肌松药的临床应用The

第九章肌松药的临床应用Theclinicaluseofneuromuscularblockade

DepartmentofAnesthesiologyThe2ndaffiliatedhospitalofHarbinMedicalUniversityLiHaibo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mivacuriumSuccinycholineDosage:

1-1.5mg/kg,repeatedsmalldose10mgor1gin500or1000ml,titratedtoeffectSideeffectsandclinicalconsiderations:

A.CardiovascularB.FasciculationsC.HyperkalemiaD.MusclepainsE.IntragastricpressureelevationF.IntraocularpressureelevationG.GeneralizedcontractionsH.ProlongedparalysisI.IntracranialpressureTubocurarine(筒箭毒碱)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-甲基四氢罂粟碱)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(多沙氯铵)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0.07mg/kg吡啶斯的明0.28mg/kg依酚氯铵1mg/kg抗胆碱酯酶药+抗胆碱药:

新斯的明0.035--0.07mg/kg+格隆溴铵7g/kg依酚氯铵0.5--1mg/kg+阿托品7g/kg临床常用：新斯的明+阿托品2：1肌松药的拮抗时机:T1>25%Neuromuscularmonitoring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。Supramaximalstimulation20to25percentabovethatnecessaryforamaximalresponseTheoptimalpulsedurationis0.2to0.3msTheimpulseshouldbemonophasicandrectangular(i.e.,itshouldbeasquarewave)becauseabiphasicpulsemaycauseaburstofactionpotentialsinthenerve(repetitivefiring),increasingtheresponsetothestimulationPatternsofstimulation1.单刺激（singletwitchstimulation）2.强直刺激（tetanicstimulation）3.四个成串刺激（trainoffourTOF）4.强直刺激后记数（posttetaniccountPTC）5.双短强直刺激（double-burststimulationDBS）Singletwitchstimulationfrequenciesof0.1to1.0Hz

Trainoffour(TOF)TetanicstimulationPost-TetanicCountStimulation

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

THENERVESTIMULATOR

Thestimulusshouldproduceamonophasicandrectangularwaveform,andt