小兒肌松綜述報(bào)告

1、麻醉科-劉海娥,嬰幼兒患者合理應(yīng)用肌松劑的研究進(jìn)展,2,0,1,8,,內(nèi)容,不用肌松藥行氣管插管術(shù),,肌松藥分類,,基于患兒病情選擇肌松藥,,摘 要,各類肌松藥在嬰幼兒中的應(yīng)用情況及研究進(jìn)展進(jìn)行 綜述 不同的麻醉藥物與肌松藥之間的相互作用 不使用肌松藥行氣管插管術(shù)在嬰幼兒患者中的應(yīng)用 情況 肌松藥謹(jǐn)慎合理應(yīng)用,1,2,3,4,關(guān)

2、鍵 詞,肌肉松弛藥；嬰幼兒；合理應(yīng)用,前 言,1942年肌松劑首次在美國用于輔助氣管插管近年來肌松劑在小兒麻醉中的使用明顯下降臨床麻醉中，特殊患者在選擇肌松藥種類和劑量等多方面，有其特殊性不同種類的肌松藥在不同手術(shù)中應(yīng)用都有其利弊，現(xiàn)綜述各類在嬰幼兒中應(yīng)用的最新進(jìn)展,肌肉松弛藥,神經(jīng)肌肉接頭前膜和后膜乙酰膽堿受體,肌松藥作用于接頭后膜受體,阻滯神經(jīng)肌肉興奮正常傳遞,產(chǎn)生肌肉松弛,,,,,,,分類：,1,

3、非去極化肌松藥,甾體類,芐異喹啉類,如;維庫溴銨、羅庫溴銨、順阿曲庫銨等,2,去極化肌松藥,如：琥珀膽堿,,,,代謝產(chǎn)物有肌松作用,,,,,,,,琥珀膽堿,,對小兒的5項(xiàng)研究中發(fā)現(xiàn)，羅庫溴銨和琥珀膽堿在創(chuàng)造絕佳的氣管插管條件（危險(xiǎn)率0.86， 95%CI （0.70-1.06），n=536，I²=81%）上沒有統(tǒng)計(jì)學(xué)差異。Tran, D.T.T., et al., Rocuronium vs. succinylcholine

4、 for rapid sequence intubation: a Cochrane systematic review. Anaesthesia, 2017. 72(6): p. 765-777因此琥珀膽堿在小兒的使用目前地位仍需要進(jìn)一步研究。,,米庫溴銨,是臨床上唯一可以使用的短效非去極化肌松藥 恢復(fù)迅速

5、Ruifeng Zeng等人發(fā)現(xiàn)在于2-12個(gè)月的小兒，將米庫溴銨的劑量增加使其起效時(shí)間可以加快30sZeng, R., et al., The efficacy and safety of mivacurium in pediatric patients .BMC Anesthesiol. 2017 Apr 17;17(1):58與靜脈藥聯(lián)合明顯加快起效時(shí)間,,特點(diǎn),時(shí)效短,無蓄積,,阿曲庫銨,阿曲庫銨的副作用主

6、要與其組胺的釋放有關(guān),,適用于大多數(shù)兒科手術(shù),順式阿曲庫銨,研究發(fā)現(xiàn)：術(shù)后通氣時(shí)間和重癥監(jiān)護(hù)停留時(shí)間與羅庫溴銨相似，但其能夠有效拓展小兒心臟外科快通道麻醉中的芬太尼劑量范圍，延長肌松藥停藥時(shí)間，值得推廣。張與晏馥霞, 順式阿曲庫銨在小兒心臟外科快通道麻醉中的應(yīng)用. 中國醫(yī)刊2016. 51(6): 第76-78頁副作用是起效相對較慢,,維庫溴銨,大劑量副作用也相對較少，故而常被用于ICU患兒長期維持肌肉松弛作用Playfor,

7、 S., et al., Consensus guidelines for sustained neuromuscular blockade in critically ill children嬰幼兒不成熟器官肌松維持延長因而維庫溴銨可能更適合用于較年長兒童,,羅庫溴銨,隨著肌松藥拮抗劑Sugammadex（舒更葡糖）在臨床的使用，使得羅庫溴銨的使用得到更進(jìn)一步的增加,特點(diǎn),起效快,對心臟影響甚微,注射痛,,預(yù)先利多或瑞芬,,廣

