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1、概概 述述 肌松药是全麻中重要的辅助用药肌松药是全麻中重要的辅助用药 肌松药是麻醉药吗？肌松药是麻醉药吗？ 不是不是 1942年以前年以前 深麻醉深麻醉-良好肌松良好肌松 1942年箭毒应用于临床，临床麻醉就发生了革年箭毒应用于临床，临床麻醉就发生了革命性的变化：命性的变化： 浅麻醉浅麻醉+肌松药肌松药-良好肌松良好肌松1 Awareness 术中知晓（术中知晓（awareness）是一种严重）是一种严重的全麻术中并发症，会给病人造成巨大的全麻术中并发症，会给病人造成巨大的精神损害。尤其易发生于肌松药应用的精神损害。尤其易发生于肌松药应用不当的全麻麻醉中。不当的全麻麻醉中。2 临床常用肌松药临
2、床常用肌松药n去极化肌松药去极化肌松药琥珀胆碱琥珀胆碱suxamethonium,succinylcholine ,scolinen非去极化肌松药非去极化肌松药潘库溴铵潘库溴铵pancuronium,pavulon维库溴铵维库溴铵vecuronium阿曲库铵阿曲库铵atracurium,tracrium哌库溴铵哌库溴铵pipecuronium罗库溴铵罗库溴铵rocuronium美维松美维松mivacurium3 SuccinycholinenDosage: 1-1.5mg/kg, repeated small dose 10mg or 1g in 500 or 1000ml, titrated
3、 to effectnSide effects and clinical 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 4 Tubocurarine(筒箭毒碱)nDosage for i
4、ntubation:0.5-0.6mg/kg for intra-operative: 0.15mg/kg 0.05mg/kgnSide effects and clinical considerations: hypotension and tachycardia 5 Metocurine甲筒箭毒nDosage For intubation :0.3mg/kg For intraoperative:0.08mg/kg 0.03mg/kgnSide effects and clinical considerations: Hypotension tachycardia ,bronchospas
5、m ,allergic reactions6 AtracuriumnDosage For intubation :0.5mg/kg For intraoperative:0.25mg/kg 0.1mg/kg every 10-20minnSide effects and clinical considerations: It must be stored at 2-8. laudanosine (N-甲基四氢罂粟碱)toxicity 7 CistracuriumnDosageFor intubation :0.1-0.15mg/kg within 2minFor infusion:1-2g/k
6、g/minnSide effects and clinical considerations: Laudanosine toxicity, pH and temperature sensitivity, and chemical incompatibility (alkaline solution such as thiopental precipitate) 8 MivacuriumnDosage For intubation :0.1-0.2mg/kg For infusion:4-10g/kg/minnSide effects and clinical considerations: 9
7、 Doxacurium(多沙氯铵)nDosage For intubation :0.05mg/kg within 5min For intraoperative:0.02mg/kg 0.005mg/kgnSide effects and clinical considerations: Devoid of cardiovascular and histamine-releasing side effects.Duration time:60-90minOnset time slower :4-6min10 PancuroniumnDosage For intubation :0.08-0.1
8、2mg/kg For intraoperative:0.04mg/kg 20-40min 0.01mg/kgnSide effects and clinical considerations: It must be stored at 2-8. Hypertension and tachycardia Allergic reactions Dysrhythmias11 VecuroniumnDosageFor intubation :0.08-0.12mg/kgFor intraoperative:0.04mg/kg 0.01mg/kg every 15-20min For infusion:
9、1-2g/kg/minnSide effects and clinical considerations: Devoid of cardiovascular effectsLiver failure12 PipecuroniumnDosageFor intubation :0.06-0.1mg/kg Side effects and clinical considerations: Compared with pancuronium ,pipecuronium devoid of cardiovascular and histamine release side effects, onset
10、of action and duration of action are similar for both drugs13 RocuroniumnDosageFor intubation : 0.45-0.9mg/kgFor intraoperative:0.15mg/kg For infusion:5-12g/kg/minSide effects and clinical considerations: 0.9-1.2mg/kg within 60-90s14 RapacuroniumDosage:For intubation : 1.5mg/kg within 1min in 85%pat
