肌松药残余阻滞作用与呼吸功能恢复

肌松药的残余阻滞作用对呼吸功能的恢复有一定的影响，将呼吸力学监测、肌松监测以及临床征象相结合进行合理的判断，对肌松药残余阻滞作用可能造成的呼吸系统并发症有较好的预防作用。     

肌松药残余阻滞作用与呼吸功能恢复

肌松药的残余阻滞作用对呼吸功能的恢复有一定的影响 ,将呼吸力学监测、肌松监测以及临床征象相结合进行合理的判断 ,对肌松药残余阻滞作用可能造成的呼吸系统并发症有较好的预防作用。     

肌松药在日间手术麻醉中的应用进展

日间手术涉及的手术种类越来越多,肌松药是日间手术麻醉中不可或缺的一部分,但是其药效个体差异大且可能导致残余肌松,严重危害日间手术患者的健康。文章综述了临床常用和有应用前景的肌松药、肌松拮抗剂,讨论了不同日间手术对肌松的需求和肌松监测技术,以期为患者提供适宜的肌松管理。     

老年人术后肌松作用消退与呼吸力学恢复的关系

Kopman等建议以TOF≥90％替代过去的TOF≥70％作为肌松残余作用和呼吸功能恢复的标准。本研究拟观察老年患者术后肌松作用自然消退过程中，肌松监测TOF比值与呼吸力学恢复之间的关系，为老年患者肌松药的合理应用和避免肌松药残余作用提供参考。     

术后非去极化肌松药肌松残余拮抗新进展

背景非去极化肌松药在临床麻醉中使用非常普遍,术后不可避免地发生肌松残余作用,其危害主要为呼吸不良事件,严重可导致死亡。 目的有效合理的肌松拮抗能降低术后肌松残余的发生率,减少相关并发症,因此,拮抗至关重要。内容阐述非去极化肌松药使用后手术结束时是否需要拮抗、拮抗的时机、拮抗剂的剂量和新的拮抗模式。趋向选择性肌松拮抗可...     

重视肌松药残余作用的几点建议

晚近 ,欧美先后对全麻后并发症进行了大量的调查 ,而肌松药残余作用所致的并发症发生率之高已引起高度重视。Ｔｉｒｅｔ等调查与分析法国 2 0万例全麻病人 ,因麻醉原因致死的 65例病人中 ,近半数系肌松药残余作用所致。英国Ｌｕｎｎ等报道 1 1例全麻后呼吸抑制患者 ,其中 6例为肌松药残余作用所引起。英格兰Ｃｏｏｐｅｒ总结 5年的全麻后并发症 ,53例中即有 2 4例系因应用肌松药后拮抗不充分致呼吸抑制。澳大利亚、威尔士的学者分析近 2 0年的全麻并发症 ,应用肌松药后拮抗不充分乃系死亡的主因之一。国内肌松监测乃系一薄弱环节 ,此方面的…     

Sugammadex：一个新型的肌松拮抗药

Sugammadex是一种经过修饰的γ-环糊精．能够与氨基甾类非去极化肌松药形成稳定的复合物从肾脏排泄．迅速逆转肌松作用。并且对深度肌松也能够快速逆转．有助于降低术后残余肌松．是一个接近理想状态的肌松拮抗剂。     

去极化与非去极化肌松药间的相互作用

传统的观点认为去极化与非去极化肌松药间的作用相互拮抗,但在某些情况下两者间可产生增效作用。本文综述临床上三种混合使用去极化与非去极化肌松药情况下两类肌松药之间的相互作用。     

新肌松药TAAC3和拮抗药Org25969的研究近况

研究者们一直在探索一个理想的肌松药来取代琥珀胆碱用于快速诱导插管，TAAC3就是一个新合成的起效快且时效短的非去极化肌松药。另外，临床上所用的肌松药拮抗剂都是抗胆碱酯酶药，最新研究的Org25969对肌松药的拮抗是通过完全不同的机制来起作用。本文对TAAC3和Org25969的近期研究进行综述。     

肌松药的术后残余箭毒化作用

新的神经肌肉传递功能完全恢复的全标准是TOF比值≥0.9,TOF值〈0.9可视为有术后残余肌松箭毒化作用（PORC）,在临床工作中,全麻恢复期能观察到有残余肌松阻滞,为了降低PORC的发生率,使患者完全恢复骨骼肌收缩功能和反射活动,以抗胆碱酯酶药作为拮抗剂拮抗残余肌松。但抗胆碱酯酶药有术后恶心,呕吐,心动过缓等副作用,衡量肌松拮抗的利弊,并做出合理的决定,对麻醉医师来说尤为重要。本篇就术后肌松残余阻滞作用及肌松拮抗应用方面的争议作一综述。     

