肌松药的临床应用

肌松药的临床应用Theclinicaluseofneuromuscularblockade

2021/4/261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2021/4/262Awareness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。2021/4/263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mivacurium2021/4/264SuccinycholineDosage:

1-1.5mg/kg,repeatedsmalldose10mgor1gin500or1000ml,titratedtoeffectSideeffectsandclinicalconsiderations:

A.CardiovascularB.FasciculationsC.HyperkalemiaD.MusclepainsE.IntragastricpressureelevationF.IntraocularpressureelevationG.GeneralizedcontractionsH.ProlongedparalysisI.Intracranialpressure2021/4/265Tubocurarine(筒箭毒碱)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-甲基四氢罂粟碱)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、人的价值，在招收诱惑的一瞬间被决定。2023/2/32023/2/3Friday,February3,202310、低头要有勇气，抬头要有低气。2023/2/32023/2/32023/2/32/3/20234:34:27PM11、人总是珍惜为得到。2023/2/32023/2/32023/2/3Feb-2303-Feb-2312、人乱于心，不宽余请。2023/2/32023/2/32023/2/3Friday,February3,202313、生气是拿别人做错的事来惩罚自己。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、一个人炫耀什么，说明他内心缺少什么。。二月232023/2/32023/2/32023/2/32/3/202316、业余生活要有意义，不要越轨。2023/2/32023/2/303February202317、一个人即使已登上顶峰，也仍要自强不息。2023/2/32023/2/32023/2/32023/2/3Doxacurium(多沙氯铵)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2021/4/2618二、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2021/4/2619肌松药的不良反应1.自主神经系统作用2.组胺释放2021/4/2620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2021/4/2621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2021/4/2622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2021/4/2623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/kg2021/4/2624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2：12021/4/2625肌松药的拮抗时机:T1>25%2021/4/2626Neuromuscularmonitoring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。2021/4/2627Supramaximalstimulation20to25percentabovethatnecessaryforamaximalresponseTheoptimalpulsedurationis0.2to0.3msTheimpulseshouldbemonophasicandrectangular(i.e.,itshouldbeasquarewave)becauseabiphasicpulsemaycauseaburstofactionpotentialsinthenerve(repetitivefiring),increasingtheresponsetothestimulation2021/4/2628Patternsofstimulation1.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）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肌松监测的临床应用1.肝肾功能障碍2.重症肌无力3.为避免术后肌松拮抗的病人4.呼吸功能严重受损，术后需肌松充分恢复的病人5.长时间应用或持续静点肌松药的病人。2021/4/2643CaseDiscussionA72-year-oldmanhasundergonegeneralanesthesiafortransurethralresectionoftheprostate。Twentyminutesafterconclusi