持续泵注顺式阿曲库铵的临床应用分析

目的 探讨持续泵注顺式阿曲库铵静脉麻醉的临床优势.方法 选取ASA分级为I～Ⅱ级,无神经肌肉疾患,拟在全麻下行择期手术的患者40例,随机分为1组(顺式阿曲库铵持续泵注组)、2组(顺式阿曲库铵间断静脉注射组),每组各20例,麻醉静脉诱导均应用异丙酚、芬太尼,术中麻醉维持应用七氟烷;全程实施肌松监测,观察拇内收肌收缩情况,分别记录各组肌松起效、维持及恢复时间(全部病例在肌松恢复期均未予以拮抗,使其在安静状态下自然恢复),并记录各组顺式阿曲库铵维持用药量.结果 1组顺式阿曲库铵维持用药量显著低于2组,差异有统计学意义(P＜0.05);1组、2组患者肌松起效及维持时间比较,差异均无统计学意义(P均＞0.05);停止泵注后两组的恢复时间、恢复指数比较,差异无统计学意义(P＞无0.05).结论 持续泵注顺式阿曲库铵不仅能使肌松保持恒定水平,而且可节省维持用药量,缩短肌松恢复时间.     

顺式阿曲库铵用于肾移植患者麻醉的药效学研究

目的:观察非去极化肌松药顺式阿曲库铵用于肾移植患者麻醉中的肌松效应和安全性。方法:30例终末期肾功能衰竭接受肾移植患者,随机分为A组(2倍ED95组)、B组(3倍ED95组),30例肾功能正常接受其他手术患者随机分为C组(2倍ED95组)、D组(3倍ED95组)作为对照。观察各组诱导前后生命体征(MAP、HR)的变化、肌肉松弛作用达最大插管条件和肌松效应。肌肉松弛监测采用4个成串刺激(train-of-four,TOF)。肌肉松弛效应观察指标包括,起效时间、T125%恢复时间、T195%恢复时间、TOF比值恢复到70%的时间以及恢复指数(T125%恢复到75%的时间)。结果:各组患者的血流动力学变化组间比较差异无统计学意义(P>0.05)。各组患者的插管条件组间比较差异无统计学意义(P>0.05)。B组起效时间较短,T195%恢复时间、四个成串刺激(TOF)比值恢复到70%的时间较长,与A组比较差异有统计学意义(P<0.05)。D组起效时间较短,T195%恢复时间、四个成串刺激(TOF)比值恢复到70%的时间较长,与C组比较差异有统计学意义(P<0.05)。A组与C组比较差异无统计学意义(P>0.05),B组与D组比较差异无统计学意义(P>0.05)。结论:顺式阿曲库铵可以安全用于肾移植患者的麻醉,3倍ED95剂量的顺式阿曲库铵比2倍ED95剂量起效更快。     

顺式阿曲库铵药理学及其临床应用

顺式阿曲库铵是一种新型强效中时效非去极化型肌松药,现已较广泛用于临床。本文从不同因素对顺式阿曲库铵药代动力学的影响以及目前国内外对其药效学的研究做一综述,以期为临床合理用药优化组合提供参考。     

闭环靶控输注顺式阿曲库铵在骨科手术麻醉中的应用效果观察

目的探讨顺式阿曲库铵经闭环肌松靶控输注系统给药用于骨科手术的效果。方法选择60例ASAI～III级骨科择期手术患者,按随机数字表法分为闭环组与对照组各30例。闭环组经闭环肌松靶控输注系统给药,对照组在肌松监测下间断静脉推注给药。记录比较两组肌松药起效时间、肌松恢复时间、顺式阿曲库铵使用总量等指标。结果两组诱导和维持期间均能满足插管和术中肌松条件。闭环组肌松停药至TOF恢复到0．2、0．5、0．7、0．9时间均短于对照组（P〈0．05;停药至拔管时间较对照组明显缩短（P〈0．05）。两组诱导和维持肌松药用量差异无统计学意义（P〉0．05）。结论闭环靶控输注顺式阿曲库铵用于骨科手术中能达到满意肌松效果,且术后肌凇恢复比间断静脉推注更快。     