Immunoassays in the diagnosis of anaphylaxis to neuromuscular blocking drugs: the value of morphine for the detection of IgE antibodies in allergic subjects

Radioimmunoassays (RIAs) for IgE antibodies to specific neuromuscular blocking drugs (NMBDs) are an important tool in the diagnosis of anaphylaxis during anaesthesia although they are performed in only a few laboratories throughout the world. NMBDs bind to antibodies by their substituted ammonium ions. We measured serum IgE antibodies to morphine and specific NMBDs in 347 patients with suspected anaphylaxis using blood specimens sent for mast cell tryptase assays. Morphine, which has a single substituted ammonium group, avidly binds in vitro to antibodies that react with NMBDs. The morphine RIA proved to be both a more sensitive and efficient test for the detection of IgE antibodies to NMBDs than the specific NMBD RIAs. We have adopted the morphine RIA in our laboratory in preference to the specific RIAs and predict that use of this single assay will become widespread for the in vitro diagnosis of allergic sensitivities to NMBDs.     

The use of neuromuscular blocking drugs in adult cardiac surgery: results of a national postal survey

Available data suggest that the choice of neuromuscular blocking drugs (NMBDs) can influence early clinical recovery of the fast-track cardiac surgical patient. The aim of this study was to use a survey tool to determine practice patterns of anesthesiologists for the use of NMBDs in the cardiac surgical setting. We mailed a survey to one third of the 3295 active members of the Society of Cardiovascular Anesthesiologists. A follow-up letter and survey were sent to each individual who did not respond to the initial mailing. After the second mailing, 459 surveys were returned, yielding a response rate of 43%. Pancuronium was listed as the primary NMBD used in the majority of patients undergoing cardiopulmonary bypass (69%) and off-pump (41%) procedures. Only 28% of respondents routinely used a peripheral nerve stimulator to monitor neuromuscular blockade in the operating room. Residual neuromuscular blockade was routinely reversed before tracheal extubation by only 9% of cardiac anesthesiologists. This survey demonstrates that long-acting NMBDs are often administered to fast-track cardiac patients. Peripheral nerve stimulator monitoring is rarely used in the operating room or intensive care unit, and reversal drugs (anticholinesterases) are infrequently administered in the postoperative period. IMPLICATIONS: This postal survey of cardiac anesthesiologists demonstrates that long-acting muscle relaxants are frequently administered to fast-track cardiac surgical patients. Neuromuscular blockade is rarely monitored or reversed in this patient population.     

Skin sensitivity to rocuronium and vecuronium: a randomized controlled prick-testing study in healthy volunteers

Prick tests are frequently used for the authentication of neuromuscular blocking drugs (NMBDs) as causative drugs for anaphylactic reactions during anesthesia. Unfortunately, the actual threshold concentration for skin testing remains debatable for most NMBDs. We studied the flare and wheal responses to prick tests with rocuronium and vecuronium. Thirty healthy, nonatopic, anesthesia-naive male and female volunteers (14 men and 16 women) from 18 to 40 yr of age were assigned randomly to receive a total of 10 prick tests-4 ascending dilutions (1:1000, 1:100, 1:10, and 1) of rocuronium and vecuronium and 2 controls-on both forearms. An assessor blinded to the assignment monitored systemic and skin responses to NMBDs and measured wheal and flare surfaces immediately after and 15 min after prick tests. None of the volunteers experienced any immediate systemic or cutaneous responses to rocuronium or vecuronium. Although a dilution of 1:1000 of both NMBDs failed to promote any skin response at 15 min, 50% and 40% of the subjects had a positive skin reaction to undiluted rocuronium and vecuronium, respectively. We demonstrated a sex effect related to smaller threshold concentration-induced cutaneous reactions in female volunteers to both muscle relaxants. Our observation questions the reliability of prick testing with undiluted solutions of rocuronium and vecuronium for the diagnosis of allergy. IMPLICATIONS: Building concentration-skin response curves to prick tests with rocuronium and vecuronium in healthy, nonatopic, anesthesia-naive male and female volunteers demonstrated that the nonreactive concentration for both muscle relaxants is the 1:1000 dilution of the stock solutions. Our observation calls into question the past practice of prick-testing skin for sensitivity to neuromuscular blocking drugs by using undiluted solutions.     

