肌松殘余作用與肌松監(jiān)測(cè)PPT課件

.,1,殘余肌松作用與肌松監(jiān)測(cè),上海交通大學(xué)附屬仁濟(jì)醫(yī)院麻醉科聞大翔,.,2,RNMB的危害,21年前：RNMB42%,21年后：RNMB42%50%術(shù)后進(jìn)入ICU（麻醉相關(guān)的呼吸功能不全）的患者與RNMB有關(guān)（Cooperetal.)20%術(shù)后呼衰死亡病人與RNMB有關(guān)（Lunnetal.)RNMB26%vs5.3%(PanvsVec86：755-757,殘余肌松的診斷與安全標(biāo)準(zhǔn),.,18,三個(gè)階段,第一階段：1950s1960s臨床體征：抬頭5s、抬腿、睜眼、握拳呼吸力學(xué)：潮氣量、肺活量、最大吸氣力等不可靠，難以區(qū)別RNMB和殘余麻醉藥作用,.,19,第二階段：1970s1990sTOF監(jiān)測(cè)+呼吸力學(xué)監(jiān)測(cè)TOFRatio0.7(Ali,1971,GoldenIndicator),潮氣量(Vt)呼吸頻率(RR)分鐘通氣量(VE)最大吸氣力(MIP)最大吸氣流速(PIFR)自主呼吸做功(WOBp)肺順應(yīng)性(Cdyn),TOFRatio0.7,Normal,.,20,外周神經(jīng)刺激器（PNS）視覺(jué)（visual）+觸覺(jué)（tactile）,Eveniftheobserverisexperienced,.,21,第三階段：1997snowTOFRatio0.9(Kopman,1997)0.70.75:復(fù)視、視覺(jué)障礙、握力下降、不能坐起、不能門(mén)齒對(duì)咬、不能用吸管吸水0.850.9:視覺(jué)障礙，全身乏力0.9:復(fù)視現(xiàn)象減輕1.0:眼外肌仍未完全恢復(fù),.,22,25%50%70%80%90%,潮氣量(Vt)呼吸頻率(RR)分鐘通氣量(VE)最大吸氣流速(PIFR)食管壓力(Pes)自主呼吸做功(WOBp)肺順應(yīng)性(Cdyn)呼吸驅(qū)動(dòng)力(P0.1),TOF比值,抬頭5s握拳睜眼,臨床征象,呼吸力學(xué)各項(xiàng)參數(shù)恢復(fù),監(jiān)測(cè)指標(biāo),時(shí)間t25,時(shí)間t50,時(shí)間t70,時(shí)間t80,時(shí)間t90,聞大翔等.老年人術(shù)后肌松作用消退與呼吸力學(xué)恢復(fù)的關(guān)系中華麻醉學(xué)雜志2004；24（4）：306-308,.,23,抬頭5s與TOFRatio的關(guān)系,.,24,Conclusionfromourinvestigation:TOFRatio0.7：呼吸力學(xué)恢復(fù)正常TOFRatio0.8：臨床試驗(yàn)恢復(fù)正常（老年病人）,.,25,肌松藥對(duì)通氣調(diào)節(jié)功能的影響,正常情況下二氧化碳刺激引起的通氣調(diào)節(jié)功能并不受肌松殘余作用的影響，能較好地維持通氣量和呼氣末二氧化碳?jí)毫υ谡５姆秶鷥?nèi)Vt與RR變化的關(guān)系說(shuō)明在肌松藥的殘余阻滯作用仍然存在的情況下，通氣調(diào)節(jié)功能可以處于相當(dāng)高的水平,.,26,.,27,.,28,低氧狀態(tài)下：SpO2為85%，TOFRatio為0.7時(shí)，通氣反應(yīng)下降約1560%，提示肌松殘余作用對(duì)缺氧狀態(tài)下的通氣調(diào)節(jié)功能有抑制作用維庫(kù)溴銨引起的部分肌松阻滯作用可以降低頸動(dòng)脈體化學(xué)感受器的敏感性，導(dǎo)致機(jī)體對(duì)缺氧刺激的通氣調(diào)節(jié)功能受損,Mechanism?Erikssonetal.Anesthesiology,1993;78:693-699,.,29,丹麥麻醉醫(yī)師對(duì)于PORC的認(rèn)識(shí)(n=251):大于50%不能分辨可靠的與不可靠的臨床試驗(yàn)小于50%在日常實(shí)踐中采用可靠的臨床試驗(yàn),75%不知道臨床PORC不能通過(guò)觸覺(jué)或視覺(jué)評(píng)判來(lái)排除,只有8%認(rèn)識(shí)到使用中效肌松藥后仍有較高的PORC發(fā)生率,Sorgenfreietal,ActaAnaesthScand.2003,我們的認(rèn)識(shí)？,.,30,Mythsandtruthaboutevaluationofneuromuscularfunctionduringandafteranaesthesia,JrgenViby-MogensenAcademicDepartmentofAnaesthesiaCopenhagenUniversityHospitalH:SRigshospitalet,Copenhagen,對(duì)術(shù)后神經(jīng)肌肉功能判斷的一些認(rèn)識(shí)誤區(qū),.,31,1.神經(jīng)肌肉功能可通過(guò)臨床試驗(yàn)來(lái)獲得可靠評(píng)價(jià),長(zhǎng)時(shí)效肌松藥，手術(shù)90min中時(shí)效肌松藥，手術(shù)90min,PORC發(fā)生率,25-50%,25-50%,.,32,臨床判斷與肌松監(jiān)測(cè),潘庫(kù)溴銨(n=40)ClinicalAMG麻醉時(shí)間136min124min潘庫(kù)溴銨劑量8mg/kg-18mg/kg-1TOFratio0.752%5%*拔管時(shí)間10min15min*,Mortensenetal,ActaAnaesthScand.1995,.,33,羅庫(kù)溴銨(n=40)ClinicalAMG麻醉時(shí)間119min105min羅庫(kù)溴銨劑量58mg57mgTOFratio0.817%3%*拔管時(shí)間10min12.5min*,Gtkeetal,ActaAnaesthScand.2002,臨床判斷與肌松監(jiān)測(cè),.,34,不可靠的臨床試驗(yàn):,睜眼伸舌舉臂至對(duì)肩正常潮氣量正?；蚪咏７位盍孔畲笪鼩鈮毫?5cmH2O,.,35,最佳臨床試驗(yàn):,抬頭堅(jiān)持5sec.抬腿堅(jiān)持5sec.壓舌板試驗(yàn)最大吸氣壓力50cmH2O(正常的吞咽反射?),.,36,KnowledgeanduseofclinicaltestsamongDanishanaesthetist(n=251):,Morethan50%wereunabletodistinguishbetweenunreliableandmorereliableclinicaltestsLessthan50%routinelyappliedthemorereliableclinicaltestsinclinicalpractice,Sorgenfreietal,ActaAnaesthScand.2003,.,37,2.