肥胖患者应用顺苯磺酸阿曲库铵的肌松效应探讨

目的探讨肥胖患者应用顺苯磺酸阿曲库铵的肌松效应。方法选取该院收治的行全身气管插管静脉麻醉择期手术患者90例作为研究对象,按照患者体质量分为A组(正常体质量组)、B组和C组(肥胖组,C组体质量略高于B组)。3组均给予顺苯磺酸阿曲库铵麻醉诱导并采用肌松监测仪进行拇内收肌肌松监测,T1/Tc不足10%时给予气管插管,A组和B组按照患者实际体质量给药,C组按照理想体质量给药,比较3组患者的恢复指数、起效时间、作用时间以及气管插管条件评级等。结果 B组药物作用时间延长,药物起效时间缩短,C组药物作用时间缩短,药物起效时间延长,差异有统计学意义(P0.05)。结论按实际体质量给肥胖患者应用顺苯磺酸阿曲库铵肌松效果良好,起效时间短,作用时间长,改善患者耐受性,具有积极的临床使用和推广价值。     

麻黄碱、氯胺酮对顺式阿曲库胺肌松效应的影响

目的:观察麻黄碱或氯胺酮对顺式阿曲库铵(简称Cis)肌松效应的影响.方法:全组75例,ASA Ⅰ或Ⅱ级,随机均分为3组.麻黄碱组(E组,90μg/kg);氯胺酮组(K组,1.5 mg/kg)和生理盐水对照组(C组).比较三组间的肌松起效时间、肌松恢复时间、气管插管条件和插管期间的血流动力学变化.结果:E组和K组Cis起效时间明显快于C组,(分别P<0.05).最大肌松抑制3组相似>99%;25%恢复时间3组互比无统计学差异(P>0.05);95%恢复时间E组和K组明显快于C组(分别P<0.05),其他组互比无统计学意义.肌松完全恢复时间(T4:T1≥0.75)E组和K组明显快于C组5～6 min,5%～95%恢复指数E组和K组明显快于C组4 min,分别(P<0.01).E组和K组在插管时1 min MAP和HR明显增加,分别(P<0.05);C组在插管即刻和插管时1 min MAP分别明显下降(P<0.01),HR也分别明显下降(分别P<0.01).插管条件E组和K组明显好于C组(分别P<0.01～P<0.05),未发现其他毒副作用.结论:芬太尼和丙泊酚麻醉诱导时辅用麻黄碱90μg/kg或氯胺酮1.5 mg/kg后≥3 min时,再给予Cis 0.15 mg/kg可有效缩短起效时间和95%恢复时间;同时能够改善气管插管条件.     

不同剂量氯胺酮对顺式阿曲库胺肌松效应的影响

目的:观察不同剂量氯胺酮对顺式阿曲库铵(简称Cis)肌松效应的影响.方法:全组75例,ASAⅠ或Ⅱ级,随机均分为3组.即氯胺酮K,组(1 mg/kg)、氯胺酮K2组(1.5 mg/kg)和生理盐水对照组(C组).比较3组间的肌松起效时间、肌松恢复时间、气管插管条件和插管期间的血流动力学变化.结果:K2组Cis起效时间明显快于C组(14.3%,t=2.3518,P<0.05).95%恢复时间K2组明显快于C组(分别为54.9和61.3 min,P<0.05);肌松完全恢复时间(T4:T1≥0.75)K2组明显快于C组6 min,5%～95%恢复指数K2组明显快于C组4 min(分别P<0.05～0.01).K2组在插管时1 min MAP和HR明显增加(P<0.05);C组在插管即刻和插管时1 min MAP和HR明显下降(P<0.01).插管条件K2组明显好于C组(P<0.05).结论:芬太尼和丙泊酚麻醉诱导时辅用1.5 mg/kg氯胺酮可有效缩短Cis起效时间和95%恢复时间,同时能够改善气管插管条件,增强麻醉效果.     

