肌松藥的臨床應(yīng)用Theclinicaluseofneuromuscularblockade

2021/4/261概述肌松藥是全麻中重要的輔助用藥肌松藥是麻醉藥嗎？不是1942年以前……深麻醉---良好肌松1942年箭毒應(yīng)用于臨床，臨床麻醉就發(fā)生了革命性的變化：淺麻醉+肌松藥-----良好肌松2021/4/262Awareness術(shù)中知曉（awareness）是一種嚴(yán)重的全麻術(shù)中并發(fā)癥，會(huì)給病人造成巨大的精神損害。尤其易發(fā)生于肌松藥應(yīng)用不當(dāng)?shù)娜槁樽碇小?021/4/263臨床常用肌松藥去極化肌松藥琥珀膽堿suxamethonium,succinylcholine,scoline非去極化肌松藥潘庫(kù)溴銨pancuronium,pavulon維庫(kù)溴銨vecuronium阿曲庫(kù)銨atracurium,tracrium哌庫(kù)溴銨pipecuronium羅庫(kù)溴銨rocuronium美維松mivacurium2021/4/264SuccinycholineDosage:

1-1.5mg/kg,repeatedsmalldose10mgor1gin500or1000ml,titratedtoeffectSideeffectsandclinicalconsiderations:

A.CardiovascularB.FasciculationsC.HyperkalemiaD.MusclepainsE.IntragastricpressureelevationF.IntraocularpressureelevationG.GeneralizedcontractionsH.ProlongedparalysisI.Intracranialpressure2021/4/265Tubocurarine(筒箭毒堿)Dosage

forintubation:0.5-0.6mg/kgforintra-operative:0.15mg/kg0.05mg/kgSideeffectsandclinicalconsiderations:

hypotensionandtachycardia

2021/4/266Metocurine甲筒箭毒Dosage

Forintubation:0.3mg/kgForintraoperative:0.08mg/kg0.03mg/kgSideeffectsandclinicalconsiderations:

Hypotensiontachycardia,bronchospasm,allergicreactions2021/4/267AtracuriumDosage

Forintubation:0.5mg/kgForintraoperative:0.25mg/kg0.1mg/kgevery10-20minSideeffectsandclinicalconsiderations:

Itmustbestoredat2-8℃.

laudanosine(N-甲基四氫罌粟堿)toxicity2021/4/268CistracuriumDosageForintubation:0.1-0.15mg/kgwithin2minForinfusion:1-2μg/kg/minSideeffectsandclinicalconsiderations:Laudanosinetoxicity,pHandtemperaturesensitivity,andchemicalincompatibility(alkalinesolutionsuchasthiopentalprecipitate)

2021/4/269MivacuriumDosage

Forintubation:0.1-0.2mg/kgForinfusion:4-10μg/kg/minSideeffectsandclinicalconsiderations:

2021/4/26109、人的價(jià)值，在招收誘惑的一瞬間被決定。2023/2/32023/2/3Friday,February3,202310、低頭要有勇氣，抬頭要有低氣。2023/2/32023/2/32023/2/32/3/20234:34:27PM11、人總是珍惜為得到。2023/2/32023/2/32023/2/3Feb-2303-Feb-2312、人亂于心，不寬余請(qǐng)。2023/2/32023/2/32023/2/3Friday,February3,202313、生氣是拿別人做錯(cuò)的事來(lái)懲罰自己。2023/2/32023/2/32023/2/32023/2/32/3/202314、抱最大的希望，作最大的努力。03二月20232023/2/32023/2/32023/2/315、一個(gè)人炫耀什么，說(shuō)明他內(nèi)心缺少什么。。二月232023/2/32023/2/32023/2/32/3/202316、業(yè)余生活要有意義，不要越軌。2023/2/32023/2/303February202317、一個(gè)人即使已登上頂峰，也仍要自強(qiáng)不息。2023/2/32023/2/32023/2/32023/2/3Doxacurium(多沙氯銨)Dosage

Forintubation:0.05mg/kgwithin5minForintraoperative:0.02mg/kg0.005mg/kgSideeffectsandclinicalconsiderations:Devoidofcardiovascularandhistamine-releasingsideeffects.Durationtime:60-90minOnsettimeslower:4-6min2021/4/2612PancuroniumDosage

Forintubation:0.08-0.12mg/kgForintraoperative:0.04mg/kg20-40min0.01mg/kgSideeffectsandclinicalconsiderations:Itmustbestoredat2-8℃.HypertensionandtachycardiaAllergicreactionsDysrhythmias2021/4/2613VecuroniumDosageForintubation:0.08-0.12mg/kgForintraoperative:0.04mg/kg0.01mg/kgevery15-20minForinfusion:1-2μg/kg/minSideeffectsandclinicalconsiderations:DevoidofcardiovasculareffectsLiverfailure2021/4/2614PipecuroniumDosageForintubation:0.06-0.1mg/kg

