小儿不同剂量顺式阿曲库铵的肌松作用

目的通过观察小儿不同剂量顺式阿曲库铵的肌松作用,评价是否存在封顶效应,探讨小儿合适的麻醉诱导剂量。方法45例择期手术的息儿,年龄15～50月,ASAⅠ或Ⅱ级,随机分为3组(n=15):顺式阿曲库铵0.1 mg/kg组(A组)、顺式阿曲库铵0.15 mg/kg组(B组)、顺式阿曲库铵0.2 mg/kg(C组)。采用TOF-Guard肌松监测仪对尺神经行连续四个成串(TOF)刺激,监测拇内收肌肌颤搐变化;静脉注射异丙酚2 mg/kg、芬太尼2μg/kg及相应剂量顺式阿曲库铵麻醉诱导,吸入O2-N2O和静脉持续输注异丙酚维持麻醉;评价气臂插管条件评估分级,监测诱导期间血液动力学变化,记录起效时间(肌松药注毕至T1达最大抑制的时间)、临床肌松维持时间(肌松药注毕至T1恢复5%的时间)、临床肌松有效作用时间(T1从最大抑制至恢复25%的时间)、恢复指数(T1恢复从25%至75%的时间)、体内肌松作用时间(肌松药注毕至T1恢复95%的时间)。结果3组气管插管条件评估分级比较差异无统计学意义;三组T1达最大抑制时心率、平均动脉压组间和组内比较差异均无统计学意义。与A组相比,B组、C组起效时间较短,临床肌松维持时间、临床肌松有效作用时间、体内肌松作用时间较长(P<0.01);三组恢复指数差异无统计学意义。与B组相比,C组起效时间差异无统计学意义,但临床肌松维持时间、临床肌松有效作用时间、体内肌松作用时间较长(P<0.05或0.01)。结论小儿芬太尼复合异丙酚时,顺式阿曲库铵0.15 mg/kg(3倍ED95)是麻醉诱导的适宜剂量。     

Modulation of rat brain synaptosomal plasma membrane achieved by atracurium and its metabolite laudanosine

Objective: Atracurium besylate and laudanosine cause excitement and seizures when introduced into the central nervous system of laboratory animals. We examined the modulation of lipid-protein interaction in the lipid environment of rat brain synaptosomal plasma membrane (SPM)-bound enzymes as a possible mechanism leading to these effects. Methods: The effect of various concentrations of atracurium besylate and laudanosine, or of varying duration of SPM, on the activity of Na⁺/K⁺ stimulated ATPase, Mg²⁺-stimulated ATPase and 5′-nucleotidase were assessed. The modulation of lipid protein interaction by laudanosine was estimated on the basis of the temperature dependence and cooperative behaviour of Na⁺/K⁺-stimulated ATPase. Results: The effect of atracurium besylate or laudanosine on Na⁺/K⁺-stimulated ATPase activity was biphasic. Maximal enzyme stimulation appeared at 10⁻⁴ M atracurium besylate or 10⁻⁸ M laudanosine, and at 30 min of pre-incubation with both drugs. Arrhenius plots of Na⁺/K⁺-stimulated ATPase showed a transition temperature of 23.0 ± 1.2 °C in control SPM and shifted to 16.5 ± 0.9 °C (p < 0.01) in SPM treated with 10⁻⁸ M laudanosine. The Hill coefficients for the allosteric inhibition of Na⁺/K⁺-stimulated ATPase by fluoride decreased from 1.99 ± 0.22 in controls to 1.06 ± 0.11 (p < 0.001) in the presence of 10⁻⁸ M laudanosine. Conclusions: Our results suggest that laudanosine, one of the principal metabolites of atracurium besylate, affects nerve cell function in rats through the perturbation of the membrane lipid structure accompanied by SPM-bound enzyme dysfunction. Received: 21 July 1997 Accepted: 19 February 1998     