硫酸镁对阻塞性黄疸患者顺式阿曲库铵肌松效应的影响

顺式阿曲库铵是一种新型的非去极化肌松药,其代谢不依赖肝肾功能,主要以霍夫曼(Hofmann)反应的方式消除,少部分经酶解代谢,在体内无蓄积作用,尤其适用于肝肾损害的患者.但顺式阿曲库铵的起效时间较长,本研究旨在观察麻醉诱导前静脉注射(静注)硫酸镁对顺式阿曲库铵肌松时效的影响.     

顺式阿曲库铵在儿童麻醉中应用

随着麻醉学科快速发展,新的肌松剂不断生产和应用。中效非去极化肌松剂顺式阿曲库铵因其特殊的代谢方式——Hofmann途径降解,对肝、肾功能异常患者有明显优势,且不释放组胺,在成人麻醉中应用较普遍,但在儿科患者中应用较少。本文就其在儿童麻醉中的应用作一综述。     

急性高容量血液稀释对顺式阿曲库铵起效时间的影响

目的观察在宫颈癌根治术中应用急性高容量血液稀释对顺式阿曲库铵起效时间的影响。方法选择行宫颈癌根治择期手术60例,年龄35-60岁,ASA分级Ⅰ～Ⅱ级,随机分为两组：AHH组（A组,n=30）和对照组（C组,n=30）,两组均在术前补充生理需要量,AHH组以15ml/kg用6%羟乙基淀粉酶130/0.4进行血液稀释,两组分别以用顺式阿曲库铵2倍ED95,3倍ED95,4倍ED95的剂量采用TOF-Watch○R SX肌松监测仪器监测肌松,比较两组的顺式阿曲库铵肌松作用的起效时间,气管插管条件及诱导期的血流动力学变化。结果与C组相比,A组肌松起效时间延长（P〈0.05）、CVP增高（P〈0.05）、MAP增高但无统计学意义（P〉0.05）,HR变化无统计学意义。结论 AHH可延长顺式阿曲库铵的起效时间而不会引起血液动力学的显著变化。     

静脉预注利多卡因对顺式阿曲库铵肌松起效时间的影响

目的观察麻醉诱导期间静脉预注利多卡因对顺式阿曲库铵肌松起效时间的影响。方法选择ASAI～II级气管插管全麻下择期手术患者60例,随机分为利多卡因组和对照组,每组各30例。给予异丙酚和芬太尼全麻诱导,并采用加速度法四个成串刺激(TOF)监测肌松。利多卡因组静注利多卡因1.5mg/kg,对照组静注等量0.9%氯化钠注射液,2min后两组都静注顺式阿曲库铵0.15mg/kg,记录肌松起效时间(注药结束至TOF的T1肌颤搐抑制95%的时间)及气管插管条件。结果肌松起效时间:利多卡因组与对照组分别为(116.12±29.31)s、(210.13±33.11)s,利多卡因组明显快于对照组,差异有统计学意义(t=11.65,P<0.05)。气管插管条件:利多卡因组也明显优于对照组,差异有统计学意义(Zc=2.90,P<0.05)。结论利多卡因明显缩短顺式阿曲库铵肌松起效时间、改善气管插管条件,有助于增加顺式阿曲库铵的临床适用范围。     

Cisatracurium: myographical and electrophysiological studies in the isolated rat muscle

