Abstract：
Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient\'s outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n = 24 000) to the finally relevant clinical studies ( n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).
摘要：
最近的数据表明神经肌肉阻滞管理不当的发生率很高，残留麻痹和松弛相关的术后并发症发生率很高。这些数据令人震惊，因为可用的神经肌肉监测，以及肌肉松弛剂及其拮抗剂基本上允许对神经肌肉阻滞进行良好的耐受管理。在这个关于神经肌肉阻滞围手术期管理的第一个欧洲麻醉和重症监护学会（ESAIC）指南中，我们的目标是提出汇总和循证的建议,以协助临床医生提供最佳医疗护理并确保患者安全.我们确定了三个主要的临床问题：是否需要肌松药来促进成人气管插管？神经肌肉阻滞的强度是否会影响患者在腹部手术中的预后？残余麻痹的诊断和治疗策略是什么？在此基础上，PICO（病人，干预，比较器,结果)得出的问题指导了结构化的文献检索。使用逐步方法将初始研究（n=24000）的试验数量减少到最终相关临床研究（n=88）。分级方法(建议分级，评估,开发和评估）用于根据纳入研究的结果及其方法学质量制定建议。使用两步Delphi过程来确定小组成员与以下建议的一致性：R1我们建议使用肌肉松弛剂来促进气管插管（1A）。R2我们建议使用肌肉松弛剂来减少气管插管后的咽部和/或喉部损伤(1C)。R3我们建议使用速效肌肉松弛剂进行快速序列诱导插管（RSII），例如琥珀酰胆碱1mgkg-1或罗库溴铵0.9至1.2mgkg-1（1B）。R4如果需要改善手术条件，我们建议加深神经肌肉阻滞（1B）。R5没有足够的证据推荐深层神经肌肉阻滞来减轻术后疼痛或降低围手术期并发症的发生率。(2C).R6我们建议对内收肌使用尺神经刺激和定量神经肌肉监测，以排除残余麻痹（1B）。R7我们建议使用sugammadex对抗深层，氨基类固醇药物诱导的中度和浅层神经肌肉阻滞(罗库溴铵，维库溴铵)(1A)。R8我们建议在开始基于新斯的明的逆转之前进行晚期自发恢复（即TOF比率>0.2），并继续对神经肌肉阻滞进行定量监测，直到TOF比率达到0.9以上。(1C)。
