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1、第九章 肌松药的临床应用The clinical use of neuromuscular blockade,Department of AnesthesiologyThe 2nd affiliated hospital of Harbin Medical UniversityLi Haibo,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
2、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mivacurium,Succinycholine,Dosage:1-1.5mg/kg,repeated small dose 10mg or 1g in 500 or 1000ml,titrated to effectSide effects and clinica
3、l considerations:A.Cardiovascular B.Fasciculations C.Hyperkalemia D.Muscle pains E.Intragastric pressure elevation F.Intraocular pressure elevation G.Generalized contractions H.Prolonged paralysis I.Intracranial pressure,Tubocurarine(筒箭毒碱),Dosage for intra-operative:0.15mg/kg 0.05mg/kgSide effects a
4、nd clinical considerations:hypotension and tachycardia,Metocurine甲筒箭毒,Dosage For intubation:0.3mg/kg For intraoperative:0.08mg/kg 0.03mg/kgSide effects and clinical considerations:Hypotension tachycardia,bronchospasm,allergic reactions,Atracurium,Dosage For intubation:0.5mg/kg For intraoperative:0.2
5、5mg/kg 0.1mg/kg every 10-20minSide effects and clinical considerations:It must be stored at 2-8.laudanosine(N-甲基四氢罂粟碱)toxicity,Cistracurium,DosageFor infusion:1-2g/kg/minSide effects and clinical considerations:Laudanosine toxicity,pH and temperature sensitivity,and chemical incompatibility(alkaline
6、 solution such as thiopental precipitate),Mivacurium,Dosage For infusion:4-10g/kg/minSide effects and clinical considerations:,Doxacurium(多沙氯铵),Dosage For intubation:0.05mg/kg within 5min For intraoperative:0.02mg/kg 0.005mg/kgSide effects and clinical considerations:Devoid of cardiovascular and his
7、tamine-releasing side effects.Duration time:60-90minOnset time slower:4-6min,Pancuronium,Dosage For intraoperative:0.04mg/kg 20-40min 0.01mg/kgSide effects and clinical considerations:It must be stored at 2-8.Hypertension and tachycardia Allergic reactions Dysrhythmias,Vecuronium,DosageFor intraoper
8、ative:0.04mg/kg 0.01mg/kg every 15-20min For infusion:1-2g/kg/minSide effects and clinical considerations:Devoid of cardiovascular effectsLiver failure,Pipecuronium,Dosage Side effects and clinical considerations:Compared with pancuronium,pipecuronium devoid of cardiovascular and histamine release s
9、ide effects,onset of action and duration of action are similar for both drugs,Rocuronium,DosageFor intraoperative:0.15mg/kg For infusion:5-12g/kg/minSide effects and clinical considerations:,Rapacuronium,Dosage:For intubation:1.5mg/kg within 1min in 85%patiens and duration time 10-20minSide effects
10、and clinical considerations:Hypertension and raise HR mild and transient Severe bronchospasm,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
11、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 0.07 mg/kg 吡啶斯的明 0.28 mg/kg 依酚氯铵 1 mg/kg,抗胆碱酯酶药+抗胆碱药:mg/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
12、2：1,肌松药的拮抗时机:T125%,Neuromuscular monitoring,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。,Supramaximal stimulation,20 to 25 percent above that necessary for a maximal responseThe optimal pulse duration is 0.2 to 0.3 msThe impulse should be monophasic and rectangular(i.e.,it should be a
13、 square wave)because a biphasic pulse may cause a burst of action potentials in the nerve(repetitive firing),increasing the response to the stimulation,Patterns of stimulation,1.单刺激（single twitch stimulation）2.强直刺激（tetanic stimulation）3.四个成串刺激（train of four TOF）4.强直刺激后记数（post tetanic count PTC）5.双短强
14、直刺激（double-burst stimulation DBS）,Single twitch stimulation,frequencies of 0.1 to 1.0 Hz,Train of four(TOF),Tetanic stimulation,Post-Tetanic Count Stimulation,Relationship between time to the first reaction to TOF nerve stimulation and the number of post-tetanic twitches(i.e.,the post-tetanic count)
15、during intense blockade caused by pancuronium,atracurium,and vecuronium.Mean curves and 95 percent prediction regions are shown,Double-Burst Stimulation,THE NERVE STIMULATOR,The stimulus should produce a monophasic and rectangular waveform,and the length of the pulse should not exceed 0.2 to 0.3 ms6
16、0 to 70 mA,but not more than 80 mA,RECORDING OF EVOKED RESPONSES,Mechanomyography Electromyography Acceleromyography,Electromyography,Acceleromyography,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。,Case Discussion,A 72-year-old man has undergone general anesthesia for transurethral resection of the prostate。Twenty minutes after conclusion of the procedure，he is still intubated and shows no evidence of spontaneous respiration or consciousness。,思考题,1，肌松药延迟恢复对术后病人有哪些影响？2，在ICU内如何应用肌松药？,