Myographical and electrophysiological studies of cisatracurium were performed, in vitro, in the isolated sciatic nerve-extensor digitorum longus muscle preparation of the rat. Indirect twitches were generated at 0.1 Hz and tetanic contractions at 50 Hz. endplate potentials (epps) were generated in trains of 50 Hz. The electrophysiological variables used in the analysis of the epps were: amplitude of the first epp in the train, average amplitude of the 30 degrees to the 59 degrees epp in the train (epps-plateau), tetanic rundown (percent loss in amplitude of epps-plateau relative to the first epp in the train), quantal size and quantal content. The myographical results showed that the inhibitory concentration 50% (IC(50)) of cisatracurium for the blockade of twitches (0.48 microm) is 12 times its IC(50) for the induction of tetanic fade (0.04 microm). The electrophysiological results showed a concentration dependent decrease in the amplitudes of first epps in the trains and of epps-plateau in the two used concentrations (0.13 microm and 0.38 microm). The tetanic rundown was intensified only in the presence of the higher (0.38 microm) concentration of cisatracurium. In cisatracurium 0.13 microm (a concentration which affects only tetanic contractions, inducing their fade, while leaving the twitch unaffected) there was a decrease in the quantal content of the first epp and of epps-plateau in the train. In cisatracurium (0.38 microm), a concentration, which affects the twitch, there was a decrease of the quantal size and of quantal content of epps-plateau, but not of the quantal content of the first epp in the train. The results indicate that the fade of the tetanic contraction induced by cisatracurium at the concentration of 0.13 microm is entirely because of a pre-synaptic blocking effect while the decrease in the twitch induced by cisatracurium at the concentration of 0.38 microm is due to a post-synaptic blocking effect.     

Selective versus non-selective neural stimulation in the monitoring of muscular relaxation during general anesthesia

Aim. The depth of muscular relaxation during general anesthesia is monitored through the analysis of the contraction evoked by selective electrical stimulation of a peripheral nerve. The aim of this study was to compare the method of selective stimulation (SS) to a new method based on non-selective electrical stimulation (NSS) delivered over the muscle. Method. Electrical stimuli were delivered as train-of-four impulses to the ulnar nerve (SS) and to the ventral aspect of the contralateral forearm (NSS). The muscular responses of the adductor pollicis brevis (SS) and the forearm supinator longus (NSS) were studied at 30–60 s intervals with piezoelectric transducers before and after the administration of atracurium bolus doses of 0.5 mg/kg to patients under general anesthesia. SS and NSS evoked muscular responses were quantitized as percentages of the control response and compared with linear correlation and concordance analysis. Results. Twenty patients were studied. Basal and post-atracurium muscular responses were similar for the SS and the NSS methods. Precision between SS and NSS was > 85% and accuracy > 92%. Concordance was: basal < 15%, relaxation < 5%, recovery < 10%. Conclusion. NSS is equivalent to SS for muscular relaxation monitoring during general anesthesia. This has important implications to simplify muscular relaxation monitor design.     

利多卡因或罗哌卡因对3ED95顺苯磺阿曲库铵肌松作用的影响

目的 观察静脉或硬膜外注射利多卡因、硬膜外注射罗哌卡因对3ED95顺苯磺阿曲库铵的神经肌肉阻滞作用的影响.方法 60例患者随机分为4组.患者均以顺苯磺阿曲库铵0.15mg/kg诱导,并用TOF监测仪对足拇短屈肌进行监测.静脉利多卡因组（VL组）在诱导前15min静注2%利多卡因1.5mg/kg后以0.03mg/（kg·min）注射,硬膜外利多卡因组（EL组）或罗哌卡因组（ER组）均在诱导前15min行硬膜外穿刺,EL组给予3.3mg/kg 2%利多卡因,1h后追加1.8mg/kg.ER组给予与EL组等容积的0.5%罗哌卡因.记录4组的T1消失、T2和T3恢复时间.结果 VL组T1消失时间比对照组（C组）短（4.44±1.37 vs 6.17 ±1.91min;P〈0.05）;VL组和EL组T2（64.47±9.87、63.87 ±10.06min）、T3恢复时间（66.82±9.80、65.94 ±10.1min）均比C组（54.90 ±5.96、56.59±5.86min）长（P〈0.05）.ER组与C组无显著差异（P〉0.05）.结论 静注利多卡因缩短顺苯磺阿曲库铵的起效时间,静注或硬膜外注射利多卡因都会延长其临床作用时间,但硬膜外注射罗哌卡因对其神经肌肉阻滞作用没有影响.     

