Pencegahan Rekurarisasi Setelah Pemberian Reversal
Agen pembalikan didefinisikan sebagai obat yang digunakan untuk membalikkan efek anestesi, narkotika, atau agen yang berpotensi beracun. Pembalikan blokade neuromuskular secara rutin sering terjadi di banyak negara setelah operasi dengan anestesi umum, untuk mencegah kekambuhan “recurarization”.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dUGiZ9yD","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":1960,"uris":["http://zotero.org/users/local/02ZTa67H/items/LN3FCAEC"],"itemData":{"id":1960,"type":"article-journal","abstract":"The introduction of newer reversal agents such as sugammadex has revolutionised anaesthesia practice. However, much needs to be done in terms of reversal agents in critical care and toxicology.","container-title":"Indian Journal of Anaesthesia","DOI":"10.4103/0019-5049.167484","ISSN":"0019-5049","issue":"10","journalAbbreviation":"Indian J Anaesth","language":"en","page":"664-9","source":"DOI.org (Crossref)","title":"Reversal agents in anaesthesia and critical care","URL":"https://journals.lww.com/10.4103/0019-5049.167484","volume":"59","author":[{"family":"Pani","given":"Nibedita"},{"family":"Dongare","given":"PradeepA"},{"family":"Mishra","given":"RajeebKumar"}],"accessed":{"date-parts":[["2023",11,13]]},"issued":{"date-parts":[["2015"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->1<!--[if supportFields]><![endif]--> Recurarization didefinisikan sebagai peningkatan blok neuromuskular setelah periode pemulihan yang bervariasi. Recurarization sangat umum terjadi pada NMBA lama seperti gallamine,69 d-tubocurarine,104 dan pancuronium. Masalahnya berkurang dengan munculnya atracurium dan vecuronium, sebagian karena faktor lain seperti peningkatan pemantauan neuromuskular.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JdIRmInP","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":1962,"uris":["http://zotero.org/users/local/02ZTa67H/items/32C6YU3L"],"itemData":{"id":1962,"type":"article-journal","container-title":"British Journal of Anaesthesia","DOI":"10.1093/bja/aep093","ISSN":"00070912","issue":"1","journalAbbreviation":"British Journal of Anaesthesia","language":"en","page":"115-129","source":"DOI.org (Crossref)","title":"Reversal of neuromuscular block","URL":"https://linkinghub.elsevier.com/retrieve/pii/S0007091217340485","volume":"103","author":[{"family":"Srivastava","given":"A."},{"family":"Hunter","given":"J.M."}],"accessed":{"date-parts":[["2023",11,13]]},"issued":{"date-parts":[["2009"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->2<!--[if supportFields]><![endif]-->
Bahkan ketika molekul relaksan otot menempati 75% reseptor asetilkolin nikotinat pada sambungan neuromuskular, transmisi neuromuskular yang normal tercapai karena 25% reseptor sisanya memungkinkan kekuatan otot normal. Dengan demikian, sambungan neuromuskular memiliki faktor keamanan yang besar dalam berbagai kondisi fisiologis. Recurarization dapat terjadi dengan timbulnya asidosis respiratorik, pemberian antibiotik magnesium atau aminoglikosida, atau faktor lain yang menurunkan faktor keamanan. Beberapa molekul rocuronium tetap tidak terikat di kompartemen sentral pada beberapa pasien yang menerima dosis sugammadex yang tidak mencukupi. Molekul bebas ini dapat didistribusikan kembali ke kompartemen perifer, bermigrasi ke sambungan neuromuskular, dan menyebabkan relaksasi otot lebih lanjut.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LJiwTXWE","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":1964,"uris":["http://zotero.org/users/local/02ZTa67H/items/9PDMZZF6"],"itemData":{"id":1964,"type":"article-journal","language":"en","page":"42-43","source":"Zotero","title":"Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience","author":[{"family":"Sasakawa","given":"Tomoki"},{"family":"Miyasaka","given":"Katsuyuki"},{"family":"Sawa","given":"Tomohiro"},{"family":"Iida","given":"Hiroki"}],"issued":{"date-parts":[["2020"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->3<!--[if supportFields]><![endif]-->
Didapati kecenderungan untuk memberikan dosis rocuronium yang relatif besar untuk mempertahankan relaksasi yang dalam karena blokade neuromuskular yang dalam dapat menghasilkan kondisi operasi yang lebih baik untuk operasi laparoskopi dibandingkan dengan blokade sedang. Mengingat risiko overdosis rocuronium, blokade neuromuskular yang dalam harus dinilai menggunakan pemantauan neuromuskular intraoperatif. Jika overdosis rocuronium menyebabkan relaksasi otot yang parah dan hilangnya respons kedutan, penting untuk menunggu pemulihan spontan (awalnya dinilai berdasarkan post tetanic count [PTC]).<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dcThT6e5","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":1964,"uris":["http://zotero.org/users/local/02ZTa67H/items/9PDMZZF6"],"itemData":{"id":1964,"type":"article-journal","language":"en","page":"42-43","source":"Zotero","title":"Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience","author":[{"family":"Sasakawa","given":"Tomoki"},{"family":"Miyasaka","given":"Katsuyuki"},{"family":"Sawa","given":"Tomohiro"},{"family":"Iida","given":"Hiroki"}],"issued":{"date-parts":[["2020"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->3<!--[if supportFields]><![endif]-->
