.,1,殘余肌松作用與肌松監測,上海交通大學附屬仁濟醫院麻醉科聞大翔,.,2,RNMB的危害,21年前：RNMB42%,21年后：RNMB42%50%術后進入ICU（麻醉相關的呼吸功能不全）的患者與RNMB有關（Cooperetal.)20%術后呼衰死亡病人與RNMB有關（Lunnetal.)RNMB26%vs5.3%(PanvsVec86：755-757,殘余肌松的診斷與安全標準,.,18,三個階段,第一階段：1950s1960s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，難以區別RNMB和殘余麻醉藥作用,.,19,第二階段：1970s1990sTOF監測+呼吸力學監測TOFRatio0.7(Ali,1971,GoldenIndicator),潮氣量(Vt)呼吸頻率(RR)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(WOBp)肺順應性(Cdyn),TOFRatio0.7,Normal,.,20,外周神經刺激器（PNS）視覺（visual）+觸覺（tactile）,Eveniftheobserverisexperienced,.,21,第三階段：1997snowTOFRatio0.9(Kopman,1997)0.70.75: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0.850.9:視覺障礙，全身乏力0.9:復視現象減輕1.0:眼外肌仍未完全恢復,.,22,25%50%70%80%90%,潮氣量(Vt)呼吸頻率(RR)分鐘通氣量(VE)最大吸氣流速(PIFR)食管壓力(Pes)自主呼吸做功(WOBp)肺順應性(Cdyn)呼吸驅動力(P0.1),TOF比值,抬頭5s握拳睜眼,臨床征象,呼吸力學各項參數恢復,監測指標,時間t25,時間t50,時間t70,時間t80,時間t90,聞大翔等.老年人術后肌松作用消退與呼吸力學恢復的關系中華麻醉學雜志2004；24（4）：306-308,.,23,抬頭5s與TOFRatio的關系,.,24,Conclusionfromourinvestigation:TOFRatio0.7：呼吸力學恢復正常TOFRatio0.8：臨床試驗恢復正常（老年病人）,.,25,肌松藥對通氣調節功能的影響,正常情況下二氧化碳刺激引起的通氣調節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，通氣調節功能可以處于相當高的水平,.,26,.,27,.,28,低氧狀態下：SpO2為85%，TOFRatio為0.7時，通氣反應下降約1560%，提示肌松殘余作用對缺氧狀態下的通氣調節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功能受損,Mechanism?Erikssonetal.Anesthesiology,1993;78:693-699,.,29,丹麥麻醉醫師對于PORC的認識(n=251):大于50%不能分辨可靠的與不可靠的臨床試驗小于50%在日常實踐中采用可靠的臨床試驗,75%不知道臨床PORC不能通過觸覺或視覺評判來排除,只有8%認識到使用中效肌松藥后仍有較高的PORC發生率,Sorgenfreietal,ActaAnaesthScand.2003,我們的認識？,.,30,Mythsandtruthaboutevaluationofneuromuscularfunctionduringandafteranaesthesia,JrgenViby-MogensenAcademicDepartmentofAnaesthesiaCopenhagenUniversityHospitalH:SRigshospitalet,Copenhagen,對術后神經肌肉功能判斷的一些認識誤區,.,31,1.神經肌肉功能可通過臨床試驗來獲得可靠評價,長時效肌松藥，手術90min中時效肌松藥，手術90min,PORC發生率,25-50%,25-50%,.,32,臨床判斷與肌松監測,潘庫溴銨(n=40)ClinicalAMG麻醉時間136min124min潘庫溴銨劑量8mg/kg-18mg/kg-1TOFratio0.752%5%*拔管時間10min15min*,Mortensenetal,ActaAnaesthScand.1995,.,33,羅庫溴銨(n=40)ClinicalAMG麻醉時間119min105min羅庫溴銨劑量58mg57mgTOFratio0.817%3%*拔管時間10min12.5min*,Gtkeetal,ActaAnaesthScand.2002,臨床判斷與肌松監測,.,34,不可靠的臨床試驗:,睜眼伸舌舉臂至對肩正常潮氣量正常或接近正常肺活量最大吸氣壓力25cmH2O,.,35,最佳臨床試驗:,抬頭堅持5sec.抬腿堅持5sec.壓舌板試驗最大吸氣壓力50cmH2O(正常的吞咽反射?),.,36,KnowledgeanduseofclinicaltestsamongDanishanaesthetist(n=251):,Morethan50%wereunabletodistinguishbetweenunreliableandmorereliableclinicaltestsLessthan50%routinelyappliedthemorereliableclinicaltestsinclinicalpractice,Sorgenfreietal,ActaAnaesthScand.2003,.,37,2.用神經刺激器，根據視覺或觸覺反應可以有效地判斷神經肌肉功能,Drencketal,Anesthesiology1989,Pedersenetal,Anesthesiology1990,Kopmanetal,Anesthesiology1996,Fruergaardetal,ActaAnaesthScand1998,.,38,3.