《麻醉學》殘余肌松作用與肌松監(jiān)測

殘余肌松作用與肌松監(jiān)測RNMB的危害21年前：RNMB

42%,

21年后：RNMB

42%50%術后進入ICU（麻醉相關的呼吸功能不全）的患者與RNMB有關（Cooper

et

al.)20%術后呼衰死亡病人與RNMB有關（Lunn

et

al.)RNMB

26%

vs

5.3%(Pan

vs

Vec&Atr)

(Berg

et

al.)使用肌松藥的術后死亡病人是不使用肌松藥6倍，

且其中2/3與呼吸抑制及缺氧有關(Beecher

et

al.)肌松藥藥效存在個體差異原因：1.

合并用藥的相互作用氨基糖甙類、酰胺類等抗生素抗癲癇藥、氨茶堿衍生物局麻藥、抗心律失常藥心血管活性藥物等等2.神經肌肉疾病增加對肌松藥敏感性延長肌松作用時效3.麻醉藥物種類和深度吸入麻醉藥Des>Sev>Iso>Enf>Hal>N

2

O靜脈麻醉藥（不明顯）麻醉深度、用藥時間聞大翔等.地氟醚、異氟醚對老年患者維庫溴銨肌松效應的影響中華麻醉學雜志2003；23（3）：165-168Effects

of

desflurane

and

isoflurane

onpharmacodynamic

profile

of

cisatracurium4.人體結構與臟器功能肥瘦、肌肉總量性別、年齡、遺傳肝、腎臟器功能等影響：分布、代謝、清除不同肌群對肌松藥的敏感性膈?。╠iaphr

agm）膈肌耐藥現(xiàn)象（diaphr

agm

sparing）敏感性

(sensit

ivity)<拇內收肌(adductor

pollicis

muscle)LLaarr

ggee

ddoosseessooff

NNMMBBAA

mmaayy

bbee

nneeeeddeedd

ttoo

ssuupppprr

eesssdiaphragmatic

movement

and

coughing肌松藥E

D50E

D95膈肌/拇內收肌膈肌/拇內收肌P

ancuronium22Rocuroniu

m22Vecur

onium1.471.56Atracurium1.551.93膈肌VS拇內收肌：起效快：35%

Apnea

develops

befor

ecompleteblock

is

seen

in

per

ipheral

hand

muscles阻滯淺:

握拳

0

，肺活量

52

%拇內收肌抑制90%，膈肌抑制5

3

~56%恢復快：膈肌恢復100%，拇內收肌恢復50%喉?。╨aryngeal

muscles）喉內收?。ōh(huán)甲?。硗庹辜。ōh(huán)杓后?。┘∷伤嶦

D50E

D95喉肌/拇內收肌喉肌/拇內收肌Rocuroniu

m1.522.21Vecur

onium1.931.73喉肌VS拇內收肌：起效快：0.04mg/kgvec,喉肌(3.3min),拇內收肌(5.7min)阻滯淺:恢復快：0.07mg/kg

vec,喉肌(23.3min),拇內收肌(40.3min肌松藥劑量

(mg/kg)T

ma

x喉內收肌拇內收肌Vec0.0455%89%0.0788%100%上呼吸道肌肉(upper

air

way

muscles)咽肌(pharyngeal

muscle)&骸骨舌骨肌(geniohyoideus)上呼吸道肌群骸骨舌骨肌咽肌非呼吸肌拇內收肌呼吸肌膈肌對肌松藥敏感性阻滯深度先肌松作用消退后高低肌松藥對不同肌肉作用效果不同的可能機制1.肌纖維構成不同：快氧化纖維突觸后膜面積>慢氧化纖維肌松藥分子進入NMJ

速度更快膈肌喉肌起效快于拇內收肌肌纖維作用肌肉對肌松藥敏感性快收縮白纖維(快速糖酵解)短時相有力活動脛前肌腓腸肌高快收縮紅纖維(快氧化纖維)維持時相活動膈肌喉肌較低慢收縮紅纖維(慢氧化纖維)慢速維持肌緊張拇內收肌比目魚肌較高血流供應不同：膈肌、喉肌等血供較拇內收肌豐富，起效快藥物和劑量：不同肌松藥與不同受體的結合，離解速率不同，因而肌松作用特點不同。Indicators

of

Recovery

ofNeuromuscular

FunctionTime

for

Change?Sorin

J

.

