肌松藥的臨床應(yīng)用The29

1、第九章 肌松藥的臨床應(yīng)用The clinical use of neuromuscular blockadeDepartment of AnesthesiologyThe 2nd affiliated hospital of Harbin Medical UniversityLi Haibo1概 述 肌松藥是全麻中重要的輔助用藥 肌松藥是麻醉藥嗎？ 不是 1942年以前 深麻醉-良好肌松 1942年箭毒應(yīng)用于臨床，臨床麻醉就發(fā)生了革命性的變化： 淺麻醉+肌松藥-良好肌松2Awareness 術(shù)中知曉（awareness）是一種嚴重的全麻術(shù)中并發(fā)癥，會給病人造成巨大的精神損害。尤其易發(fā)生于肌松藥

2、應(yīng)用不當?shù)娜槁樽碇小?臨床常用肌松藥去極化肌松藥琥珀膽堿suxamethonium,succinylcholine ,scoline非去極化肌松藥潘庫溴銨pancuronium,pavulon維庫溴銨vecuronium阿曲庫銨atracurium,tracrium哌庫溴銨pipecuronium羅庫溴銨rocuronium美維松mivacurium4SuccinycholineDosage: 1-1.5mg/kg, repeated small dose 10mg or 1g in 500 or 1000ml, titrated to effectSide effects and clin

3、ical considerations: A. Cardiovascular B . Fasciculations C. Hyperkalemia D. Muscle pains E. Intragastric pressure elevation F. Intraocular pressure elevation G. Generalized contractions H. Prolonged paralysis I. Intracranial pressure 5Tubocurarine(筒箭毒堿)Dosage for intubation:0.5-0.6mg/kg for intra-o

4、perative: 0.15mg/kg 0.05mg/kgSide effects and clinical considerations: hypotension and tachycardia 6Metocurine甲筒箭毒Dosage For intubation :0.3mg/kg For intraoperative:0.08mg/kg 0.03mg/kgSide effects and clinical considerations: Hypotension tachycardia ,bronchospasm ,allergic reactions7AtracuriumDosage

5、 For intubation :0.5mg/kg For intraoperative:0.25mg/kg 0.1mg/kg every 10-20minSide effects and clinical considerations: It must be stored at 2-8. laudanosine (N-甲基四氫罌粟堿)toxicity 8CistracuriumDosageFor intubation :0.1-0.15mg/kg within 2minFor infusion:1-2g/kg/minSide effects and clinical consideratio

6、ns: Laudanosine toxicity, pH and temperature sensitivity, and chemical incompatibility (alkaline solution such as thiopental precipitate) 9MivacuriumDosage For intubation :0.1-0.2mg/kg For infusion:4-10g/kg/minSide effects and clinical considerations: 10Doxacurium(多沙氯銨)Dosage For intubation :0.05mg/

7、kg within 5min For intraoperative:0.02mg/kg 0.005mg/kgSide effects and clinical considerations: Devoid of cardiovascular and histamine-releasing side effects.Duration time:60-90minOnset time slower :4-6min11PancuroniumDosage For intubation :0.08-0.12mg/kg For intraoperative:0.04mg/kg 20-40min 0.01mg

8、/kgSide effects and clinical considerations: It must be stored at 2-8. Hypertension and tachycardia Allergic reactions Dysrhythmias12VecuroniumDosageFor intubation :0.08-0.12mg/kgFor intraoperative:0.04mg/kg 0.01mg/kg every 15-20min For infusion:1-2g/kg/minSide effects and clinical considerations: D

9、evoid of cardiovascular effectsLiver failure13PipecuroniumDosageFor intubation :0.06-0.1mg/kg Side effects and clinical considerations: Compared with pancuronium ,pipecuronium devoid of cardiovascular and histamine release side effects, onset of action and duration of action are similar for both dru

10、gs14RocuroniumDosageFor intubation : 0.45-0.9mg/kgFor intraoperative:0.15mg/kg For infusion:5-12g/kg/minSide effects and clinical considerations: 0.9-1.2mg/kg within 60-90s15RapacuroniumDosage:For intubation : 1.5mg/kg within 1min in 85%patiens and duration time 10-20minSide effects and clinical con

