肌松药的使用

心系人民健康忠诚保健事业NeuromuscularmanagementandpatientoutcomesbyGlennMurphyM.D.2014ASAPostoperativeresidualneuromuscularblockadeisacommoncomplicationobservedinthepostanesthesiacareunit(PACU)aftergeneralanesthesia.Recentlarge-scaleclinicalinvestigationshavedemonstratedthatupto24%to42%ofsurgicalpatientsarriveinthePACUwithevidenceofincompleteneuromuscularrecovery.Althoughmostcliniciansarenowusingintermediate-actingmusclerelaxants,theriskofresidualneuromuscularblockdoesnotappeartobedecreasingovertime.术后肌松阻滞残留是全麻后发生在PACU的一个常见并发症。最近的大型临床研究显示有24%到42%的外科患者在达到PACU时，肌松恢复不完全。虽然很多临床大夫现在应用的是中效肌松药，不过肌松阻滞残余的风险似乎并没有因此而降低。Severallargedatabasestudieshaveshownanassociationbetweenneuromuscularblockingagent(NMBA)useandanincreasedriskofmorbidityandmortalityintheearlyperiodaftersurgery.RecentclinicaltrialshavedemonstratedthatresidualneuromuscularblockinthePACUresultsinairwayobstruction,hypoxemia,andpulmonarycomplicationsduringrecoveryfromgeneralanesthesia.PatientswithresidualblockareatriskforunpleasantsymptomsofmuscleweaknessandprolongedPACUadmissiontimes.很多大样本数据研究显示肌松药和术后早期并发症发生率和死亡率的增高有明显关系。最近的临床试验也显示全麻术后患者在PACU期间的肌松阻滞残留会导致气道梗阻、缺氧和呼吸系统并发症。有肌松阻滞残留的患者也面临肌肉乏力的不适感和PACU停留时间延长的问题Carefulmanagementofneuromuscularblockadeintheoperatingroommayreducetheincidenceofpostoperativeresidualparalysisandthecomplicationsassociatedwithresidualblock.SeveralprinciplesrelatedtoNMBAdosing,monitoring,andreversalhavebeenshowntoreducetheriskofincompleteneuromuscularrecoveryinpostoperativepatients.Theaimofthisreviewistoprovidea“best-availableevidence”assessmentofmethodsthatcanbeusedbyclinicianstoreducetheriskofcomplicationsduetoresidualneuromuscularblockade.手术间内对肌松药使用的认真管理有可能降低术后肌无力的发生率和与肌松残留相关的并发症发生率。研究表明一些与NMBA剂量、监测和拮抗有关的管理原则可以降低术后肌松恢复不完全的风险。这篇综述的目的是提供一个“好的和可行”的评估方法，从而指导临床大夫降低与肌松残留相关的并发症发生的风险。Q1:Doesqualitativeneuromuscularmonitoringreducetheriskofresidualblock?Asubjective(qualitative)visualortactileassessmentofamuscularresponsetoperipheralnervestimulationisthemostcommonmethodofneuromuscularmonitoringusedintheOR.Pedersenetal.randomized80subjectstoreceiveeitherTOFmonitoringornoneuromuscularmonitoring(clinicalcriteriasuchasbreathingormoving).MedianTOFratiosof0.75and0.79wereobservedinthetwogroupsonarrivaltothePACU(nodifference).Q1:定性肌松监测可以降低肌松残留的发生风险吗？客观上感知患者对外周神经刺激的反应是手术间里最常用的一种肌松监测方法。Pedersen等将80名患者随机分配接受TOF监测或非肌松监测（临床标准：呼吸或活动动度）。达到PACU时两组患者的TOF中位值分别是0.75和0.79，没有区别。