肌松药的临床应用课件（可编辑）

肌松药的临床应用课件第九章肌松药的临床应用THECLINICALUSEOFNEUROMUSCULARBLOCKADEDEPARTMENTOFANESTHESIOLOGYNDTHE2AFFILIATEDHOSPITALOFHARBINMEDICALUNIVERSITYLIHAIBO概述肌松药是全麻中重要的辅助用药肌松药是麻醉药吗不是1942年以前深麻醉良好肌松1942年箭毒应用于临床,临床麻醉就发生了革命性的变化浅麻醉肌松药良好肌松AWARENESS术中知晓AWARENESS是一种严重的全麻术中并发症,会给病人造成巨大的精神损害。尤其易发生于肌松药应用不当的全麻麻醉中。临床常用肌松药去极化肌松药琥珀胆碱SUXAMETHONIUM,SUCCINYLCHOLINE,SCOLINE非去极化肌松药潘库溴铵PANCURONIUM,PAVULON维库溴铵VECURONIUM阿曲库铵ATRACURIUM,TRACRIUM哌库溴铵PIPECURONIUM罗库溴铵ROCURONIUM美维松MIVACURIUMSUCCINYCHOLINEDOSAGE115MG/KG,REPEATEDSMALLDOSE10MGOR1GIN500OR1000ML,TITRATEDTOEFFECTSIDEEFFECTSANDCLINICALCONSIDERATIONSACARDIOVASCULARBFASCICULATIONSCHYPERKALEMIADMUSCLEPAINSEINTRAGASTRICPRESSUREELEVATIONFINTRAOCULARPRESSUREELEVATIONGGENERALIZEDCONTRACTIONSHPROLONGEDPARALYSISIINTRACRANIALPRESSURETUBOCURARINE筒箭毒碱DOSAGEFORINTUBATION0506MG/KGFORINTRAOPERATIVE015MG/KG005MG/KGSIDEEFFECTSANDCLINICALCONSIDERATIONSHYPOTENSIONANDTACHYCARDIAMETOCURINE甲筒箭毒DOSAGEFORINTUBATION03MG/KGFORINTRAOPERATIVE008MG/KG003MG/KGSIDEEFFECTSANDCLINICALCONSIDERATIONSHYPOTENSIONTACHYCARDIA,BRONCHOSPASM,ALLERGICREACTIONSATRACURIUMDOSAGEFORINTUBATION05MG/KGFORINTRAOPERATIVE025MG/KG01MG/KGEVERY1020MINSIDEEFFECTSANDCLINICALCONSIDERATIONSITMUSTBESTOREDAT28LAUDANOSINEN甲基四氢罂粟碱TOXICITYCISTRACURIUMDOSAGEFORINTUBATION01015MG/KGWITHIN2MINFORINFUSION12G/KG/MINSIDEEFFECTSANDCLINICALCONSIDERATIONSLAUDANOSINETOXICITY,PHANDTEMPERATURESENSITIVITY,ANDCHEMICALINCOMPATIBILITYALKALINESOLUTIONSUCHASTHIOPENTALPRECIPITATEMIVACURIUMDOSAGEFORINTUBATION0102MG/KGFORINFUSION410G/KG/MINSIDEEFFECTSANDCLINICALCONSIDERATIONSDOXACURIUM多沙氯铵DOSAGEFORINTUBATION005MG/KGWITHIN5MINFORINTRAOPERATIVE002MG/KG0005MG/KGSIDEEFFECTSANDCLINICALCONSIDERATIONSDEVOIDOFCARDIOVASCULARANDHISTAMINERELEASINGSIDEEFFECTSDURATIONTIME6090MINONSETTIMESLOWER46MINPANCURONIUMDOSAGEFORINTUBATION008012MG/KGFORINTRAOPERATIVE004MG/KG2040MIN001MG/KGSIDEEFFECTSANDCLINICALCONSIDERATIONSITMUSTBESTOREDAT28HYPERTENSIONANDTACHYCARDIAALLERGICREACTIONSDYSRHYTHMIASVECURONIUMDOSAGEFORINTUBATION008012MG/KGFORINTRAOPERATIVE004MG/KG