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Vecuronium 투여후 mechanomyography, electromyography, accelerograph에 의한 근이완회복의 비교연구

Vecuronium 투여후 mechanomyography, electromyography, accelerograph에 의한 근이완회복의 비교연구
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The comparison between Mechanical, Electromyographic and Accelerographic responses during recovery from vecuronium induced neuromusclar blockade
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대학원 의학과
이화여자대학교 대학원
전신 마취시 근이완제의 사용이 보편화됨에 따라 안전한 마취관리를 위하여 신경근 차단의 양상 및 회복에 대한 올바른 평가가 필요하다(Miller 등, 1990, Viby-Mogensen, 1982). 임상적으로 유용하게 쓰이는 근이완 감시 장치로는 신경 자극에 의한 근수축 반응의 힘을 측정하는 mechanomyography(MMG), 근복합 활동 전위를 기록하는 electromyography(EMG), 근 수축 반응시 음직임의 가속도를 측정하는 accelerography(ACC)가 있다(Epstein, 1973, miller 등, 1990, Viby-Mogensen 등, 1988). mechanomyography는 장비와 설치가 복잡하고 시간을 요하며 electromyography는 측정치가 부정확한 면이 있으며 값이 비싸다. 이에 비하여 accelerography는 가장 최근에 개발된 감시장치로 사용과 설치가 아주 쉬우면서도 그 반응이 안정되어 있고, mechanomyography에 의한 결과와도 유의한 상관관계를 나타내는 감시장치이다(Miller 등, 1990, Viby-Mogensen 등, 1988, Jensen등, 1988). 근이완 감시장치에 의한 평가는 각 근이완제에 대하여 약물 특이적인 차이를 보이며 동일한 근이완제에서도 각 기구에 대한 상이한 반응결과가 보고되었다. 세 장치간의 평가결과가 좋은 상관관계를 이루지 못한다면 이 중 한 장치만을 사용한 근이완회복의 평가는 적절치 않을 수 있다. 실제 몇몇 연구의 의하면 vecuronium에 의한 근이완의 경우 electromyography에 의한 회복양상은 mechanomyography에 비해 과대평가되어 회복실에서의 잔여 근이완의 위험성이 있다(Astley 등, 1987, Stanley 및 stanley, 1986, Dupuis 등, 1990). 이에 저자는 비탈분극성 근이완제인 vecuronium에 의한 근이완으로부터 자발회복시 mechanomyography, electromyography, accelerography에 나타나는 회복 양상에 대해 비교 연구해 보고자 T₁/Tс비율의 회복 시간, MMG의 T₁/Tс 비율과 TOF(train-of-four) 비율이 각각 10%, 20%, …90% 일때 electromyography와 accelerography에 나타나는 T₁/Tс비율과 TOF 비율의 크기를 측정하여 다음과 같은 결과를 얻었다. 1) MMG, EMG 및 ACC에 의한 T₁/Tс회복 시간은 유의한 차이가 없었다. 2) T₁/Tс MMG에 대한 EMG와 ACC는 유의한 상관관계를 나타내었다. 3) T₄/T₁ MMG에 대한 EMG와 ACC는 유의한 상관관계를 나타내었다. 결론적으로 vecuronium투여 후 MMG에 대한 EMG, ACC에 의한 T₁/Tс회복시간은 유사하였다. T₁/Tс 및 T₄/T₁ 크기는 유의한 상관관계를 나타내었으며 임상적으로는 큰 문제없이 사용할 수 있다고 생각한다. ;As the use of muscle relaxants routinize in the clinical general anesthesia, the proper estimation of neuromuscular blockade and recovery is needed for the more safe anesthetic management. Three recording methods of measurement in recovery are available ; measurement of the evoked mechanical responses(mechanomyography), measurement of the evoked electrical responses(electromyography), and measurement of the acceleration of the muscle responses. According to previous studies, when the electromyography is compared with mechanical responses measured by the force displacement transducer, the former tends to underestimate the degree of neuromuscular blockade. Thus full recovery of the evoked EMG responses may be indicated when the mechanomyography shows inadquate recovery from neuromuscular blockade. In addton, the control TOF ratio of accelerographic responses measured by the force displacement transducer. The purpose of this study was to evaluate the correlations between mechanomyograophyic, electromyographic and accelographic responses during recovery from vecuronium induced neuromuscular blockade. 15 ASA class 1 adult patients were studied. All patients were premedicated with 100-150mg of phenobarbital and 0.2mg of glycopyrrolate IM, 1 hour before induction. After induction with 2-4mg/kg of thiopental sodium and 5-8ug/kg of fentanyl IV, neuromuscular monitoring was carried out by stimulation of the ulnar nerve at the wrist with supramaximal stimuli at a frequency of 2Hz repeated every 10 seconds using a peripheral nerve stimulator of EMG and MGG. The electromyographic reponses of adductor pollicis was continuously recorded on one hand. MMG and ACC were setted of the other hand and recorded the responses of adductor pollicis using the same TOF stimuli. Following stabilization of control twitch height, the nondepolarizing relaxant, vecuronium, was injected as 0.1mg/kg, and tracheal intubation was performed when the first twitch height of the train(T₁) was 5% of the control. Anesthesia was maintained with O₂-N₂O(2;4 L/MIN) and additional fentanyl as needed. Measurement were as follows: 1) Recovery time of T₁/Tс of 25%, 50%, 75%, 90% and 100% in each device. 2) Recovery index in each device. 3) The values of T₁/Tс in EMG and ACC corresponding to that of MMG 4) The values of TOF ratio in EMG and ACC corresponding to that of MMG The results were as follows: 1) Recovery time of T₁/Tс measured by MMG, EMG, ACC was similar. 2) Linear relationship was found between MMG T₁/Tс and EMG and ACC. 3) Linear relationship was found between MMG T₄/T₁ and EMG and ACC. Therefore it is concluded that these three neuromuscular transmission monitoring devices can be used interchangrably without any serious clinical problems.
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