AsimilarstudydemonstratedthattheproportionofpatientswithTOFratios0.7wassignificantlylessinamonitoredgroup(15%)comparedtounmonitoredpatients(47%).Anotherrandomizedtrialdemonstratedthattactileevaluationoftheresponsetodouble-burststimulation(DBS)reduced,butdidnoteliminate,theoccurrenceofresidualparalysis.SignificantlyfewerpatientsinthemonitoredgrouphadTOFratios0.7(24%)comparedtotheunmonitoredgroup(57%).一项相似的研究显示：肌松监测组患者到达PACU时TOF0.7的比例（15%）要明显低于没有监测组（47%）。另一项随机试验显示感觉患者对双爆发刺激（DBS）的反应可以降低，但不能消除残留肌松的发生。有肌松监测组的患者TOF0.7的概率（24%）要低于没有肌松监测组的患者（57%）。Q2:Doesquantitativeneuromuscularmonitoringreducetheriskofresidualblock?Astudyshowedduring40patients,thereare50%patientsinthenomonitoringhadTOFratios0.7inthePACU,comparedtoonly5.3%intheAMG(acceleromyograph)group.Aanotherstudyshowedthat17%ofpatientsinthenomonitoringgrouphadresidualblock(definedasaTOF0.8)comparedtoonly3%intheAMGgroup.Q2:定量肌松监测降低肌松残留的发生风险吗？一项研究显示在40例患者中，在PACU期间在非监测组有50%的患者TOF0.7，而在加速度仪监测组只有5.3%的患者TOF0.7.另一项研究显示非监测组有17%的患者有肌松残留（定义为TOF0.8），而加速度仪组只有3%的患者有肌松残留Inthelargeststudy,185patientswererandomizedtoreceiveeitherstandardqualitativemonitoring(peripheralnervestimulator)orAMGmonitoring(TOF-Watch).30%ofpatientsintheformergrouphadaTOFratio0.9inthePACU,versusonly4.5%intheAMGgroup.在一项大样本研究中，185例患者被随机分配为标准定性监测（外周神经刺激）或者AMG监测（TOF-Watch）。前一组中有30%的患者在PACU期间TOF0.9，而AMG组只有4.5%的患者TOF0.9Q3:Canneuromuscularmonitoringimpactpostoperativerecovery?Althoughthereisevidencethatqualitativemonitoringcanreducetheriskofpostoperativeresidualblock,atthepresenttimethereisnodatademonstrationthatthistypeofmonitoringimprovesclinicaloutcomes.Incontrast,thereisemergingevidencethatintraoperativequantitativemonitoringcanbeneficiallyimpactpostoperativerecoveryinsurgicalpatients.MortensenetalnotedthatpatientsrandomizedtoreceiveAMGmonitoringhadfewerclinicalsignsofmuscleweaknessinthePACU.Q3:神经肌肉监测可以反应术后的恢复情况吗？虽然有证据表明定性的监测可以降低术后肌松残留的风险，不过目前，还是没有数据说明这种监测可以改善临床愈后。与此相反，有证据提示术中的肌松定量监测对手术患者的术后恢复有一定好处。Mortensen等发现接受AMG监测的患者在PACU期间很少表现出肌肉乏力的临床征象。Astudyshowedthatasignificantlyhigherincidenceofhypoxemiaevents(oxygensaturation90%)andairwayobstructionwasobservedintheperipheralnervestimulatorgroup(21.1%and11.1%)comparedtotheAMGgroup(0%and0%)inPACU.PatientsrandomizedtoreceiveAMGmonitoringhadsignificantlyfewersymptomsofmuscleweaknessinthePACUduringthefirst60minutes,andoverallqualityofrecoveryatthetimePACUdischargewassignificantlyimprovedinthesepatients.一项研究显示与AMG组（0%和0%）相比，仅接受外周神经刺激监测的患者在PACU期间发生低氧血症（SPO290%）和呼吸道梗阻的概率明显增高。AMG组的患者，在PACU期间的第一小时内，肌无力的症状较少，从PACU出去时的恢复质量也明显较高。Q4:Shouldananticholinesterasereversalagentbeadministeredtomostpatientsattheendofsu