中效肌松藥使用中不需要神經肌肉功能監測,nTOF0.7手術(min)Atracurium68242%(29-65)60-95Vecuronium41428%(25-52)107Rocuronium34619%(15-35)85-110,中時效肌松藥與PORC發生率,Hayesetal,2001;Baillardetal,2002;McCauletal,2002;Appelboametal,2003;Kimetal,2002;Gtkeetal,2002,.,39,4.用中時效肌松藥進行插管誘導時無需肌松監測,nTOF注藥至0.70.9記錄時時間(min)肌松藥*52616%45%12756,*Atracurium(n=79),Vecuronium(n=47),Rocuronium(n=400),Debaeneetal,Anesthesiology2003,.,40,5.PORC沒有臨床意義，不威脅患者安危，所以，沒有必要進行肌松監測1）增加低氧（和高碳酸血癥）發生率Bergetal,ActaAnaesthScand1997;Bissingeretal,Physiol.Res.20002）降低化學感受器對缺氧敏感性Eriksson,ActaAnaesthScand1992;Wyonetal,Anesthesiology,19993）咽和上食道肌群功能未恢復，增加了返流誤吸的風險Eriksson,Anesthesiology,1997,Sundman,Anesthesiology,20004）增加了術后肺部并發癥的風險Bergetal,ActaAnesthScand,1997,.,41,Bergetal,ActaAnaesthScand1997,腹部術后肺部并發癥的風險,.,42,Conclusions:1,Residualpostoperativeneuromuscularblockcausesdecreasedchemoreceptorsensitivitytohypoxiafunctionalimpairmentofthemusclesofthepharynxandupperesophagusimpairedabilitytomaintaintheairwayanincreasedriskforthedevelopmentofpostoperativepulmonarycomplications,.,43,Conclusions:2,Itisdifficult,andoftenimpossible,byclinicalevaluationtoexcludewithcertaintyclinicallysignificantresidualcurarization,.,44,Conclusions:3,AbscenceoftactilefadeintheresponsetoTOFstimulation,tetanicstimulationandDBSdoesnotexcludesignificantresidualblock,.,45,Conclusions:4,Adequaterecoveryofpostoperativeneuromuscularfunctioncannotbeguaranteedwithoutobjectiveneuromuscularmonitoring,.,46,Conclusions:5,Goodevidence-basedpracticedictatesthatcliniciansshouldalwaysquantitatetheextentofneuromuscularblockadeusingobjectivemonitoring,.,47,Recommendations:1,Avoidtotaltwitchdepressionduringsurgery.Keep,wheneverpossibleoneortwoTOFresponses,.,48,Recommendations:2,Antagonismoftheneuromuscularblockshouldnotbeinitiatedbeforeatleasttwo,preferablythreeorfour,responsestoTOFstimulationareobserved,.,49,Recommendations:3,ToexcludeclinicallysignificantresidualneuromuscularblockadetheTOFratiowhenmeasuredmechanicallymustexceed0.9,and1.0whenmeasuredusingacceleromyography,.,50,Recommendations:4,Ifsufficientrecoveryhasnotbeendocumentedobjectivelyattheendofthesurgicalprocedure,theneuromuscularblockshouldbeantagonized,.,51,”scientificfindingsdonotfallonblankmindsthatgetmadeupasaresult.ScienceengageswithbusymindsthathavestrongviewsabouthowthingsareandoughttobePeopleswillingnesstotakeactioninfluencestheirviewoftheevidence,ratherthanevidenceinfluencingtheirwillingnesstotakeaction”.,MichaelMarmot,Lancet,2004,vol264,p.1735,.