肌松藥的臨床應(yīng)用The

第九章肌松藥的臨床應(yīng)用Theclinicaluseofneuromuscularblockade

DepartmentofAnesthesiologyThe2ndaffiliatedhospitalofHarbinMedicalUniversityLiHaibo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Awareness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)生于肌松藥應(yīng)用不當(dāng)?shù)娜槁樽碇?。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mivacuriumSuccinycholineDosage:

1-1.5mg/kg,repeatedsmalldose10mgor1gin500or1000ml,titratedtoeffectSideeffectsandclinicalconsiderations:

A.CardiovascularB.FasciculationsC.HyperkalemiaD.MusclepainsE.IntragastricpressureelevationF.IntraocularpressureelevationG.GeneralizedcontractionsH.ProlongedparalysisI.IntracranialpressureTubocurarine(筒箭毒堿)Dosage

forintubation:0.5-0.6mg/kgforintra-operative:0.15mg/kg0.05mg/kgSideeffectsandclinicalconsiderations:

hypotensionandtachycardia

Metocurine甲筒箭毒Dosage

Forintubation:0.3mg/kgForintraoperative:0.08mg/kg0.03mg/kgSideeffectsandclinicalconsiderations:

Hypotensiontachycardia,bronchospasm,allergicreactionsAtracuriumDosage

Forintubation:0.5mg/kgForintraoperative:0.25mg/kg0.1mg/kgevery10-20minSideeffectsandclinicalconsiderations:

Itmustbestoredat2-8℃.

laudanosine(N-甲基四氫罌粟堿)toxicityCistracuriumDosageForintubation:0.1-0.15mg/kgwithin2minForinfusion:1-2μg/kg/minSideeffectsandclinicalconsiderations:

Laudanosinetoxicity,pHandtemperaturesensitivity,andchemicalincompatibility(alkalinesolutionsuchasthiopentalprecipitate)

MivacuriumDosage

Forintubation:0.1-0.2mg/kgForinfusion:4-10μg/kg/minSideeffectsandclinicalconsiderations:

Doxacurium(多沙氯銨)Dosage

Forintubation:0.05mg/kgwithin5minForintraoperative:0.02mg/kg0.005mg/kgSideeffectsandclinicalconsiderations:Devoidofcardiovascularandhistamine-releasingsideeffects.Durationtime:60-90minOnsettimeslower:4-6minPancuroniumDosage

Forintubation:0.08-0.12mg/kgForintraoperative:0.04mg/kg20-40min0.01mg/kgSideeffectsandclinicalconsiderations:Itmustbestoredat2-8℃.HypertensionandtachycardiaAllergicreactions

DysrhythmiasVecuroniumDosageForintubation:0.08-0.12mg/kgForintraoperative:0.04mg/kg0.01mg/kgevery15-20minForinfusion:1-2μg/kg/minSideeffectsandclinicalconsiderations:DevoidofcardiovasculareffectsLiverfailurePipecuroniumDosageForintubation:0.06-0.1mg/kg

Sideeffectsandclinicalconsiderations:Comparedwithpancuronium,pipecuroniumdevoidofcardiovascularandhistaminereleasesideeffects,onsetofactionanddurationofactionaresimilarforbothdrugsRocuroniumDosageForintubation:0.45-0.9mg/kgForintraoperative:0.15mg/kgForinfusion:5-12μg/kg/minSideeffectsandclinicalconsiderations:0.9-1.2mg/kgwithin60-90sRapacuroniumDosage:Forintubation:1.5mg/kgwithin1minin85%patiensanddurationtime10-20minSideeffectsandclinicalconsiderations:

HypertensionandraiseHRmildandtransient

Severebronchospasm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.組胺釋放影響肌松藥作用的因素影響肌松藥的藥代動力學(xué)肝腎功能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0.07mg/kg吡啶斯的明0.28mg/kg依酚氯銨1mg/kg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臨床常用：新斯的明+阿托品2：1肌松藥的拮抗時機:T1>25%Neuromuscularmonitoring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)。Supramaximalstimulation20to25percentabovethatnecessaryforamaximalresponseTheoptimalpulsedurationis0.2to0.3msTheimpulseshouldbemonophasicandrectangular(i.e.,itshouldbeasquarewave)becauseabiphasicpulsemaycauseaburstofactionpotentialsinthenerve(repetitivefiring),increasingtheresponsetothestimulationPatternsofstimulation1.單刺激（singletwitchstimulation）2.強直刺激（tetanicstimulation）3.四個成串刺激（trainoffourTOF）4.強直刺激后記數(shù)（posttetaniccountPTC）5.雙短強直刺激（double-burststimulationDBS）Singletwitchstimulationfrequenciesof0.1to1.0Hz

Trainoffour(TOF)TetanicstimulationPost-TetanicCountStimulation

RelationshipbetweentimetothefirstreactiontoTOFnervestimulationandthenumberofpost-tetanictwitches(i.e.,thepost-tetaniccount)duringintenseblockadecausedbypancuronium,atracurium,andvecuronium.Meancurvesand95percentpredictionregionsareshownDouble-BurstStimulation

THENERVESTIMULATOR

Thestimulusshouldproduceamonophasicandrectangularwaveform,andt