用神經(jīng)刺激器，根據(jù)視覺(jué)或觸覺(jué)反應(yīng)可以有效地判斷神經(jīng)肌肉功能,Drencketal,Anesthesiology1989,Pedersenetal,Anesthesiology1990,Kopmanetal,Anesthesiology1996,Fruergaardetal,ActaAnaesthScand1998,.,38,3.中效肌松藥使用中不需要神經(jīng)肌肉功能監(jiān)測(cè),nTOF0.7手術(shù)(min)Atracurium68242%(29-65)60-95Vecuronium41428%(25-52)107Rocuronium34619%(15-35)85-110,中時(shí)效肌松藥與PORC發(fā)生率,Hayesetal,2001;Baillardetal,2002;McCauletal,2002;Appelboametal,2003;Kimetal,2002;Gtkeetal,2002,.,39,4.用中時(shí)效肌松藥進(jìn)行插管誘導(dǎo)時(shí)無(wú)需肌松監(jiān)測(cè),nTOF注藥至0.70.9記錄時(shí)時(shí)間(min)肌松藥*52616%45%12756,*Atracurium(n=79),Vecuronium(n=47),Rocuronium(n=400),Debaeneetal,Anesthesiology2003,.,40,5.PORC沒(méi)有臨床意義，不威脅患者安危，所以，沒(méi)有必要進(jìn)行肌松監(jiān)測(cè)1）增加低氧（和高碳酸血癥）發(fā)生率Bergetal,ActaAnaesthScand1997;Bissingeretal,Physiol.Res.20002）降低化學(xué)感受器對(duì)缺氧敏感性Eriksson,ActaAnaesthScand1992;Wyonetal,Anesthesiology,19993）咽和上食道肌群功能未恢復(fù)，增加了返流誤吸的風(fēng)險(xiǎn)Eriksson,Anesthesiology,1997,Sundman,Anesthesiology,20004）增加了術(shù)后肺部并發(fā)癥的風(fēng)險(xiǎn)Bergetal,ActaAnesthScand,1997,.,41,Bergetal,ActaAnaesthScand1997,腹部術(shù)后肺部并發(fā)癥的風(fēng)險(xiǎn),.,42,Conclusions:1,Residualpostoperativeneuromuscularblockcausesdecreasedchemoreceptorsensitivitytohypoxiafunctionalimpairmentofthemusclesofthepharynxandupperesophagusimpairedabilitytomaintaintheairwayanincreasedriskforthedevelopmentofpostoperativepulmonarycomplications,.,43,Conclusions:2,Itisdifficult,andoftenimpossible,byclinicalevaluationtoexcludewithcertaintyclinicallysignificantresidualcurarization,.,44,Conclusions:3,AbscenceoftactilefadeintheresponsetoTOFstimulation,tetanicstimulationandDBSdoesnotexcludesignificantresidualblock,.,45,Conclusions:4,Adequaterecoveryofpostoperativeneuromuscularfunctioncannotbeguaranteedwithoutobjectiveneuromuscularmonitoring,.,46,Conclusions:5,Goodevidence-basedpracticedictatesthatcliniciansshouldalwaysquantitatetheextentofneuromuscularblockadeusingobjectivemonitoring,.,47,Recommendations:1,Avoidtotaltwitchdepressionduringsurgery.Keep,wheneverpossibleoneortwoTOFresponses,.,48,Recommendations:2,Antagonismoftheneuromuscularblockshouldnotbeinitiatedbeforeatleasttwo,preferablythreeorfour,responsestoTOFstimulationareobserved,.,49,Recommendations:3,ToexcludeclinicallysignificantresidualneuromuscularblockadetheTOFratiowhenmeasuredmechanicallymustexceed0.9,and1.0whenmeasuredusingacceleromyography,.,50,Recommendations:4,Ifsufficientrecoveryhasnotbeendocumentedobjectivelyattheendofthesurgicalprocedure,theneuromuscularblockshouldbeantagonized,.,51,”scientificfindingsdonotfallonblankmindsthatgetmadeupasaresult.ScienceengageswithbusymindsthathavestrongviewsabouthowthingsareandoughttobePeopleswillingnesstotakeactioninfluencestheirviewoftheevidence,ratherthanevidenceinfluencingtheirwillingnesstotakeaction”.,MichaelMarmot,Lancet,2004,vol264,p.1735,.