残余肌松作用与肌松监测

残余肌松作用与肌松监测RNMB的危害21年前：RNMB42%,21年后：RNMB42%50%

术后进入ICU（麻醉相关的呼吸功能不全）

的患者与RNMB有关（Cooper

et

al.)20%

术后呼衰死亡病人与RNMB有关（Lunn

et

al.)

RNMB26%vs5.3%(Pan

vsVec&Atr

)

(Berget

al.)

使用肌松药的术后死亡病人是不使用肌松药6倍，且其中2/3与呼吸抑制及缺氧有关

(Beecher

et

al.)肌松药药效存在个体差异原因：1.合并用药的相互作用氨基糖甙类、酰胺类等抗生素抗癫痫药、氨茶碱衍生物

局麻药、抗心律失常药心血管活性药物等等2.神经肌肉疾病增加对肌松药敏感性

延长肌松作用时效3.麻醉药物种类和深度吸入麻醉药Des>Sev

>

Iso

>

Enf

>

Hal

>N2O静脉麻醉药（不明显）麻醉深度、用药时间闻大翔等.地氟醚、异氟醚对老年患者维库溴铵肌松效应的影响中华麻醉学杂志2003；23（3）：165-168Effectsof

desfluraneand

isoflurane

on

p

harmacodynamicprofileofcisatracurium4.人体结构与脏器功能肥瘦、肌肉总量性别、年龄、遗传

肝、肾脏器功能等影响：分布、代谢、清除不同肌群对肌松药的敏感性肌松药ED50ED95膈肌/拇内收肌膈肌/拇内收肌Pancuronium22Rocuronium22Vecur

onium1.471.56Atracurium1.551.93膈

肌（diaphragm）膈肌耐药现象（diaphr

agmsparing）敏感性(sensitivity)<

拇内收肌(adductor

pollicismuscle)Lar

gedosesofNMBAmaybeneededtosuppr

essdiaphragmaticmovementand

coughing膈肌

VS拇内收肌：起效快：35%

Apnea

developsbefor

ecompleteblock

isseen

in

peripheralhand

muscles阻滞浅:

握拳

0

，肺活量

52%拇内收肌抑制90%，膈肌抑制53~56%恢复快：膈肌

恢复100%，拇内收肌恢复50%肌松药ED50ED95喉肌/拇内收肌喉肌/拇内收肌Rocuronium1.522.21Vecur

onium1.931.73喉肌（laryngealmuscles）喉内收肌（环甲肌），

喉外展肌（环杓后肌）肌松药剂量

(mg/kg)Tmax喉内收肌拇内收肌Vec0.0455%89%0.0788%100%喉肌

VS拇内收肌：起效快：0.04mg/kgvec,

喉肌(3.3min),拇内收肌(5.7min)

阻滞浅:恢复快：

0.07mg/kgvec,

喉肌(23.3min),拇内收肌(40.3min)上呼吸道肌肉(upper

airwaymuscles)咽肌(pharyngealmuscle)&骸骨舌骨肌(geniohyoideus)上呼吸道肌群骸骨舌骨肌

咽肌先肌松作用消退非呼吸肌

拇内收肌对肌松药敏感性阻滞深度呼吸肌膈肌低后高肌纤维作用肌肉对肌松药敏感性快收缩白纤维

(快速糖酵解)短时相有力活动胫前肌腓肠肌高快收缩红纤维

(快氧化纤维)维持时相活动膈肌喉肌较低慢收缩红纤维

(慢氧化纤维)慢速维持肌紧张拇内收肌

比目鱼肌较高肌松药对不同肌肉作用效果不同的可能机制1.

肌纤维构成不同：快氧化纤维

突触后膜面积

>慢氧化纤维肌松药分子

进入NMJ

速度更快膈肌喉肌

起效快于

拇内收肌2.

血流供应不同：膈肌、喉肌等血供较拇内收肌丰富，起效快3.

药物和剂量：不同肌松药与不同受体的结合，离解速率不同，因而肌松作用特点不同。残余肌松的诊断与安全标准IndicatorsofRecoveryof

NeuromuscularFunctionTimefor

Change?Sor

in

J

.Brull,MDAnesthesiology,

1997;86：755-757三个阶段第一阶段：1950s~1960s临床体征：抬头5s、抬腿、睁眼、握拳呼吸力学：潮气量、肺活量、最大吸气力等不可靠，难以区别RNMB和残余麻醉药作用第二阶段：1970s~1990sTOF