11、iens and duration time 10-20minSide effects and clinical considerations: Hypertension and raise HR mild and transient Severe bronchospasm15 肌松药的临床应用肌松药的临床应用一、在麻醉中的主要应用一、在麻醉中的主要应用n1.气管插管气管插管(intubation) 去极化肌松药去极化肌松药-琥珀胆碱琥珀胆碱 非去极化肌松药非去极化肌松药-潘库溴铵、维库溴铵、阿潘库溴铵、维库溴铵、阿曲库铵、米库氯铵、罗库溴铵曲库铵、米库氯铵、罗库溴铵n2.肌松的术中维持肌松的
12、术中维持 满足手术需要满足手术需要n3. 其他：其他：ICU 及治疗痉挛性疾病及治疗痉挛性疾病16 二、肌松药的给药方法二、肌松药的给药方法 单次间断静注给药单次间断静注给药 持续静脉输注给药持续静脉输注给药 计算机自动化反馈控制给药计算机自动化反馈控制给药 予给量法予给量法 肌松药的复合应用肌松药的复合应用-最好应用同一种肌松药最好应用同一种肌松药 17 肌松药的不良反应肌松药的不良反应1.自主神经系统作用自主神经系统作用2.组胺释放组胺释放18 影响肌松药作用的因素影响肌松药作用的因素n影响肌松药的药代动力学影响肌松药的药代动力学n肝肾功能肝肾功能19 影响肌松药的药效动力学影响肌松药的药
13、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20 药物的相互作用药物的相互作用1.吸入全麻药吸入全麻药2.局麻药和抗心律失常药局麻药和抗心律失常药3.抗生素抗生素4.抗惊厥药和精神病药抗惊厥药和精神病药5.其他其他21 肌松药的拮抗肌松药的拮抗 增加乙酰胆碱浓度或延长乙酰胆碱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作用时间的药物均能拮抗非去极化肌松药的肌松作用。药的肌松作用。 抗胆碱酯酶药物抗胆碱酯酶药物: 新斯的明新斯的明 极量极量 0.07 mg/kg 吡啶斯的明吡啶斯的明 0 .28 mg/kg 依酚氯铵依酚氯铵 1
14、 mg/kg22 抗胆碱酯酶药抗胆碱酯酶药+抗胆碱药抗胆碱药: 新斯的明新斯的明0.035-0.07mg/kg+格隆溴铵格隆溴铵7 g/kg 依酚氯铵依酚氯铵 0.5-1mg/kg+阿托品阿托品7 g/kg 临床常用：新斯的明临床常用：新斯的明+阿托品阿托品 2 ： 123 肌松药的拮抗时机肌松药的拮抗时机: T125%24 Neuromuscular monitoring 肌松监测：刺激外周神经干（一般为尺肌松监测：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，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、据肌收缩效应评价肌松药的作用程度、时效及阻滞性质。时
15、效及阻滞性质。25 Supramaximal stimulationn20 to 25 percent above that necessary for a maximal responsenThe optimal pulse duration is 0.2 to 0.3 msnThe impulse should be monophasic and rectangular (i.e., it should be a square wave) because a biphasic pulse may cause a burst of action potentials in the nerve
16、 (repetitive firing), increasing the response to the stimulation26 Patterns of stimulation1.单刺激（单刺激（single twitch stimulation）2.强直刺激（强直刺激（tetanic stimulation）3.四个成串刺激（四个成串刺激（train of four TOF）4.强直刺激后记数（强直刺激后记数（post tetanic count PTC）5.双短强直刺激（双短强直刺激（double-burst stimulation DBS）27 Single twitch stimu
17、lationnfrequencies of 0.1 to 1.0 Hz 28 Train of four (TOF)29 Tetanic stimulation30 Post-Tetanic Count Stimulation 31 nRelationship between time to the first reaction to TOF nerve stimulation and the number of post-tetanic twitches (i.e., the post-tetanic count) during intense blockade caused by panc
18、uronium, atracurium, and vecuronium. Mean curves and 95 percent prediction regions are shown32 Double-Burst Stimulation 33 THE NERVE STIMULATOR nThe stimulus should produce a monophasic and rectangular waveform, and the length of the pulse should not exceed 0.2 to 0.3 msn60 to 70 mA, but not more th
19、an 80 mA34 35 RECORDING OF EVOKED RESPONSES nMechanomyography nElectromyography nAcceleromyography 36 Electromyography37 38 Acceleromyography 39 40 肌松监测的临床应用肌松监测的临床应用1.肝肾功能障碍肝肾功能障碍2.重症肌无力重症肌无力3.为避免术后肌松拮抗的病人为避免术后肌松拮抗的病人4.呼吸功能严重受损，术后需肌松充分恢呼吸功能严重受损，术后需肌松充分恢复的病人复的病人5.长时间应用或持续静点肌松药的病人。长时间应用或持续静点肌松药的病人。41
20、 Case DiscussionnA 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。 42 思考题思考题1，肌松药延迟恢复对术后病人有哪些影响？，肌松药延迟恢复对术后病人有哪些影响？2，在，在ICU内如何应用肌松药？内如何应用肌松药？43