Br

ull,

MDAnesthesiology,

1997;86：755-757殘余肌松的診斷與安全標準三個階段第一階段：1950s~1960s臨床體征：抬頭5s、抬腿、睜眼、握拳呼吸力學：潮氣量、肺活量、最大吸氣力等不可靠，難以區(qū)別RNMB和殘余麻醉藥作用第二階段：1970s~1990sTOF監(jiān)測+呼吸力學監(jiān)測TOF

Ratio

0.7

(Ali,

1971,

Golden

Indicator)潮氣量(Vt)呼吸頻率(R

R)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(WO

Bp)肺順應性(C

dy

n)TOF

Ratio

0.7Normal外周神經刺激器（PNS）視覺（visual）+觸覺（tactile）Even

if

the

observeris

experienced刺激方式TO

F

RatioT

OF0.4

(adu

lts)0.44(children)T

eta

nic≤0.3DBS≤

0.6第三階段：1997s~nowTOF

Ratio

0.9

(

Kopman,

1997

)0.7~0.75:復視、視覺障礙、握力下降、不能坐起、不能門齒對咬、不能用吸管吸水0.85~0.9:

視覺障礙，全身乏力0.9:1.0:復視現(xiàn)象減輕眼外肌仍未完全恢復25%50%70%80%90%潮氣量(Vt)呼吸頻率

(R

R)分鐘通氣量(VE)最大吸氣流速(PIFR)食管壓力(Pes)自主呼吸做功(WO

Bp)肺順

應性(C

dy

n)呼吸驅動力(P0.1)TOF比值抬頭5

s握拳

睜眼臨床征象呼吸力學各項參監(jiān)測指標時間t2

5時間t5

0時間t7

0時間t8

0時間t9

0數(shù)恢聞大翔等.老年人術后肌松作用消退與呼吸力學恢復的關中華復麻醉學雜志2

004；2

4（4）：3

06-30

8抬頭5s與TOF

Ratio的關系研究者T

OF

R

atio肌松藥監(jiān)E

l

Mik

atti

et

al.0.5Pip

ecuroniumE

MDup

uis

et

a

l.0.7Vecuroniu

mE

MShar

pe

et

a

l.0.6Atr

acu

riumE

ME

ngb

ak

et

a

l.0.8Atr

acu

riumE

MK

op

man

et

al.0.62Mivacu

riu

mE

M聞大翔等.0.76(elder

ly)

Vecuroniu

mAM0.68(youn

g)Vecuroniu

m0.77(elder

ly

)

Rocuroniu

m0.70(youn

g)

Rocuroniu

mConclusion

fr

om

our

investigation:TOF

Ratio>0.7：呼吸力學恢復正常TOF

Ratio>0.8：臨床試驗恢復正常（老年病人）肌松藥對通氣調節(jié)功能的影響正常情況下二氧化碳刺激引起的通氣調節(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壓力在正常的范圍內Vt與RR變化的關系說明在肌松藥的殘余阻滯作用仍然存在的情況下，通氣調節(jié)功能可以處于相當高的水平低氧狀態(tài)下：SpO2為85%，TOF

Ratio為0.7時，通氣反應下降約

15~60%，提示肌松殘余作用對缺氧狀態(tài)下的通氣調節(jié)功能有抑制作用維庫溴銨引起的部分肌松阻滯作用可以降低頸動脈體化學感受器的敏感性，導致機體對缺氧刺激的通氣調節(jié)功能受損Mechanism?Eriksson

et

al.

Anesthesiology,

1993;78:

693-699Myths

and

truth

about

evaluationof

neuromuscular

functionduring

and

after

anaesthesiaJ?rgen

Viby-MogensenAcademic

Department

of

AnaesthesiaCopenhagen

University

HospitalH:S

Rigshospitalet,

CopenhagenMyth

no

1Neuromuscular

function

can

beevaluated

reliably

usingclinical

testsThe

truthIt

is

not

possible

by

clinical

tests

toreliably

evaluate

neuromuscularfunction

postoperativelyPORC

after

routine

surgery

withoutquantitative

monitoring

ofneuromuscular

functionLong

acting

MR

used

forprocedures

lasting

90

minIntermediate

acting

MR

usedfor

procedures

lasting

<

90

min?25-50%25-50%IncidenceClinical

versus

quantitative

evaluationPancuronium

(n=40)Clinical

AMGDuration

of

anaesthesiaDose

of

Pancuronium

TOF

ratio

0.7Time

to

extubation136

min8

mg/kg-152%10

min124

min8mg/kg-15%*15

min*Mortensen

et

al,

Acta

Anaesth

Scand.

1995Clinical

versus

quantitative

evaluationRocuronium

(n=40)Clinical

AMGDuration

of

anaesthesiaDose

of

RocuroniumTOF

ratio

0.8Time

to

extubation119

min58

mg17%10

min105

min57

mg3%*12.5

min*G?tke

et

al,

Acta

Anaesth

Scand.

2002Unreliable

clinical

tests:Sustained

eye

openingProtrusion

of

the

tongueArm

li

ft

to

opposite

shoulderNormal

tidal

volumeNormal

or

near

normal

vital

capacityMaximum

inspiratory

pressure

25

cm

H2

OBest

clinical

tests:Sustainedhead

lift

for

5

sec.Sustained

leg

li

ft

for

5

sec.Sustained

tongue

depressor

testMaximum

inspiratory

pressure(Normalswallowing

reflexes?)50

cm

H2

OKnowledge

and

use

ofclinical

tests

amongDanish

anaesthetist

(n=251):More

than

50%

were

unable

to

distinguishbetween

unreliable

and

more

reliable

clinical

tests

Less

than

50%

routinely

applied

the

more

reliableclinical

tests

in

clinical

practiceSorgenfrei

et

al,

Acta

Anaesth

Scand.

