肌松藥的臨床應(yīng)用Theclinicaluseofneuromuscularblockade課件

第九章肌松藥的臨床應(yīng)用Theclinicaluseofneuromuscularblockade

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Awareness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＜∷伤幍呐R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---潘庫溴銨、維庫溴銨、阿曲庫銨、米庫氯銨、羅庫溴銨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)肌肉疾病重癥肌無力5.假性膽堿酯酶異常藥物的相互作用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?？鼓憠A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/kg肌松藥的拮抗時(shí)機(jī):T1>25%Neuromuscularmonitoring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)。Supramaximalstimulation20to25percentabovethatnecessaryforamaximalresponseTheoptimalpulsedurationis0.2to0.3msTheimpulseshouldbemonophasicandrectangular(i.e.,itshouldbeasquarewave)becauseabiphasicpulsemaycauseaburstofactionpotentialsinthenerve(repetitivefiring),increasingtheresponsetothestimulationSingletwitchstimulationfrequenciesof0.1to1.0Hz

Trainoffour(TOF)TetanicstimulationRelationshipbetweentimetothefirstreactiontoTOFnervestimulationandthenumberofpost-tetanictwitches(i.e.,thepost-tetaniccount)duringintenseblockadecausedbypancuronium,atracurium,andvecuronium.Meancurvesand95percentpredictionregionsareshownDouble-BurstStimulation

THENERVESTIMULATOR

Thestimulusshouldproduceamonophasicandrectangularwaveform,andthelengthofthepulseshouldnotexceed0.2to0.3ms60to70mA,butnotmorethan80mARECORDINGOF

EVOKEDRESPONSES

MechanomyographyElectromyographyAcceleromyography

Electromyography肌松監(jiān)測(cè)的臨床應(yīng)用1.肝腎功能障礙2.重癥肌無力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。CaseDiscussionA72-year-oldmanhasundergonegeneralanesthesiafortransurethralresectionoftheprostate。Twentyminutesafterconclusionoftheprocedure，heisstill