11、siderations: Hypertension and raise HR mild and transient Severe bronchospasm16肌松藥的臨床應(yīng)用一、在麻醉中的主要應(yīng)用1.氣管插管(intubation) 去極化肌松藥-琥珀膽堿 非去極化肌松藥-潘庫溴銨、維庫溴銨、阿曲庫銨、米庫氯銨、羅庫溴銨2.肌松的術(shù)中維持 滿足手術(shù)需要3. 其他：ICU 及治療痙攣性疾病17二、肌松藥的給藥方法 單次間斷靜注給藥 持續(xù)靜脈輸注給藥 計算機自動化反饋控制給藥 予給量法 肌松藥的復(fù)合應(yīng)用-最好應(yīng)用同一種肌松藥 18肌松藥的不良反應(yīng)1.自主神經(jīng)系統(tǒng)作用2.組胺釋放19影響肌松藥作用的

12、因素影響肌松藥的藥代動力學(xué)肝腎功能20影響肌松藥的藥效動力學(xué)1.水、電解質(zhì)和酸堿平衡2.低溫3.年齡4神經(jīng)肌肉疾病重癥肌無力5.假性膽堿酯酶異常21藥物的相互作用1.吸入全麻藥2.局麻藥和抗心律失常藥3.抗生素4.抗驚厥藥和精神病藥5.其他22肌松藥的拮抗 增加乙酰膽堿濃度或延長乙酰膽堿作用時間的藥物均能拮抗非去極化肌松藥的肌松作用。 抗膽堿酯酶藥物: 新斯的明 極量 0.07 mg/kg 吡啶斯的明 0 .28 mg/kg 依酚氯銨 1 mg/kg23抗膽堿酯酶藥+抗膽堿藥: 新斯的明0.035-0.07mg/kg+格隆溴銨7g/kg 依酚氯銨 0.5-1mg/kg+阿托品7g/kg 臨床常

13、用：新斯的明+阿托品 2 ： 124肌松藥的拮抗時機: T125%25Neuromuscular monitoring 肌松監(jiān)測：刺激外周神經(jīng)干（一般為尺神經(jīng)），誘發(fā)該神經(jīng)支配的肌群收縮，據(jù)肌收縮效應(yīng)評價肌松藥的作用程度、時效及阻滯性質(zhì)。26Supramaximal stimulation20 to 25 percent above that necessary for a maximal responseThe optimal pulse duration is 0.2 to 0.3 msThe impulse should be monophasic and rectangular (i.

14、e., it should be a square wave) because a biphasic pulse may cause a burst of action potentials in the nerve (repetitive firing), increasing the response to the stimulation27Patterns of stimulation1.單刺激（single twitch stimulation）2.強直刺激（tetanic stimulation）3.四個成串刺激（train of four TOF）4.強直刺激后記數(shù)（post te

15、tanic count PTC）5.雙短強直刺激（double-burst stimulation DBS）28Single twitch stimulationfrequencies of 0.1 to 1.0 Hz 29Train of four (TOF)30Tetanic stimulation31Post-Tetanic Count Stimulation 32Relationship between time to the first reaction to TOF nerve stimulation and the number of post-tetanic twitches

16、(i.e., the post-tetanic count) during intense blockade caused by pancuronium, atracurium, and vecuronium. Mean curves and 95 percent prediction regions are shown33Double-Burst Stimulation 34THE NERVE STIMULATOR The stimulus should produce a monophasic and rectangular waveform, and the length of the

17、pulse should not exceed 0.2 to 0.3 ms60 to 70 mA, but not more than 80 mA3536RECORDING OF EVOKED RESPONSES Mechanomyography Electromyography Acceleromyography 37Electromyography3839Acceleromyography 4041肌松監(jiān)測的臨床應(yīng)用1.肝腎功能障礙2.重癥肌無力3.為避免術(shù)后肌松拮抗的病人4.呼吸功能嚴重受損，術(shù)后需肌松充分恢復(fù)的病人5.長時間應(yīng)用或持續(xù)靜點肌松藥的病人。42Case Discussion

18、A 72-year-old man has undergone general anesthesia for transurethral resection of the prostate。Twenty minutes after conclusion of the procedure，he is still intubated and shows no evidence of spontaneous respiration or consciousness。 43思考題1，肌松藥延遲恢復(fù)對術(shù)后病人有哪些影響？2，在ICU內(nèi)如何應(yīng)用肌松藥？44Zq$u*x-A2D5H8KbNfQiTlXo#s

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