawg sugammadex (175 tus neeg mob) thiab pawg neostigmine (175 tus neeg mob). Kev piav qhia piav qhia tau siv los sau cov qauv ntawm cov yam ntxwv. Qhov normality ntawm kev faib tawm ntawm cov yam ntxwv ntau tau txheeb xyuas siv Shapiro-Wilk test. Nruam ib txwm faib cov hloov pauv tau qhia tias txhais tau tias ± tus qauv sib txawv (SD). Qhov nruab nrab thiab qhov sib npaug (IQR) qhov tseem ceeb tau tshaj tawm rau qhov tsis yog ib txwm faib cov hloov pauv. Qhov ob-tailed Student's t-test los yog ob-tailed Mann-Whitney U test tau siv los sib piv cov khoom sib txawv ib txwm thiab tsis yog ib txwm faib, raws li, ntawm cov pab pawg qab zib thiab neostigmine. Categorical cov ntaub ntawv tau tshaj tawm raws li tus lej tseeb thiab qhov feem pua ​​(%) thiab muab piv nrog kev siv χ2 lossis Fisher qhov kev xeem. Txhawm rau txiav txim siab lub zog thiab kev coj ua ntawm kev sib koom ua ke ntawm ob qhov sib txawv, Bravais-Pearson qhov kev sib txheeb sib txheeb tau siv rau cov khoom sib txawv raws li ib txwm muaj, thiab Spearman's rank correlation test yog siv rau cov tsis tshua muaj kev faib tawm. Ntau qhov kev txheeb xyuas kab rov tav tau siv los tshuaj xyuas kev sib raug zoo ntawm ib qho kev hloov pauv thiab qhov hloov pauv ywj pheej. Siv cov txheej txheem Akainformationtion, rov qab mus rau pem hauv ntej thiab rov qab mus rau theem rov qab los xaiv tus qauv zoo tshaj plaws. Correlation coefficients (CCs), kwv yees coefficients (ECs), tus qauv yuam kev (SEs), t qhov tseem ceeb, thiab p tus nqi raug txiav txim. Kev txheeb xyuas qhov tseem ceeb tau teeb tsa ntawm p tus nqi <0.05. Txhua qhov kev txheeb cais tau ua tiav siv R version 3.4.0 (2017-04-21).