Sideeffectsandclinicalconsiderations:Comparedwithpancuronium,pipecuroniumdevoidofcardiovascularandhistaminereleasesideeffects,onsetofactionanddurationofactionaresimilarforbothdrugs2021/4/2615RocuroniumDosageForintubation:0.45-0.9mg/kgForintraoperative:0.15mg/kgForinfusion:5-12μg/kg/minSideeffectsandclinicalconsiderations:0.9-1.2mg/kgwithin60-90s2021/4/2616RapacuroniumDosage:Forintubation:1.5mg/kgwithin1minin85%patiensanddurationtime10-20minSideeffectsandclinicalconsiderations:

HypertensionandraiseHRmildandtransient

Severebronchospasm2021/4/2617肌松藥的臨床應(yīng)用一、在麻醉中的主要應(yīng)用1.氣管插管(intubation)去極化肌松藥----琥珀膽堿非去極化肌松藥---潘庫(kù)溴銨、維庫(kù)溴銨、阿曲庫(kù)銨、米庫(kù)氯銨、羅庫(kù)溴銨2.肌松的術(shù)中維持滿足手術(shù)需要3.其他：ICU及治療痙攣性疾病2021/4/2618二、肌松藥的給藥方法單次間斷靜注給藥持續(xù)靜脈輸注給藥計(jì)算機(jī)自動(dòng)化反饋控制給藥予給量法肌松藥的復(fù)合應(yīng)用----最好應(yīng)用同一種肌松藥2021/4/2619肌松藥的不良反應(yīng)1.自主神經(jīng)系統(tǒng)作用2.組胺釋放2021/4/2620影響肌松藥作用的因素影響肌松藥的藥代動(dòng)力學(xué)肝腎功能2021/4/2621影響肌松藥的藥效動(dòng)力學(xué)1.水、電解質(zhì)和酸堿平衡2.低溫3.年齡4神經(jīng)肌肉疾病重癥肌無(wú)力5.假性膽堿酯酶異常2021/4/2622藥物的相互作用1.吸入全麻藥2.局麻藥和抗心律失常藥3.抗生素4.抗驚厥藥和精神病藥5.其他2021/4/2623肌松藥的拮抗增加乙酰膽堿濃度或延長(zhǎng)乙酰膽堿作用時(shí)間的藥物均能拮抗非去極化肌松藥的肌松作用。抗膽堿酯酶藥物:新斯的明極量0.07mg/kg吡啶斯的明0.28mg/kg依酚氯銨1mg/kg2021/4/2624抗膽堿酯酶藥+抗膽堿藥:

新斯的明0.035--0.07mg/kg+格隆溴銨7g/kg依酚氯銨0.5--1mg/kg+阿托品7g/kg臨床常用：新斯的明+阿托品2：12021/4/2625肌松藥的拮抗時(shí)機(jī):T1>25%2021/4/2626Neuromuscularmonitoring肌松監(jiān)測(cè)：刺激外周神經(jīng)干（一般為尺神經(jīng)），誘發(fā)該神經(jīng)支配的肌群收縮，據(jù)肌收縮效應(yīng)評(píng)價(jià)肌松藥的作用程度、時(shí)效及阻滯性質(zhì)。2021/4/2627Supramaximalstimulation20to25percentabovethatnecessaryforamaximalresponseTheoptimalpulsedurationis0.2to0.3msTheimpulseshouldbemonophasicandrectangular(i.e.,itshouldbeasquarewave)becauseabiphasicpulsemaycauseaburstofactionpotentialsinthenerve(repetitivefiring),increasingtheresponsetothestimulation2021/4/2628Patternsofstimulation1.單刺激（singletwitchstimulation）2.強(qiáng)直刺激（tetanicstimulation）3.四個(gè)成串刺激（trainoffourTOF）4.強(qiáng)直刺激后記數(shù)（posttetaniccountPTC）5.雙短強(qiáng)直刺激（double-burststimulationDBS）2021/4/2629Singletwitchstimulationfrequenciesof0.1to1.0Hz

2021/4/2630Trainoffour(TOF)2021/4/2631Tetanicstimulation2021/4/2632Post-TetanicCountStimulation

2021/4/2633RelationshipbetweentimetothefirstreactiontoTOFnervestimulationandthenumberofpost-tetanictwitches(i.e.,thepost-tetaniccount)duringintenseblockadecausedbypancuronium,atracurium,andvecuronium.Meancurvesand95percentpredictionregionsareshown2021/4/2634Double-BurstStimulation

2021/4/2635THENERVESTIMULATOR

Thestimulusshouldproduceamonophasicandrectangularwaveform,andthelengthofthepulseshouldnotexceed0.2to0.3ms60to70mA,butnotmorethan80mA2021/4/26362021/4/2637RECORDINGOF

EVOKEDRESPONSES

MechanomyographyElectromyographyAcceleromyography

2021/4/2638Electromyography2021/4/26392021/4/2640Acceleromyography

2021/4/26412021/4/2642肌松監(jiān)測(cè)的臨床應(yīng)用1.肝腎功能障礙2.重癥肌無(wú)力3.為避免術(shù)后肌松拮抗的病人4.呼吸功能嚴(yán)重受損，術(shù)后需肌松充分恢復(fù)的病人5.長(zhǎng)時(shí)間應(yīng)用或持續(xù)靜點(diǎn)肌松藥的病人。2021/4/2643CaseDiscussionA72-year-oldmanhasundergonegeneralanesthesiafortransurethralresectionoftheprostate。Twentyminutesafterconclusi