001MG/KGEVERY1520MINFORINFUSION12G/KG/MINSIDEEFFECTSANDCLINICALCONSIDERATIONSDEVOIDOFCARDIOVASCULAREFFECTSLIVERFAILUREPIPECURONIUMDOSAGEFORINTUBATION00601MG/KGSIDEEFFECTSANDCLINICALCONSIDERATIONSCOMPAREDWITHPANCURONIUM,PIPECURONIUMDEVOIDOFCARDIOVASCULARANDHISTAMINERELEASESIDEEFFECTS,ONSETOFACTIONANDDURATIONOFACTIONARESIMILARFORBOTHDRUGSROCURONIUMDOSAGEFORINTUBATION04509MG/KGFORINTRAOPERATIVE015MG/KGFORINFUSION512G/KG/MINSIDEEFFECTSANDCLINICALCONSIDERATIONS0912MG/KGWITHIN6090SRAPACURONIUMDOSAGEFORINTUBATION15MG/KGWITHIN1MININ85PATIENSANDDURATIONTIME1020MINSIDEEFFECTSANDCLINICALCONSIDERATIONSHYPERTENSIONANDRAISEHRMILDANDTRANSIENTSEVEREBRONCHOSPASM肌松药的临床应用一、在麻醉中的主要应用1气管插管INTUBATION去极化肌松药琥珀胆碱非去极化肌松药潘库溴铵、维库溴铵、阿曲库铵、米库氯铵、罗库溴铵2肌松的术中维持满足手术需要3其他ICU及治疗痉挛性疾病二、肌松药的给药方法单次间断静注给药持续静脉输注给药计算机自动化反馈控制给药予给量法肌松药的复合应用最好应用同一种肌松药肌松药的不良反应1自主神经系统作用2组胺释放影响肌松药作用的因素影响肌松药的药代动力学肝肾功能影响肌松药的药效动力学1水、电解质和酸碱平衡2低温3年龄4神经肌肉疾病重症肌无力5假性胆碱酯酶异常药物的相互作用1吸入全麻药2局麻药和抗心律失常药3抗生素4抗惊厥药和精神病药5其他肌松药的拮抗增加乙酰胆碱浓度或延长乙酰胆碱作用时间的药物均能拮抗非去极化肌松药的肌松作用。抗胆碱酯酶药物新斯的明极量007MG/KG吡啶斯的明028MG/KG依酚氯铵1MG/KG抗胆碱酯酶药抗胆碱药新斯的明0035007MG/KG格隆溴铵7G/KG依酚氯铵051MG/KG阿托品7G/KG临床常用新斯的明阿托品21肌松药的拮抗时机T251NEUROMUSCULARMONITORING肌松监测刺激外周神经干一般为尺神经,诱发该神经支配的肌群收缩,据肌收缩效应评价肌松药的作用程度、时效及阻滞性质。SUPRAIMALSTIMULATION20TO25PERCENTABOVETHATNECESSARYFORAIMALRESPONSETHEOPTIMALPULSEDURATIONIS02TO03MSTHEIMPULSESHOULDBEMONOPHASICANDRECTANGULARIE,ITSHOULDBEASQUAREWAVEBECAUSEABIPHASICPULSEMAYCAUSEABURSTOFACTIONPOTENTIALSINTHENERVEREPETITIVEFIRING,INCREASINGTHERESPONSETOTHESTIMULATIONPATTERNSOFSTIMULATION1单刺激SINGLETWITCHSTIMULATION2强直刺激TETANICSTIMULATION3四个成串刺激TRAINOFFOURTOF4强直刺激后记数POSTTETANICCOUNTPTC5双短强直刺激DOUBLEBURSTSTIMULATIONDBSSINGLETWITCHSTIMULATIONFREQUENCIESOF01TO10HZTRAINOFFOURTOFTETANICSTIMULATIONPOSTTETANICCOUNTSTIMULATIONRELATIONSHIPBETWEENTIMETOTHEFIRSTREACTIONTOTOFNERVESTIMULATIONANDTHENUMBEROFPOSTTETANICTWITCHESIE,THEPOSTTETANICCOUNTDURINGINTENSEBLOCKADECAUSEDBYPANCURONIUM,ATRACURIUM,ANDVECURONIUMMEANCURVESAND95PERCENTPREDICTIONREGIONSARESHOWNDOUBLEBURSTSTIMULATIONTHENERVESTIMULATORTHESTIMULU