Electromyographic monitoring of profound surgical muscle relaxation during cardiac anesthesia

Quantitative assessment of neuromuscular block produced by large doses of nondepolarizing neuromuscular blocking agents during cardiac surgery is not possible with conventional methods of monitoring. Various posttetanic responses can, however, be elicited, even when no twitch response is present. Posttetanic responses measured by electromyography were used in this study. Twenty-four male patients undergoing coronary bypass surgery were anesthetized with sufentanil plus diazepam. Neuromuscular block was provided either with pancuronium 0.1 mg/kg or with vecuronium 0.07 mg/kg initially and supplemented with small increments when indicated. Neuromuscular block was monitored from the hypothenar muscle. The ulnar nerve was stimulated by train-of-four, with supermposed periodic tetanic stimuli to evoke posttetanic responses, once every 7 to 15 minutes. The tetanically potentiated responses were detectable during 96% ± 3.6 (vecuronium) and during 97% ± 3.7 (pancuronium) of the entire intraoperative period, while the nonpotentiated electromyographic responses were present for less than 50% of the time. The sum (of the amplitudes) of 6 posttetanic responses is significantly (p<0.05) greater than the sum of 6 nonpotentiated responses and than the size of a single-peak posttetanic response when compared with the normal, nonpotentiated responses. Higher-frequency tetanic stimuli (100 or 200 Hz) produced greater posttetanic responses (p<0.05) than did the 50-Hz tetanic stimulus. There were only slight or no significant differences in the degree of posttetanic potentiation between pancuronium and vecuronium either before, during, or after cardiopulmonary bypass. With posttetanic responses, we could detect changes in the level of neuromuscular block that occur during cardiac surgery and that are related to cardiopulmonary bypass, cooling, rewarming, and large doses of corticosteroids and antibiotics. Furthermore, it was not necessary to extend the arm or to use an arm board (on which the hand is immobilized when using mechanical monitoring methods) during cardiac surgery.     

阿曲库铵靶控输注的肌松效应研究

目的：探讨七氟醚吸入麻醉或丙泊酚-瑞芬太尼全凭静脉麻醉对阿曲库铵效应室靶浓度及肌松效应的影响。方法：选择全麻下手术患者60例,随机分为丙泊酚．瑞芬太尼组（A组）及七氟醚吸入麻醉组（B组）,各30例。以TOF刺激方式监测拇内收肌的收缩反应。从诱导靶浓度2μg·mL^-1开始效应室靶控输注阿曲库铵,术中调节靶浓度维持T1≤5％。记录两组阿曲库铵靶浓度的变化、总药量、麻醉时间、恢复指数、停药至TOFR为0．9的时间。结果：两组持续给药30min后阿曲库铵效应室靶浓度显著下降（P〈0．05）,B组靶浓度低于A组（P〈0．05）;B组阿曲库铵期间用药量小于A组（P〈0．05）,且恢复指数、停药到TOFR为0．9的时间短于A组（P〈0．05）。结论：七氟醚吸入麻醉和丙泊酚-瑞芬太尼静脉麻醉均能呈时间依赖性地降低阿曲库铵效应室靶浓度,且前者的影响明显大于后者,停药后肌松恢复更为迅速。     

Double burst monitoring during surgical degrees of neuromuscular blockade: A comparison with train-of-four

