NMTYage

神经肌肉传导监测NMT,GE Healthcare朴松哲2006-09-16,Neuromuscular Transmission (NMT) Monitoring,E-NMT,NMT 监测方式,测量肌肉对刺激的收缩反应最常用尺神经,刺激,测量反应,NMT 监 测,刺激模式：TOF，DBS，ST，PTC ST 单次刺激 TOF 四个成串刺激 (临床最常用） PTC 强直刺激后计数 （监测深度神经阻滞） DBS 双强直刺激刺激强度和时间可调刺激反应在屏幕上独立显示文字提示肌松状态,应用肌松药前 TOF%100 ；TOF值4,用药初期 TOF 下降，肌松药起效,TOF值降到2或2以下时，即可进行插管。外科手术通过控制TOF值，一般TOF值0，来获得理想肌松效果。,手术结束后，当TOF值达到2或3时，即可使用拮抗药，使病人恢复。,手术恢复期，当TOF达到90时，可安全拔管。,肌松监测的临床应用,肌松状态的全程监测,肌松监测3个参数同屏全程显示,校准,气管插管,拔管,神经肌肉松弛起始,肌松恢复,TOF% 100 20 Count 4 0 PTC 10 0,浅,深,肌松程度,追加肌松药,肌松监测的临床价值,测定肌松药作用起效时间和气管插管时机选择维持术中最佳肌松状态神经肌肉阻滞的恢复判断和拔管时机选择判断神经肌肉阻滞的类型神经定位,麻醉科：,外科医生要求手术区域肌肉松弛 几乎所有的外科手术必要条件 安 全: 避免患者活动造成的伤害 e.g. 神经科，眼科及颌面外科手术 气管插管 & 拔管,肌松药的应用肌松监测,帮助机械通气 (41%) 反比通气 PCV 可容性高碳酸血症 降低呼吸功耗 改 善 氧 合 肌松时，氧耗降低 消除人机对抗 破伤风，肌肉痉挛. (13%),ICU：,肌松药的应用肌松监测,区域阻滞的监测,刺激通过针头发生40S pulse 对于清醒病人无痛苦 脉冲可调节,NMT 市场卖点,4 种刺激方式操作方便，显示全面专利的肌力传感器：从婴儿至成人与D-O其它神经电生理参数组成完整AOA监 测系统,梦想启动未来科技守护健康,Indications for Relaxation in Anesthesia,Facilitate intubation & mechanical ventilationSurgeon needs a stable site to operate onSometimes a condition of the surgery e.g. abdominal surgery: in order to get access to the cavity, muscles must not contract Safety: injuries may occur if patient moves e.g. neurosurgery, eye and ear surgery,Movement,Voluntary,Involuntary,Brain,Spinal cord,Painful stimulus,Muscle activity,Skin,Muscle,Sensory impulses,Motor impulses,Function of Neuromuscular Junction and Neuromuscular Blocking Agents,Why Monitor NMT and Relaxation ?,BASIS: measure individual effect of relaxants (remember AoA!)For obtaining optimal conditions for surgery and safe recoverytiming and dosingsafe extubationsavings in OR time and drugs safe discharge from PACU, no risk for residual paralysis Teaching & research,GE Healthcare NMT measurement,KMG (= Kinemyography, detects movement by using the MechanoSensor) Not the same asACG (= accelerography.Measures acceleration)MMG (= mechanomyography. This is basically the same technology than ours but bulkier than D-O Technology, because the hand needs to be immobilized)EMG (=Electromyography, records the electrical activity of a muscle in response to nerve stimulation)the signal obtained depends on the location of the recording electrodes relative to the muscle,Monitoring Neuromuscular Transmission,A peripheral nerve is stimulated electricallyTransfer of the electric impulse from the nerve to the muscle is measured Measured muscle response indicates the level of neuromuscular blockSeveral stimulation patternsTOF, ST, DBS, PTC,1. Stimulate,2. Measure response,100 TOF% 20,4 Count 0,10 PTC 0,Light,Deep,Clinical Use of NMT,Attach electrodes and the sensor - Press Start-up key Automatic calibration = Search for supramaximal stimulus current used for monitoring (with TOF or DBS it is not mandatory )Setting the referenceInject the first dose of relaxantIntubation when all responses disappearSafe extubation, when TOF% over 90,Clinical Use of NMT,Adequate surgical level depends on the operation and the anesthetics given often Count 1 or 2Set Recovery Note to the desired level; when note appears, inject a new bolusAdequate level in critical care depends on the patient; often in the Count rangeNew: Recovery Note proceeds into a yellow alarm,Regional block,Regional anesthesia: Anesthetic agent is injected to a peripheral nerve to produce a block of responses in a certain anatomical area (the hand /plexus nerve)Nerve location tool for Regional block helps in finding the optimum site of the regional nerve to be blocked and helps to optimizes the bolus of the anesthetic to be injected. The correct location also protects the patient against mechanical nerve and vessel lesions.,Other technologies,GE Healthcare: a modular solution Philips/Agilent has licensed the acceleration measurement technology from Organon TeknikaStand-alone competitors:Peripheral nerve stimulators with no quantitative measurementTOF Guard or TOF Watch (Organon Teknika): accelerographyParagraph (Vital Signs): piezoelectricMechanoMyography,Comparison to peripheral nerve stimulators,Only stimulation, no quantitative measurementrequires user intervention inaccurateno documentation ( no trends!)Battery operatedFew stimulation modesPrice: PNS module (or given free),Comparison to TOF Watch / TOF Guard,Measures the acceleration of the thumbBattery operatedSeparate vs. integrated an extra display to look at no documentation, no data integrationEase of use acceleration transducer vs. MechanoSensorD-O: recovery notePrice: TOF Watch module,Accelerometry,An acceleration transducer in the tip of the fingerThe thumb must always move in the same direction, hand must be immobilizedAttachment not as easy as with the MechanoSensorLess robust,The NMT Module Strengths,Ease of useMechanoSensor Automatic operationRecovery NoteIntegrated, all-in oneT