复合小剂量阿曲库铵对顺苯磺酸阿曲库铵起效时间的影响

目的观察顺苯磺酸阿曲库铵同时复合阿曲库铵用于全凭静脉诱导的起效时间。方法择期全麻手术患者80例,随机均分为A、B、C、D四组。A组单用3ED95(0.15 mg/kg)顺苯磺酸阿曲库铵作为对照组;另三组分别用3ED95顺苯磺酸阿曲库铵复合阿曲库铵0.05 mg/kg(B组)、0.10 mg/kg(C组)或0.15 mg/kg(D组)。采用TOF-Watch SX肌松监测。静注咪唑安定0.05mg/kg、芬太尼5μg/kg、依托咪酯0.3 mg/kg及相应剂量肌松药,记录起效时间,进行气管插管条件评级。结果B、C、D组肌松起效时间依次加快,均明显短于A组(P<0.01),但B、C、D组之间差异无统计学意义。结论复合小剂量阿曲库铵能缩短3ED95顺苯磺酸阿曲库铵的起效时间。     

恶性肿瘤对顺阿曲库铵肌松效应的影响

目的 探讨恶性肿瘤对顺阿曲库铵肌松效应的影响.方法 选择头颈部肿瘤患者60例,ASA分级Ⅰ或Ⅱ级,年龄18～64岁,分为4组(n=15),良性肿瘤组(B组,3×ED95);45例恶性肿瘤患者按顺阿曲库铵使用剂量分为C1组(2×ED95)、C2组(3×ED95)和C3组(4 × E95).采用TOF-Watch SX型加速度肌松监测仪对尺神经行单次颤搐刺激,监测拇内收肌颤搐情况.麻醉诱导:靶控输注异丙酚(血浆靶浓度3μg//ml)和瑞芬太尼(效应室靶浓度3 ng/ml),患者意识消失后开启加速度肌松监测仪.B组静脉注射顺阿曲库铵0.15 mg/kg行气管插管.C1组、C2组和C3组分别静脉注射顺阿曲库铵0.10、0.15和0.20mg/kg行气管插管.记录顺阿曲库铵起效时间,临床作用时间、T/Tc恢复至75%的时间及其恢复指数.结果 与B组比较,C2组顺阿曲库铵临床作用时间、T/Tc恢复至75%的时间及恢复指数延长(P＜0.05),起效时间差异无统计学意义(P＞0.05).与C1组比较,C2组和C3组顺阿曲库铵起效时间缩短,临床作用时间、T/Tc恢复至75%的时间延长(P＜0.05),恢复指数差异无统计学意义(P＞0.05).与C2组比较,C3组顺阿曲库铵起效时间缩短,临床作用时间、T/Tc恢复至75%时间延长(P＜0.05),恢复指数差异无统计学意义(P＞0.05).结论 恶性肿瘤患者应用顺阿曲库铵肌松效应的维持和恢复时间延长.     

Impact d’une démarche d’évaluation des pratiques professionnelles sur l’utilisation du monitorage de la curarisation et l’antagonisation des curares

Introduction

As part of a quality assurance in the anaesthesia department, this study was designed to enhance the rate of neuromuscular blockade monitoring for patients receiving muscle relaxant during anaesthesia.

Methods

After approval of our local ethical committee, we assessed 200 computerized anaesthesia records in which neuromuscular relaxants were used. The following data were collected: demographic characteristics, durations of anaesthesia and surgery, use of neuromuscular monitoring, reversal agents and the quality of neuromuscular monitoring. The results were discussed with all anaesthesia providers of the department and an internal guideline was elaborated with the endpoint that all patients having muscle relaxants should have quantitative neuromuscular monitoring. Six months later, another assessment of 200 consecutive records collected the same data to check the efficiency of the elaborated guideline.

Results

The monitoring rate was of 67% at the first assessment and increased to 94% (p < 0.05). The reversal rate was at 48% in the first assessment and was stable at the second assessment (50%). The rate of patients not monitored and not reversed decreased from 5 to 2% (p < 0.05).

Discussion

This study shows that as part of a quality assurance program systematic quantitative monitoring of neuromuscular blockade can be significantly increased.     