Brief review: Nondepolarizing neuromuscular blocking drugs and critical illness myopathy

PURPOSE: Critically-ill patients who receive nondepolarizing neuromuscular blocking drugs (NMBDs) may be at risk of developing profound muscle weakness that may last for months after the NMBD is discontinued, especially when large cumulative doses of NMBDs and corticosteroids are co-administered to septic, mechanically ventilated patients. This review focuses on the etiology and clinical features of critical illness myopathy (CIM), summarizes specific risk factors for its development, and discusses strategies that might be used to attenuate or even prevent the development of this potentially devastating syndrome. CLINICAL FEATURES: The etiology of CIM is unknown. Whether it can develop in at-risk patients who undergo lengthy operations during which they receive NMBDs is also unknown. In some patients following exposure to NMBDs their motor systems are impaired secondary to loss of thick (myosin) filaments that render the muscle unexcitable to direct electrical stimulation, while the sensory system is spared. Management of patients who develop NMBD myopathy is supportive, consisting of nutritional support, physical therapy, and daily trials of decreased ventilatory support. CONCLUSION: Recent guidelines recommend that NMBDs be used in critically ill patients only when absolutely necessary, that the depth of muscle paralysis be monitored to avoid overdosing and metabolite accumulation, and that drug administration be curtailed periodically to allow interruption of sustained NMBD effect.     

Cisatracurium- and rocuronium-associated residual neuromuscular dysfunction under intraoperative neuromuscular monitoring and postoperative neostigmine reversal: a single-blind randomized trial

BackgroundPostoperative residual neuromuscular blockade (RNMB) is a common complication in the postanesthesia care unit (PACU), but also one of the most controversial issues. Many studies and trials demonstrated that some methods and techniques can reduce the incidence and the extent of the phenomenon.Study ObjectiveTo determine the incidence of RNMB in the PACU at standardized times after extubation with the implementation of a protocol of careful neuromuscular blockade management.DesignRandomized, single-blinded controlled clinical trial.SettingOperating room and PACU.PatientsA total of 120 patients of either sex with American Society of Anesthesiologists grades 1, 2, and 3, aged 18 to 80 years were scheduled to undergo elective abdominal surgical procedures lasting for at least 60 minutes.InterventionsPatients were randomized to receive either cisatracurium (n = 60) or rocuronium (n = 60) at the time of intubation and during surgery. Every patient received quantitative neuromuscular monitoring during general anesthesia. On completion of surgery, patients were given neostigmine 0.05 mg kg⁻¹. Patients were extubated at a train-of-four (TOF) ratio ≥0.9.MeasurementsTOF measurements were performed 15, 30, and 60 minutes after extubation. Tolerability of neuromuscular monitoring was evaluated with a scale from 1 to 10 (with 1 meaning no discomfort at all and 10 meaning maximal discomfort or pain).ResultsSix, 11, and 14 patients (5.0%, 9.2%, and 11.7%) exhibited a TOF ratio <0.9 at 15, 30, and 60 minutes after extubation, respectively. No statistically significant difference in the postoperative RNMB between cisatracurium and rocuronium was found. The median tolerability score for neuromuscular monitoring was 3.ConclusionCareful conduction, monitoring, and subsequent reversal of neuromuscular block may allow for obtaining considerably low incidence of residual neuromuscular block. However, our trial shows that some mid- and long-term cases of TOF ratios <0.9 can still occur, possibly jeopardizing the patients' postoperative recovery.     

Muscle relaxant use for tracheal intubation in pediatric anaesthesia: a survey of clinical practice in Germany

Objectives:  Aim of this Germany-wide study was to evaluate the use and application customs of neuromuscular blocking drugs (NMBDs) for tracheal intubation in children of age 5 years or younger.
Material and Methods:  In the year 2005, a total of 3260 questionnaires were sent out to all heads of anesthesia departments at all types of hospitals as well as ambulatory anesthesia centers in Germany. The fields covered by the questionnaire were regarding institutional size, amount of general anesthesia and specifically pediatric cases, number of intubations and NMBDs used, frequency of use of the individual relaxants and techniques utilized when administering muscle relaxants.
Results:  Of the sent-out questionnaires 66.9%could be analyzed: 82% of hospitals use 1–3 muscle relaxants in children; 91% of the ambulatory anesthesia centers use a repertoire of 1–2 neuromuscular blockers for pediatric cases. However, general anesthesia with tracheal intubation in children is often induced without using any NMBD at all. Mivacurium is the predominantly used NMBD for pediatric intubation in Germany. In contrast, the use of succinylcholine is far less in ambulatory anesthesia centers than in hospitals. Despite controversial discussion, precurarization, priming, and timing are still utilized in German anesthesia practice.
Conclusion:  In Germany, mivacurium, with its favorable pharmacologic profile for short cases, is the predominantly used NMBD for pediatric tracheal intubation. Despite the known adverse effects of intubation without muscle relaxation, this technique is also wide-spread, especially among German anesthetists in ambulatory anesthesia centers. Surveys like these are important to determine a status quo of use and application customs of NMBDs in pediatric anesthesia and provide a basis for numerous other studies.     