监测

+

呼吸力学监测TOF

Ratio0.7(Ali,

1971,Golden

Indicator

)潮气量(Vt)呼吸频率(RR)分钟通气量(VE)最大吸气力(MIP)最大吸气流速(PIFR)自主呼吸做功(WO

Bp)肺顺应性(Cdyn)NormalTOF

Ratio0.7刺激方式TOF

RatioTOF0.4(adults)0.44(children)Tetanic≤0.3DBS≤

0.6外周神经刺激器（PNS）视觉（visual）+触觉（tactile）Even

if

theobserver

isexperienced第三阶段：1997s~nowTOF

Ratio0.9

(Kopman

,

1997)0.7~0.75:复视、视觉障碍、握力下降、不能坐起、不能门齿对咬、

不能用吸管吸水0.85~0.9:视觉障碍，全身乏力0.9:

复视现象减轻1.0:

眼外肌仍未完全恢复呼吸力学各项参数恢复潮气量(Vt)呼吸频率(RR)分钟通气量(VE)最大吸气流速(PIFR)

食管压力(Pes)自主呼吸做功(WO

Bp)

肺顺应性(Cdyn)呼吸驱动力(P0.

1)时间t50时间t70时间t80时间t90闻大翔

等.老年人术后肌松作用消退与呼吸力学恢复的关系

中华麻醉学杂志2004；24（4）：306-30825%

50%

70%

80%

90%临床征象抬头5s握拳睁眼TOF

比值监

测指

标时间t25研究者TOF

Ratio肌松药监测仪ElMikattiet

al.0.5Pipecur

oniumEMGDupuiset

al.0.7VecuroniumEMGSharpeet

al.0.6Atr

acuriumEMGEngbak

etal.0.8Atr

acuriumEMGKopman

et

al.0.62MivacuriumEMG闻大翔等.0.76(elder

ly)

0.68(young)

0.77(elder

ly)

0.70(young)Vecuronium

Vecuronium

Rocuronium

RocuroniumAMG抬头5s与TOFRatio

的关系Conclusion

fr

om

our

investigation:TOF

Ratio>

0.7

：呼吸力学恢复正常TOF

Ratio>

0.8

：临床试验恢复正常

（老年病人）肌松药对通气调节功能的影响正常情况下二氧化碳刺激引起的通气调节功能并不受

肌松残余作用的影响，能较好地维持通气

量和呼气末二氧化碳压力在正常的范围内

Vt与RR变化的关系说明在肌松药的残余阻

滞作用仍然存在的情况下，通气调节功能

可以处于相当高的水平低氧状态下：SpO2为85%，TOF

Ratio为0.7时，通气反应下降约

15~60%，提示肌松残余作用对缺氧状态下的通气调节

功能有抑制作用维库溴铵引起的部分肌松阻滞作用可以降低颈动脉体

化学感受器的敏感性，导致机体对缺氧刺激的通气调节

功能受损Mechanism?Eriksson

et

al.Anesthesiology,

1993;78:693-699Jørgen

Viby-MogensenAcademicDepartment

of

AnaesthesiaCopenhagen

UniversityHospitalH:S

Rigshospitalet,CopenhagenMyths

and

truth

about

evaluationof

neuromuscularfunctionduring

and

after

anaesthesiaNeuromuscularfunction

can

beevaluated

reliably

usingclinical

testsMyth

no

1It

is

not

possible

by

clinical

tests

toreliably

evaluate

neuromuscularfunction

post

operativelyThe

truth•

Long

acting

MRused

forprocedures

lasting90

min•Intermediateacting

MR

usedfor

procedures

lasting

<90minIncidence25-50%

25-50%PORC

after

routinesurgerywithoutquantitativemonitoring

ofneuromuscular

functionClinicalAMGDuration

of

anaesthesia136

min124

minDose

of

Pancuronium8

mg/kg-18mg/kg-1TOF

ratio

0.752%5%*Timeto

extuba

tion10

min15

min*Clinical

versus

quantitative

evaluationPancuronium(n=40)Mortensen

et

al,Acta

Anaesth

Scand.