Verminderte Wirksamkeit von Atracurium bei Patienten mit intrathorakalem Eiterherd

Objective: Based on personal observations the neuromuscular blocking potency of atracurium was supposed to be diminished in purulent intrathoracic diseases. This hypothesis was tested in a prospective clinical trial. Methods: 52 adult patients undergoing general anaesthesia (methohexitone, sufentanil, flunitrazepam, N₂O, enflurane) for elective thoracic surgery were investigated. After the intubation dose of 0.6?mg/kg atracurium was applied continuously to maintain a 90% suppression of the evoked compound electromyogram. According to the intraoperatively established diagnosis patients were allocated to three categories: 1) non-malignant tumor as the control group (n=15), 2) lung cancer (n=22), 3) purulent intrathoracic process without tumor (n=15). The groups were compared regarding onset time, DUR 10% and maintenance dose of atracurium. Results: Patients with lung cancer did not differ significantly from the controls regarding efficiency of atracurium. In contrast, patients with a purulent intrathoracic process showed a significantly longer onset time (6.3±2.5?vs. 2.9±0.8?min, p<0.001), and a significantly shorter DUR 10% (23±6?vs. 36±10?min, p<0.001) compared to the control group. Mean infusion rate of atracurium to maintain a 90% suppression of the evoked compound electromyogram was significantly higher in patients with a purulent process compared to the controls (10.5±3.2?vs. 6.0±1.2?μg/kg.min, p<0.001). Conclusion: Our results support the hypothesis that patients with a purulent intrathoracic disease show a clear reduction in neuromuscular blocking potency of atracurium.     

Self-learning fuzzy control of atracurium-induced neuromuscular block during surgery

Self-learning fuzzy logic control has the important property of accommodating uncertain, non-linear and time-varying process characteristics. This intelligent control scheme starts with no fuzzy control rules and learns how to control each process presented to it in real time, without the need for detailed process modelling. A suitable medical application to investigate this control strategy is atracurium-induced neuromuscular block (NMB) of patients in the operating theatre. Here, the patient response exhibits high non-linearity, and individual patient dose requirements can vary five-fold during an operating procedure. A portable control system was developed to assess the clinical performance of a simplified self-learning fuzzy controller in this application. A Paragraph (Vital Signs) NMB device monitored T₁, the height of the first twitch in a train-of-four nerve stimulation mode. Using a T₁ setpoint=10% of baseline in ten patients undergoing general surgery, a mean T₁ error of 0.45% (SD=0.44%) is found while a 0.13–0.70 mg k⁻¹ h⁻¹ range in the mean atracurium infusion rate is accommodated. The result compares favourably with more complex and computationally-intensive model-based control strategies for the infusion of atracurium.     

比较静脉普鲁卡因复合麻醉下阿曲可林和琥珀胆碱的肌松效应及时量关系

24例ASA I～Ⅱ级成年手术病人随机分为两组。静脉普鲁卡因复合芬太尼麻醉分别辅以阿曲可林和琥珀胆碱持续静脉滴注。结果:①阿曲可林起效时间及维持时间明显长于琥珀胆碱,气管插管以琥珀胆碱为佳;②阿曲可林和普鲁卡因时量关系一致。琥珀胆碱组有7例产生耐药性,耐药组琥珀胆碱与普鲁卡因时量关系不一致;③阿曲可林静滴停药后的恢复时间与耐药组恢复时间无明显差异,无耐药组恢复时间明显比其它组快。     

盐酸戊乙奎醚作为术前用药对阿曲库铵肌肉松弛作用的影响

目的观察盐酸戊乙奎醚（长托宁）作为术前用药对阿曲库铵肌肉松弛作用的影响。方法选择90例无脑、心、肺、肝、肾和神经及肌肉代谢性疾病的男性全麻患者,随机分为阿托品0.5mg组（A组）、盐酸戊乙奎醚0.5mg组（B组）和盐酸戊乙奎醚1.0mg组（C组）。插管前30min按分组术前用药,观察肌肉松弛药的起效时间、临床作用时间、恢复指数、95%恢复时间及T4：T1≥0.75恢复时间。结果C组和A、B组比较阿曲库铵起效时间显著缩短,差异有显著性意义（P〈0.05）;临床作用时间、T4：T1≥0.75时间及25%～75%恢复时间无明显差异,95%恢复时间C组较A和B组延长,但差异无显著性意义（P〉0.05）。A和B组间各项观测指标差异均无显著性意义。结论盐酸戊乙奎醚作为术前用药更适合仅使用非去极化肌肉松弛剂作为肌肉松弛诱导的全麻患者。