第8章_肌松药临床应用.pptVIP

抗胆碱酯酶药新斯的明、吡啶斯的明和依酚氯铵使较多的乙酰胆碱在神经肌肉接头部位积聚，与非去极化肌松药竞争受体 新斯的明还可作用于接头前膜增加乙酰胆碱释放量，且可直接兴奋胆碱受体 * * 不良反应（作用于其他部位乙酰胆碱酯酶） 心率减慢 腺体分泌 内脏平滑肌痉挛 预防 阿托品或格隆溴铵 * * 钾通道阻滞药 4-氨基吡啶4-amiopyridine(4-AP)0.3-0.5mg/kg 机制 作用于接头前，阻滞钾离子外流，延长动作电位时程，钙离子内流增多，神经末梢释放乙酰胆碱增多 * * 剂量 neostigmine0.02mg/kg～0.04mg/kg＋ 阿托品0.01mg/kg～0.02mg/kg 格隆溴铵7?g/kg与新斯的明0. 035~0. 07mg/kg合用可减少心率变化所引起的危险，这适用于心肌缺血和心脏瓣膜疾病病人 * * 时机 肌松药应用达其维持效果后 有微弱呼吸动作 TOF ratio to more than 0.7 单次肌颤搐刺激恢复25%以上 * * 拔管指征或经验判断 Head-lift for 5 seconds maximum negative inspiratory pressure of 35 cm H2O Hand-grip Eyes open Tongue-stretch VT VA SPO2 * * 影响抗胆碱酯酶药的作用 酸碱和电解质失衡 呼吸性酸中毒不仅加强非去极化肌松药的阻滞作用，且影响抗胆碱酯酶药的作用。当动脉血二氧化碳分压（PaCO2）超过50mmHg时，抗胆碱酯酶药几乎不可能拮抗残余肌松 代谢性碱中毒、低钾血症和高镁血症时，残余肌松也同样难以为抗胆碱酯酶药所逆转 * * 低温 肌松药难以从神经肌肉接头部移出 抗胆碱酯酶药也难以进人神经肌肉接头 老年人应用抗胆碱酯酶药应谨慎，尤其是对应用了心血管系统药物的病人，如洋地黄、?-受体阻滞药和三环类抗抑郁药的病人，抗胆碱酯酶药易引起心动过缓和心律紊乱 * * Summary The main goal should be to use the lowest possible dose that will provide adequate relaxation for surgery Stimulating a peripheral nerve is the most commonly advocated method of monitoring neuromuscular function clinically Choice of Relaxant and Testing of Recovery * * THANKS * * THANKS Pipecuronium * * ? Dosage (mg/kg) Clinical Duration (min) ED95 0.04-0.05 ? Intubation (at t = + 2–3 min) 0.08-0.12 80-120 Relaxation (N2O/O2) 0.04-0.06 40-60 Relaxation (Vapor) 0.2-0.3 40-60 Maintenance 0.005-0.01 30-45 pipecuronium does not block autonomic ganglia, nor does it release histamine The major excretory pathway is the kidney Only a very small amount of the drug (5%) may be deacetylated at the 3-position * * Vecuronium * * ? Dosage (mg/kg) Clinical Duration (min) ED95 0.5 ? Intubation (at t = + 1.5–3 min) 0.1-0.2 45-90 Relaxation (N2O/O2) 0.05 25-40 Relaxation (Vapor) 0.03-0.04 25-40 Maintenance 0.01-0.02 15-30 Infusion 0.8-2.0 mg/kg/min ? more facile tracheal intubation with nondepolarizers顺畅插管 easier administration by infusion for maintenance of blockade during surgery持续维持 faster and more compl