2003Myth

no

2Neuromuscular

function

can

beevaluated

reliably

by

tactile

(or

visualevaluation

of

the

response

tonervestimulationThe

truthAbsence

of

tactile

(or

visual)

fade

inboth

the

TOF,

tetanic

and

DBSresponse

does

not

exclude

clinicallysignificant

blockDrencket

al,

Anesthesiology

1989,

Pedersenet

al,

Anesthesiology

1990,Kopmanet

al,

Anesthesiology

1996,

Fruergaardet

al,

Acta

Anaesth

Scand

1998Knowledge

of

tactile

or

visual

evaluationof

the

response

toTOF

nervestimulationamong

Danish

anaesthetists

(n=251):75%

did

not

know

that

clinically

significantPORC

can

not

be

excluded

by

tactile

or

visual

evaluation

of

the

responseSorgenfrei

et

al,

Acta

Anaesth

Scand.

2003Myth

no

3There

is

no

need

to

monitorneuromuscular

function

when

anintermediate

acting

MR

is

usedThe

truthThe

use

of

intermediate

acting

MRdoes

not

exclude

clinicallysignificant

PORCIntermediate

acting

MR

and

PORC:Repeated

dosesHayes

et

al,

2001;

Baillard

et

al,

2002;

McCaul

et

al,

2002;Appelboam

et

al,

2003;

Kim

et

al,

2002;

G?tke

et

al,

2002nTO

F

<

0

.7Su

r

g

e

r

y

(

mi

n

)A

tracurium68242%

(29-65)60-95Vecuronium41428%

(25-52)107Rocuronium34619%

(15-35)85-110Myth

no

4There

is

no

need

to

monitorneuromuscular

function

when

theintermediate

acting

MR

is

used

onlyfor

tracheal

intubationThe

truthEven

when

used

only

for

trachealintubation,

is

the

incidence

of

PORChigh

after

the

intermediate

acting

MRIncidence

of

PORC

after

one

single

dose(2

x

ED95

)

of

an

intermediate

acting

MRDebaene

et

al,

Anesthesiology

2003Drug*

526

16%

45%

127

56*

Atracurium

(

n=79),

Vecuronium

(

n=47),

Rocuronium

(

n=400)nTOFMin

from<

0.7<

0.9injection

to

recordingKnowledge

of

the

incidence

of

PORCamong

Danish

anaesthetists

(n=

251)Only

8%

were

aware

of

the

highincidence

of

PORC

following

the

useof

intermediate

acting

MRSorgenfrei

et

al,

Acta

Anaesth

Scand.

2003Myth

no

5No

need

to

monitor

because

PORC

iswithout

clinical

significance

anddoes

not

pose

a

threat

to

the

patientThe

truthPORC

is

a

threat

to

the

healthof

the

patientPostoperative

residual

block

causesIncreased

risk

of

hypoxemia

(and

hypercapnia?)Berg

et

al,

Acta

Anaesth

Scand

1997;Bissinger

et

al,

Physiol.

Res.

2000Decreased

chemoreceptor

sensitivity

to

hypoxemiaEriksson

et

al,

Acta

Anaesth

Scand

1992;Wyon

et

al,

Anesthesiology,

1999Functional

impairment

of

the

muscles

of

thepharynx

and

upper

esophagus-

increased

risk

of

regurgitation

and

aspirationEriksson

et

al,

Anesthesiology,

1997Sundman

et

al,

Anesthesiology,

2000Increased

risk

of

postoperative

pulmonarycomplicationsBerg

et

al,

Acta

Anesth

Scand,

1997Postoperative

residual

block

causesRisk

of

pulmonary

complications

(POPC)following

abdominal

surgeryBerg

et

al,

Acta

Anaesth

Scand

1997Conclusions:

1Residual

postoperative

neuromuscular

block

causesdecreased

chemoreceptor

sensitivity

to

hypoxiafunctional

impairment

of

the

muscles

of

thepharynx

and

upper

esophagusimpaired

ability

to

maintain

the

airwayan

increased

risk

for

the

developmentofpostoperative

pulmonarycomplicationsConclusions:

2It

is

difficult,

and

often

impossible,

by

clinicalevaluation

to

exclude

with

certainty

clinically

signifiresidual

curarizationConclusions:

3Abscence

of

tactile

fade

in

the

response

to

TOFstimulation,

tetanic

stimulation

and

DBS

does

notexclude

significant

residual

blockConclusions:

4Adequate

recovery

of

postoperative

neuromuscular

function

cannot

be

guaranteedwithout

objective

neuromuscular

monitoringConclusions:

5Good

evidence-based

practice

dictates

thatclinicians

should

always

quantitate

the

extent

ofneuromuscular

blockade

using

objective

monitoringRecommendations:

1Avoid

total

twitch

depression

during

surgery.

Keep,

whenever

possible

one

or

two

TOF

responsesRecommendations:

2Antagonism

of

the

neuromuscular

block

should

notbe

initiated