Sugammadex, menjadi salah satu pilihan, dengan cepat membalikkan blokade neuromuskular melalui enkapsulasi selektif rocuronium dan relaksan otot aminosteroid nondepolarisasi lainnya. Dosis yang direkomendasikan pada tingkat blokade neuromuscular sedang (muncul kembali kedutan kedua sebagai respon terhadap stimulasi TOF) adalah 2 mg/kg; tingkat blokade dalam (muncul kembali PTC 1 atau 2) adalah 4 mg/kg; dan pembalikan langsung blokade neuromuscular (3 menit setelah dosis intubasi dengan rocuronium bromide) adalah 16 mg/kg.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kocOmasE","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":1964,"uris":["http://zotero.org/users/local/02ZTa67H/items/9PDMZZF6"],"itemData":{"id":1964,"type":"article-journal","language":"en","page":"42-43","source":"Zotero","title":"Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience","author":[{"family":"Sasakawa","given":"Tomoki"},{"family":"Miyasaka","given":"Katsuyuki"},{"family":"Sawa","given":"Tomohiro"},{"family":"Iida","given":"Hiroki"}],"issued":{"date-parts":[["2020"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->3<!--[if supportFields]><![endif]-->
Pedoman JSA untuk Pemantauan Selama Anestesi mencakup rekomendasi yang lebih pasti mengenai penggunaan pemantauan neuromuskular: “Pemantauan neuromuskular harus dilakukan pada pasien yang menerima relaksan otot dan obat antagonisnya.” Meskipun tidak ada metode pemantauan khusus yang disebutkan dalam edisi terbaru, penggunaan monitor neuromuskular kuantitatif diperlukan dalam semua kasus. Metode pemantauan neuromuskular kualitatif dan semi-kualitatif, seperti tes fungsi otot klinis (misalnya, mengangkat kepala selama 5 detik dan menggenggam tangan secara berkelanjutan), hanya dapat mendeteksi rasio train-of-four (TOF) ?0,4 dan tidak berkorelasi dengan rasio TOF 0,9, ambang batas yang menunjukkan tidak adanya kelumpuhan sisa. Evaluasi perioperatif dan manajemen relaksasi otot dalam selama anestesi memerlukan pemantauan neuromuskular berdasarkan PTC atau parameter lain yang dapat diandalkan.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Jj0bs6ua","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":1964,"uris":["http://zotero.org/users/local/02ZTa67H/items/9PDMZZF6"],"itemData":{"id":1964,"type":"article-journal","language":"en","page":"42-43","source":"Zotero","title":"Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience","author":[{"family":"Sasakawa","given":"Tomoki"},{"family":"Miyasaka","given":"Katsuyuki"},{"family":"Sawa","given":"Tomohiro"},{"family":"Iida","given":"Hiroki"}],"issued":{"date-parts":[["2020"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->3<!--[if supportFields]><![endif]-->
Pencegahan lainnya yang dapat digunakan adalah penggunaan alat pemantauan neuromuscular. Berikut merupakan perangkat monitor baru yaitu berbasis elektromiografi, monitor berbasis acceleromyography (AMG) yang menggunakan algoritma pengukuran baru (akselerometer 3 dimensi), dan monitor yang terdiri dari alat ukur tekanan darah yang dimodifikasi dengan elektroda neuromuskular di bagian dalamnya. Keuntungan dari perangkat ini adalah kemudahan kalibrasi, kemudahan penggunaan, dan adanya mekanisme adaptif untuk mengkompensasi perubahan postur.<!--[if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cPNgg87J","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":1964,"uris":["http://zotero.org/users/local/02ZTa67H/items/9PDMZZF6"],"itemData":{"id":1964,"type":"article-journal","language":"en","page":"42-43","source":"Zotero","title":"Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience","author":[{"family":"Sasakawa","given":"Tomoki"},{"family":"Miyasaka","given":"Katsuyuki"},{"family":"Sawa","given":"Tomohiro"},{"family":"Iida","given":"Hiroki"}],"issued":{"date-parts":[["2020"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->3<!--[if supportFields]><![endif]-->
Referensi :
Pani N, Dongare P, Mishra R. Reversal agents in anaesthesia and critical care. Indian J Anaesth [Internet]. 2015 [cited 2023 Nov 13];59(10):664–9. Available from: https://journals.lww.com/10.4103/0019-5049.167484
Srivastava A, Hunter JM. Reversal of neuromuscular block. British Journal of Anaesthesia [Internet]. 2009 [cited 2023 Nov 13];103(1):115–29. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0007091217340485
Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience. 2020;42–3.
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