8、泛使用,,筆者認(rèn)為雖該研究僅基于體外實(shí)驗(yàn)且其機(jī)制尚未清楚，但對肝功能尚不成熟的嬰幼兒及肝功有障礙的患者應(yīng)在使用羅庫溴銨時(shí)應(yīng)謹(jǐn)慎選擇,謹(jǐn)慎使用,,泮庫溴銨,泮庫溴銨作為長效的非去極化肌松藥，劑量在新生兒中應(yīng)減量。Playfor, S., et al., Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediat

9、r Anaesth. 2007 Sep;17(9):881-7,,呼吸道并發(fā)癥,,合并心臟病慎用,麻醉藥物與肌松藥間的相互作用,肌松劑與靜脈麻醉藥物：沒有直接的影響作用 肌松藥與吸入性麻醉藥物：加強(qiáng)效應(yīng) WOLO等人發(fā)現(xiàn)七氟烷可以增強(qiáng)羅庫溴銨誘導(dǎo)的肌松作用。同時(shí)也延長肌松藥的恢復(fù)時(shí)間,,,不使用肌松藥下行氣管插管術(shù),管理小兒困難氣道時(shí)被廣泛接受美國1999年的一項(xiàng)

10、調(diào)查發(fā)現(xiàn)，對嬰幼兒及兒童選擇吸入麻醉誘導(dǎo)后不使用肌松藥物分別占38.1%和43.6%Rizvanovi N等人發(fā)現(xiàn)相比使用肌松藥組，氣管插管誘導(dǎo)使用芬太尼和丙泊酚方案使得患兒的血流動力學(xué)更加穩(wěn)定。不使用肌松藥下行氣管插管術(shù)仍存在爭議,基于患兒病情選擇肌松藥,存在先天性神經(jīng)肌肉疾病，急癥創(chuàng)傷、燒傷、脊髓損傷患者禁用琥珀膽堿肌無力綜合征病人對肌松藥都十分敏感肌強(qiáng)直綜合征病人對非去極化肌松藥反應(yīng)雖正常，但較正常人易發(fā)生術(shù)后呼吸

11、抑制；而對去極化肌松藥，可能引起全身肌肉痙攣性收縮而影響呼吸道通暢和通氣重癥肌無力選用去極化型藥更佳,,References: [1].Meakin, G.H., Role of muscle relaxants in pediatric anesthesia.. [2].Honsel, M., C. Giugni and J. Brierley, Limited professional guidance and lite

12、rature are available to guide the safe use of neuromuscular block in infants. [3].Aouad M, Y.V.M.C. and K.R. Siddik-Sayyid S, Te e?ect ofadjuvant drugs on the quality of tracheal intubationwithout muscle relaxants in

13、 children: a systematicreview of randomized trials. Paediatr Anaesth 22:616-26, 2012. [4].Woods, A.W., Tracheal intubation without the use of neuromuscular blocking agents. British Journal of Anaesthesia, 2005. 94(2):

14、 p. 150-158. [5].Tran, D.T.T., et al., Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia, 2017. 72(6): p. 765-777. [6].Kaye, A.D., et al., Pharmacologic Cons

15、iderations of Anesthetic Agents in Pediatric Patients. Anesthesiology Clinics, 2017. 35(2): p. e73-e94. [7].Kim, Y.B., T. Sung and H.S. Yang, Factors that affect the onset of action of non-depolarizing neuromuscular bl

16、ocking agents. Korean Journal of Anesthesiology, 2017. 70(5): p. 500. [8].Tracheal Intubation of Healthy Pediatric Patients Without Muscle Relaxant: A Survey of Technique Utilization and Perceptions of Safety. [9].Mi

17、gita, T., et al., The severity of sevoflurane-induced malignant hyperthermia..[10].Devys, J.M., et al., Intubating conditions and adverse events during sevoflurane induction in infants.[11].Kim, E., et al., The media

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20、ldren undergoing general anesthesia with sevoflurane: a meta-analysis. Brazilian Journal of Anesthesiology (English Edition), 2017. 67(2): p. 193-198.[14].Wulf H, K.M.L.T., Augmentation of neuromuscularblocking effect

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27、de in critically ill children.[23].The neuromuscular blocking properties of a newsteroid compound, pancuronium bromide: a pilot study in man. Br J Anaesth, 1967(39): p. 775–780.[24].張與晏馥霞, 順式阿曲庫銨在小兒心臟外科快通道麻醉中的應(yīng)用. 中國

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29、itro. European Journal of Anaesthesiology, 2017. 34(9): p. 623-627.[27].NAUHEIMER, D., et al., Muscle relaxant use for tracheal intubation in pediatric anaesthesia: a survey of clinical practice in Germany. Pediatric A

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