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罗库溴铵、维库溴铵和阿曲库铵术后残留作用的对比研究

时间:2010-08-24 11:31:36  来源:  作者:

Research of Postoperative Residual Curarization of Rocuronium: A Comparison with Vecuronium and Atracurium<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

孟冬祥*  周书元*  陈雪华#
赵诗斌
*  王 远#  李爱青#  贾乃光*
中日友好医院 麻醉科,北京 100029
北京潞河医院 麻醉科,北京 101100
Dong-xiang Meng*, Shu-yuan Zhou*, Xue-hua Chen#, Shi-bin Zhao*, Yuan Wang#,Ai-qing Li#, Nai-guang Jia
*Department of Anesthesiology, China-Japan Frienfship Hospital, Beijing 100029,China
# Department of Anesthesiology, Beijing Luhe Hospital, Beijing 101100,China

ABSTRACT

Objective:To compare the postoperative residual curarization (PORC) of rocuronium (ROC), vecuronium (VEC) and atracurium (ATR).
Methods60 ASA I-II patients for elective surgery were randomly allocated into ROC, VEC or ATR group, respectively. All patients received a combined anesthesia with propofol, fentainyl, isoflurane and N2
O. The 2×ED95 of rocuronium (600mg•kg-1, ROC group), vecuronium (120mg•kg-1, VEC group) or atracurium (500mg•kg-1, ATR group) was given during anesthesia induction (20 in each group). Neuromuscular blockade was continuously evaluated with train-of-four stimuli (TOF) during operation. As TOF rate (TOFR) reached 0.1, the 1×ED95 muscle relaxant was added. Anesthetists were blind to the muscle relaxants. After operation, the patient recovered spontaneously. Tracheal extubation trigger was defined as that patient was able to open his/her eyes and to raise his/her arm and head for 5s.
Results:
Effect duration of last dose of vecuronium(106.4±20.1min)was longer than that of rocuronium(82.6±8.5min, p<0.01)and atracurium(85.1±10.9min, p<0.05). The TOFR at the time of tracheal extubation in VEC, ROC and ATR groups were 0.60±0.17, 0.61±0.09 and 0.66±0.11(p>0.05), respectively. The duration of residual neuromuscular blockade of atracurium (15.0±9.5min) was shorter than vecuronium (24.4±11.0min, p<0.01) and rocuronium (21.6±14.2min, p<0.05).
Conclusions
All three kinds of non-depolarizing muscle relaxant have the risk of PORC after tracheal extubation under the guidance of clinical judgment.
Key wordsAnesthesia; Neuromuscular blocking agents, vecuronium, rocuronium and atracurium; Neuromuscular blockage
Corresponding author:Dong-xiao Meng,MD; E-mail: dxmeng@yahoo.com.cn

  临床上气管内插管全身麻醉后多数情况下没有以肌松监测的客观指标作为术后气管导管拔管的指征,而是凭借经验来决定是否可以拔管[1]。非去极化肌松药的体内残留以及代谢产物可能存在的药理作用,使得手术患者产生“术后残留箭毒化作用”[Postoperative residual curarization (PORC)],这种残留肌松作用有使气管拔管后病人产生肺部并发症,发生呼吸抑制的危险[2]。本文旨在研究依据临床标准拔除气管导管后体内肌松作用的残留情况并对甾类肌松药维库溴铵、罗库溴铵和苄异喹啉类肌松药阿曲库铵的术后残留进行比较。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

临床资料和方法

  1.临床资料
  (1)病例选择
  选择需要进行气管插管全身麻醉,
ASA I-II,年龄18~65岁,体重45~100kg的择期手术病人60例随机分配到维库溴铵组(VEC),罗库溴铵组(ROC)或阿曲库铵组(ATR)。若术前存在各种原因所致的神经肌肉麻痹、严重肝肾功能障碍、胆道梗阻、血色素<80g•L-1,以及手术可能影响神经肌肉恢复、术中发生严重呼吸循环功能紊乱、术后需要继续控制或辅助呼吸的患者不列入本研究的范畴。病例入选结果为:男33例,女27例,年龄47.6±10.9岁(28~65岁),体重65.6±10.6 kg(45~95 kg),外科手术有普外科39例,神经外科12例,泌尿外科8例和整形外科1例。

  2.方法
  (1)麻醉方法
  病人入室后开放上肢静脉,经三通连接输液系统。术前
30min静脉注射咪唑安定40μg•kg-1和东莨菪碱0.3mg。术中常规监测心电图、无创血压、心率、SpO2EtCO2。快速顺序诱导麻醉,先后静脉给予芬太尼3μg•kg-1,异丙酚2mg•kg-1,氯化琥珀胆碱1.5mg•kg-1。气管插管确认无误后静脉注射2×ED95非去极化肌松药: VEC组,维库溴铵(荷兰欧加农,批号509502)120μg•kg-1;ROC组:罗库溴铵(荷兰欧加农,批号176151)600μg•kg-1ATR组,阿曲库铵(江苏恒瑞,批号03012213)500μg•kg-1。维持麻醉:吸入1.5%异氟醚和66% N2O,切皮开始追加芬太尼1.5μg•kg-1,以后每1h追加1次。根据四个成串刺激(train-of-four, TOF)肌松监测结果,当TOF值(TOFR,即T4/T1)达0.1时,各组分别追加1×ED95维库溴铵60μg•kg-1、罗库溴铵300μg•kg-1或阿曲库铵250μg•kg-1手术结束前15min停异氟醚,术毕停N2O,立即送回麻醉恢复室,不用肌松拮抗剂和中枢兴奋剂,如果患者没有自主呼吸或自主呼吸很弱,用呼吸机控制或辅助呼吸,并逐步由SIMV模式过渡到CPAP模式,最后脱离呼吸机。当患者呼之睁眼,抬臂和抬头能持续5s时拔除气管导管。