With double burst stimulation (DBS) it is possible to monitor more profound degrees of neuromuscular blockade than with train-of-four stimulation (TOF). It may therefore be indicated to change between DBS and TOF stimulation during moderate to profound degrees of neuromuscular blockade. Consequently, the aim of the study was to evaluate and compare the twitch height of the first twitch (D1) in DBS and the twitch height of the first twitch (T1) in TOF stimulation during moderate to profound degrees of neuromuscular blockade. Thirty-three patients scheduled for gynaecological laparotomy under general anaesthesia were studied. Mechanomyography was used for neuromuscular monitoring. The T1 twitch height before atracurium was administered served as the control twitch height (T1 control). T1 control was considered as 100%. A constant degree of neuromuscular blockade was maintained at a T1 twitch height at a point between 4 and 11% of T1 control, using a continuous infusion of atracurium. Sequences of 16 DBS and 16 TOF stimulations were given. Two different DBS patterns were examined: DBS_3,350/50, (3 stimuli at 50 Hz followed 0.75 sec later by 3 stimuli at 50 Hz), and DBS_3,380/40, (3 stimuli at 80 Hz followed 0.75 sec later by 3 stimuli at 40 Hz). The data were analysed by the method described by Bland and Altman (1). The D1 repeatability coefficients of 1.72% for DBS_3,350/50 and 1.20% for DBS_3,380/40 were significantly greater than the repeatability coefficient of 1.02% for T1 (p<0.05). The D1 bias of 16.7% for DBS_3,350/50 was significantly less than the D1 bias of 25.7% for DBS_3,380/40 (p<0.05). The limits of agreement between D1 and T1 were 0.1 to 33.3% for DBS_3,350/50 and 2.9 to 48.5% for DBS_3,380/40. In conclusion: The repeatability of responses to DBS and TOF stimulations during moderate to profound degrees of neuromuscular blockade where only one twitch is consistently present is satisfactory. The responses to DBS were greater than responses to TOF as indicated by a positive bias of DBS. The limits of agreement between DBS and TOF responses were so wide that they cannot be used interchangeably.     

The effect of single twitch and train-of-four stimulation on twitch forces during stable neuromuscular block

Objective.We investigated whether the response to a single twitch (ST) stimulus or the first response (T1) toa train-of-four (TOF; 4 stimuli at 2 Hz) stimulus followinga stimulus interval of 10 s (i.e., the time between two consecutive ST or TOF stimuli) is influenced by the preceding stimulus in the presence of a stable 50% neuromuscular block. In addition, we determined whether ST and TOF stimulation yield different results under these circumstances. Methods.Twitch forces were measured in both tibialis anterior muscles of six cats. In the presence of a stable 50% neuromuscular block the stimulation pattern (ST or TOF) or stimulus interval (3.3, 10 or 30 s) was varied every 30min. A linear mixed model was used for statistical analysis. Results.ST forces with a stimulus interval of 3.3 s were 10.3%(95% CI: 7.3–13.3%) smaller than those with a stimulus interval of 10 s. For T1 forces this effect was 15.2% (95% CI: 12–18.4%). There was no significant difference between twitch forces with stimulus intervals of 30 and 10 s. For a stimulus interval of 3.3 s the ST forces exceeded the T1 forces by 7.6% (95% CI: 4.4–10.8%); no significant differences were found between the ST and T1 forces for stimulus intervals of 10 and 30 s. Conclusions.The ST or T1force during stimulation with a stimulus interval of 10 s or more during a stable 50% neuromuscular block in the tibialis anterior muscle of the cat is not affected by the preceding stimulus. In addition, ST and T1 forces do not differ when employing a stimulus interval of 10 s or more under these circumstances. Our results thus indicate that the known differences between ST and T1 forces after a bolus injection of a muscle relaxant can not be explained by differences in acetylcholine release when the stimulus interval exceeds10 s. This revised version was published online in July 2006 with corrections to the Cover Date.     

肌肉松弛疗法对减轻无抽搐电休克治疗术后患者疼痛的疗效研究

目的 探讨肌肉松弛疗法改善无抽搐电休克治疗(modified electric convulsive therapy, MECT)术后患者疼痛、焦虑及睡眠的效果。 方法 选取首次接受MECT治疗的抑郁症患者90例,按随机数字表法分为对照组和研究组各45例。采用长海痛尺、汉密尔顿焦虑量表、匹兹堡睡眠质量指数量表评估干预前后患者疼痛、焦虑及睡眠状况。结果 研究组的疼痛评分明显低于对照组(F_组间=22.772,P＜0.001)。研究组干预后焦虑及睡眠评分均低于对照组(t=-4.743,P<0.001; t=-2.180,P＜0.001)。 结论 肌肉松弛疗法有助于减轻患者MECT术后疼痛,缓解患者的焦虑情绪,提高患者的睡眠质量。