Persistence of allergy to anaesthetic drugs.

Intradermal testing and RIA testing for specific IgE antibodies to neuromuscular blocking drugs (NMBDs) were performed in patients referred to an Anaesthetic Allergy Clinic. Six patients were initially investigated four to 29 years after clinical anaphylaxis during anaesthesia and two of these patients and sixteen others were investigated by intradermal testing on two occasions at least four years apart. Seven patients had RIA tests for NMBD-specific IgE antibodies on two occasions at the time of skin testing. In all but two patients the evidence for drug-specific antibodies persisted 4-29 years after the reactions. In one patient all tests became negative and in another the skin test became negative but the positive RIA persisted. Evidence of antibodies to NMBDs persisted in 21 of 22 patients who had had anaphylactic reactions to these drugs during anaesthesia. In the absence of evidence of allergy diminishing with time in the majority of patients it would seem wise to avoid drugs responsible for reactions for the rest of the patient's life.     

比较维库溴铵在青年和中年女性患者全麻中的肌松效应

目的 观察并比较维库溴铵在青年和中年女性患者全麻中肌松效应的影响. 方法 将40例按美国麻醉医师协会（ASA）分级标准定为Ⅰ～Ⅱ级的乳腺包块手术女性患者分为青年组（18岁～44岁）和中年组（45岁～59岁）,每组20例.麻醉诱导期间给予2 ED95 0.1 mg/kg维库溴铵,用TOF-Watch加速度仪进行肌肉松弛监测,采用四个成串刺激（train of four,TOF）方式监测拇内收肌的收缩反应.观察起效时间、时效、体内作用时间、恢复指数、TOF比率恢复到25％的时间. 结果 青年组肌松起效时间、体内作用时间及TOF恢复到25％的时间均明显短于中年组[（156±33）、（186±44）s、（67±29）、（77±20）、（48±14）、（60±16） min] （P＜0.05）.两组时效[（37±10）、（43±11）min]、恢复指数[（21±17）、（22±13） min]差异无统计学意义（P＞0.05）.结论 与中年女性患者比较,青年女性患者对维库溴铵较敏感,起效快,体内作用时间短,但对肌松恢复过程无影响.     

“深肌松”在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用观察

目的 探讨“深肌松”方案在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用效果及优势。方法 择期行机器人辅助腹腔镜下根治性前列腺癌切除术的肥胖患者48例,随机分为常规（中度）肌松组（M组）和深肌松组（D组）。两组采用统一的镇静镇痛方案,其中M组诱导时予顺式阿曲库铵0.15~0.2 mg/kg iv,之后每间隔约45 min~1 h单次静推顺式阿曲库铵5 mg维持;D组诱导时则予罗库溴铵0.6 mg/kg静注,PTC=1~2时行气管插管;麻醉维持采用连续输注,切皮前予罗库溴铵0.6 mg/kg iv,当神经肌肉阻滞开始恢复时以5~10 μg/（kg·min）泵注。比较两组诱导插管时间、苏醒时间、拔管后视觉模拟评分法VAS评分及躁动发生率;分别于诱导前（T₀）、手术开始1小时（T₁）、术毕时（T₂）及离开PACU前（T3）抽取动脉血2 mL行血气分析,比较两组患者乳酸、血糖等结果的差异。结果 与M组相比,D组插管时间、苏醒时间较短,拔管后VAS疼痛评分及躁动发生率较低,两组差别有统计学意义（P<0.05）。同时刻相比,T₂、T₃时刻D组的乳酸、血糖值较低,与M组比较差别有统计学意义（P<0.05）。结论 与常规肌松组相比,“深肌松”麻醉方案可缩短该类患者插管时间,加速苏醒,减轻术后疼痛和躁动应激,或可改善总体麻醉质量。