1995Durationofanaesthesia119

min

105

minDoseof

Rocuronium58

mg57

mgTOF

ratio0.8

17%

3%*Timeto

extuba

tion10

min12.5

min*Clinical

versus

quantitative

evaluationRocuronium(n=40)Gätke

etal,Acta

Anaesth

Scand.2002Clinical

AMG•Sustained

eyeopening•

Protrusionofthetongue•Arm

liftto

oppositeshoulder•

Normaltidal

volume•

Normal

or

near

normalvital

capacity•

Maximum

inspiratory

pressure

25cm

H2OUnreliableclinical

tests:•

Sustained

head

lift

for

5sec

.•Sustained

leg

lift

for

5

sec

.•Sustained

tonguedepressor

test•

Maximum

inspiratory

pressure50cm

H2

O•

(Normalswallowing

reflexes?)Best

clinical

tests:•

Morethan

50%were

unableto

distinguishbetween

unreliable

and

more

reliable

clinical

tests•

Lessthan50%

routinely

appliedthemore

reliableclinical

tests

in

clinical

practiceKnowledgeand

use

ofclinical

tests

amongDanish

anaesthetist

(n

=251):Sorgenfrei

etal,Acta

Anaesth

Scand.2003Neuromuscular

function

can

beevaluated

reliably

bytactile

(orvisual)evaluationofthe

response

tonervestimulationMyth

no

2Absenceoftactile

(orvisual)fade

inboth

theTOF,tetanic

and

DBSresponsedoes

not

excludeclinicallysignificant

blockThe

truthDrenck

etal,Anesthesiology

1989,Pedersen

et

al,Anesthesiology1990,Kopmanet

al,Anesthesiology196,Fruergaardetal,Acta

Anaesth

Scand

199875%

did

not

know

that

clinically

significant

PORCcan

not

beexcluded

by

tactileorvisual

evaluation

ofthe

responseKnowledge

of

tactile

or

visual

evaluationofthe

responseto

TOFnervestimulationamong

Danish

anaesthetists

(n=251):Sorgenfrei

etal,Acta

Anaesth

Scand.2003There

is

no

need

to

monitorneuromuscular

function

when

an

intermediateacting

MR

is

usedMyth

no

3Theuseof

intermediate

acting

MRdoes

not

excludeclinicallysignificant

PORCThe

truthnTOF<

0.7Surgery

(

min)At

racurium68242%(29-65)60-95Vecuronium41428%(25-52)107Rocuronium34619%(15-35)85-110Intermediateacting

MRand

PORC:

Repeated

dosesHayeset

al,2001;Baillardetal,2002;McCauletal,

2002;Appelboam

etal,2003;

Kimetal,2002;

Gätke

etal,2002There

is

no

need

to

monitorneuromuscular

function

when

theintermediateacting

MR

is

used

onlyfortracheal

intubationMyth

no

4Even

when

used

only

fortrachealintubation

,

is

theincidenceof

PORC

high

afterthe

intermediateacting

MRThe

truth*Atracurium

(

n=79),Vecuronium

(

n=47),

Rocuronium

(

n=400)Debaene

et

al,Anesthesiology

2003nTOFMin

frominjectionto

recording<

0

.7<

0

.9Drug*52616%45%127

56Incidenceof

PORCafter

onesingle

dose

(2

x

ED95)ofan

intermediateacting

MROnly

8%wereaware

of

the

highincidenceof

PORCfollowing

the

useof

intermediateacting

MRKnowledgeofthe

incidenceof

PORC

among

Danish

anaesthetists

(n

=251)Sorgenfrei

etal,Acta

Anaesth

Scand.2003No

need

to

monitor

because

PORC

iswithout

clinical

significanceanddoes

not

poseathreat

to

the

patientMyth

no

5PORC

is

athreat

to

the

health

ofthe

patientThe

truth1.

Increased

risk

ofhypoxemia

(andhypercapnia?)Berg

etal,

Acta

Anaesth

Scand

1997;Bissinger

et

al,Physiol.

Res.20002.

Decreased

chemoreceptorsensitivityto

hypoxemiaEriksson

et

al,

Acta

Anaesth

Scand

1992;Wyon

etal,

Anesthesiology,1999Postoperative

residual

block

causes3.Functional

impairmentofthe

muscles

ofthepharynx

and

upper

esophagus-

increased

risk

ofregurgitationand

aspirationEriksson

et

al,

Anesthesiology,1997Sundman

et

al,

Anesthesiology,20004.

IncreasedriskofpostoperativepulmonarycomplicationsBerg

etal,

ActaAnesthScand,1997Postoperative

residual

block

causesRisk

of

pulmonary

complications

(POPC)

following

abdominal

surgeryBerg

etal,

Acta

Anaesth

Scand

1997Residual

postoperative

neuromuscular

block

causes•decreased

chemoreceptor

sensitivity

to

hypoxia•functional

impairmentofthe

muscles

ofthepharynxand

upperesophagus•

impairedabilitytomaintain

the

airway•an

increased

riskfor

the

development

ofpostoperative

pulmonary

complicationsConclusions:

1•

Itis

difficult,and

oftenimpossible

,

by

clinicalevaluation

to

exclude

with

certainty

clinically

significantresidual

curarizationConclusions:2•Abscence

oftactilefade

inthe

responseto

TOFstimulation

,tetanicstimulationand

DBSdoes

not

exclude

significant

residual

blockConclusions:3•Adequate

recovery

of

postoperative

neuromuscularfunction

cannot

be

guaranteed

without

objectiveneuromuscularmonitoringConclusions:4•Good

evidence-based

practice

dictates

thatcliniciansshouldalways

quant

it

atethe

extentofneuromuscular

blockade

using

objective

monitoringConclusions:5•Avoid

total

twitch

depression

during

surgery.

Keep,whenever

possible

one

or

two

TOF

responsesRecommendations:

1•Antagonism

of

the

neuromuscular

block

should

notbeinitiated