神经肌肉阻断剂PPT.ppt

1 1 CLINICAL PHARMACOLOGY OF NEUROMUSCULAR BLOCKING AGENTS Jerrold H. Levy, MD Professor of Anesthesiology Emory University School of Medicine Division of Cardiothoracic Anesthesiology and Critical Care Emory Healthcare Atlanta, Georgia HISTORY OF NEUROMUSCULAR BLOCKING AGENTS AND CLINICAL DEVELOPMENT HISTORY 1494 - Tales of travelers killed by poison darts 1551 - Ourari” or “cururu” meaning “bird killer” 1812 - Curarized cat kept alive by artificial respiration 1912 - Curare used to prevent fractures during ECT 1941 - Initial use by Griffith, Culler, and Rovenstine 1951 - Succinylcholine chloride first used in Stockholm INTRODUCTION OF NEW DRUGS 1494 - 1942 Curare 1947 - 1951 Succinylcholine chloride, Gallamine, Metocurine, Decamethonium 1960’s Alcuronium 1970’s Pancuronium bromide, Fazadinium 1980’s Vecuronium bromide, Atracurium besylate 1990 Pipecuronium bromide 1991 Doxacurium chloride 1992 Mivacurium chloride 1994 Rocuronium bromide 1999 Rapacuronium bromide STRUCTURAL CLASSES OF NONDEPOL.ARIZING RELAXANTS Steroids: Rocuronium bromide, Vecuronium bromide, Pancuronium bromide, Pipecuronium bromide Naturally occurring benzylisoquinolines: curare, metocurine Benzylisoquinoliniums: Atracurium besylate, Mivacurium chloride, Doxacurium chloride Neuromuscular Blocking Agents and Patient Evaluation Assessing Postoperative Neuromuscular Function Sustained 5-second head lift Ability to appose incisors (clench teeth) Negative inspiratory force – 40 cm H2O Ability to open eyes wide for 5 seconds Hand-grip strength Sustained arm/leg lift Quality of speaking voice Tongue protrusion Assessing Postoperative Neuromuscular Function CLINICAL ASSESSMENT Kopman AF, et al. Anesthesiology, 1997:86;765 Ali HH, et al. Br J Anaesth. 1975;47:570 Assessing Postoperative Neuromuscular Function Train-of-Four (TOF) Fade Ratio 99 97 100 100% 95 91 100 90% 94 88 100 80% 92 82 97 70%* 95 70 91 60% 100 100 100 Control =100 Peak Exp. Flow Rate Inspiratory Force Vi