 

  (2)肌松监测与观察
  用Datex-Ohmeda监护仪(芬兰,产品型号:F-CU8-22-05)进行TOF肌松监测(2Hz/s、60mA、间隔20s)。病人诱导入睡后监测开始并连续进行,当TOFR0.1时追加肌松药,术毕监测停止,拔管后肌松监测恢复,并持续到TOFR0.75时终止。记录最后一次肌松药至TOFR0.75所用时间,拔管即刻的TOFR,患者能抬臂、抬头持续5s(即拔管时刻)至TOFR0.75所用时间。
  (3)随机和单盲方法

  根据手术安排的先后,随机选择需要进行气管插管全身麻醉的病例60例顺序进入
VEC、ROC和ATR 三个试验组,每组20例。由不参与试验的专人将3种肌松药配制成只需等容积给予的药物浓度交由麻醉者使用,后者不知所用肌松药的具体内容。
  (4) 数据处理
  试验中的观察数据除拔管时各组
TOFR0.75或≥0.75的病例数为计数资料外, 其余数据均为计量资料并用均数±标准差(±s)表示。用SPSS8.0统计软件对计量资料进行单因素方差分析,计数资料进行χ2检验。 p<0.05和p<0.01分别表示具有统计学差异和非常显著的统计学差异。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

  果

  1.临床资料统计
  各组之间年龄、体重、性别分布无统计学差异。
  2. 麻醉情况
  麻醉时间及术中麻醉性镇痛药芬太尼用量见表1。各组间相互比较,平均麻醉时间、芬太尼总量及每公斤体重每小时芬太尼用量无统计学差异p>0.05)。术中异氟醚吸入浓度1.5%,N2O吸入浓度66%。异丙酚2mg•kg-1和琥珀酰胆碱1.5mg•kg-1仅在麻醉诱导时给予。
  3. 肌松监测结果
  最后一次追加肌松药至
TOFR0.75所需时间(末次肌松药作用时间)、拔管即刻的TOFR以及从拔管到TOFR0.75所需时间(肌松残留时间)见表2。从表2得知,维库溴铵末次给药作用维持时间长于罗库溴铵p<0.01)和阿曲库铵p<0.05);拔管即刻的TOFR各组间无统计学差异(p>0.05),拔管即刻TOFR<0.75例数(肌松残留者)经χ2检验各组间无统计学差异(p>0.05);肌松残留时间,阿曲库铵短于维库溴铵p<0.01)和罗库溴铵(p<0.05)。

  总之,无论使用何种非去极化肌松药,都应该注意术后肌松残留作用的存在,尤其在依据临床指征拔除气管导管时更有可能发生肌松药的术后残留。使用肌松监测仪是防止术后肌松残留引起呼吸抑制的有效方法。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

参 考 文 献
1. Cammu G, de Baerdemaeker L, den Blauwen N, et al. Postoperative residual curarization with cisatracurium and rocuronium infusions. Euro J Anaesth, 2002, 19(2):129-134.
2.  McCaul C, Tobin E, Boylan JF, et al. Atracurium is associated with postopera tive residual curarization. Br J Anaesth, 2002, 89(5):766-769.
3. Scott Jellish W, Brody M and Slogoff S. Recovery from neuromuscular block ade after either bolus and prolonged infusion of cisatracurium or rocuronium   using either isoflurane or propofol-based anesthetics. Anesth Analg, 2000, 91  (5): 1250-1255.
4. Baillard C, Gehan G, Reboul-Marty J, et al. Residual curarization in the recov  ery room after vecuronium. Br J Anaesth, 2000,84(3):394-395.
5. Van Odenbeek C, Knowles P and Harper NJN. Residual neuromuscular block caused by pancuronium after cardiac surgery. Br J Anaesth, 1999,83(2):338-339.
6. Mellinghoff H, Radbruch L, Diefenbach C, et al. A comparison of cisatracurium and atracurium:onset of neuromuscular block after bolus injection and recov  ery after subsequent infusion. Anesth Analg, 1996,83(5):1072-1075.
7. Mayer M, Doenicke A, Hofmann A, et al. Onset and recovery of rocuronium (Org9426) and vecuronium under enflurane anaesthesia. Br J Anaesth,
1992,69(3):511-512.

  孟冬祥,男,1958年生,中日友好医院麻醉科副主任医师。

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