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硬膜外麻醉对维库溴铵肌松作用的影响
The effect of epidural block on vecuronium induced neuromuscular block

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DOI:
作者:
黄丽娜，汪正平， 马皓琳，李士通，庄心良
Huang Lina, Wang Zhengping, Ma Haolin, Li Shitong,
作者单位:
上海交通大学附属第一人民医院
Shanghai First People’s Hospital, Medical College, Shanghai Jiao Tong University, Shanghai 200080, China
关键词:
硬膜外麻醉；加速度监测仪；踇短屈肌；拇内收肌；维库溴铵
Epidural anesthesia; Acceleromyography; Adductor pollicis; Flexor hallucis brevis; Vecuronium
摘要:
〔摘要〕目的：观察拇内收肌和足拇短屈肌在单纯全麻（GA）以及全麻联合硬膜外麻醉（cGEA）下的恢复情况，并探讨硬膜外麻醉对肌松作用的可能机制。方法：选择行腹式全子宫切除术病人40例，ASAⅠ～Ⅱ级，分入GA组和cGEA组。cGEA组选取L1-L2行硬膜外穿刺，插管完成后10min开始追加局麻药利布合液。麻醉诱导用咪达唑仑2mg、芬太尼0.1mg～0.15mg和异丙酚效应室靶浓度2.5～3μg/ml靶控输注。单次肌颤搐高度稳定在100%左右时，静注维库溴铵0.1 mg/kg完成气管插管。连续刺激尺神经和胫后神经，应用TOF－WATCH SX加速度仪(Organon公司，荷兰)监测4个成串刺激（TOF）及单刺激肌颤搐（T1/Tc）。间断芬太尼、靶控输注异丙酚3～5μg/kg复合吸入笑气维持麻醉。分别记录起效时间，TOF中T1、T2、T3、T4出现的时间, 及TOFR恢复至25%、50%、75%及90%的时间，及给药后每5分钟记录一次T1/Tc值。当TOFR=0.9时，拔管。术后于PACU内评价患者的Bromage运动阻滞评分。结果：首次追加后,拇指的T2、T3、T4出现的时间及临床时效在cGEA组长于GA组；足拇短屈肌在两组间没有差异。末次加药后，拇内收肌T1、T2、T3、T4出现时间以及TOFR恢复到25％以及90％的时间cGEA组长于GA组；而足踇短屈肌在两组间无差异。末次加药后，各时间点对应的TOFR及T1/Tc值，无论在拇内收肌还是在足拇短屈肌均为cGEA组小于GA组。结论：硬膜外阻滞会加速维库溴铵的起效，减慢恢复，但硬膜外阻滞不能改变拇内收肌和足拇短屈肌肌松的对应关系。
〔Abstract〕Objective: To study the effect of epidural block on vecuronium-induced neuromuscular block by observing the time-course of recovery of thumb and toe under pure general anesthesia (GA) or combined general and epidural anesthesia (cGEA). Methods: Forty patients ASA Ⅰ-Ⅱ， scheduled for abdominal total hysterectomy， were studied and were aT1/Tcigned to Group GA and Group cGEA.Patients in Group cGEA underwent epidural puncture at L1-L2. And 10 minutes after intubation, local anesthetics were administered . General anesthesia was induced with midazolam 2 mg, fentanyl 0.1mg～0.15mg and propofol given by target-controlled infusion (TCI) at a concentration of 2.5～3ug/ml. After calibration and singletwitch stimulation height (T1/Tc）was stabilized at 100%, 0.1 mg/kg vecuronium was administered to facilitate tracheal intubation. Ulnar nerve and tibial nerve was stimulated respectively；TOFR and T1/Tc were measured with the TOF－WATCH SX acceleromyograph simultaneously. Anesthesia were maintained with propofol 3～5ug/ml given by TCI, fentanyl given by bolus infusion and nitrous oxide 50%. Repetitive vecuronium was given when TOFR at the thumb recoverd to 25%. Onset times and the times to return of T1,T2,T3,T4 ,and the times of TOFR=25%、50%、75%、90% were recorded. T1/Tc were recorded every 5 minutes. When patients were transferred to PACU, Bromage scores were evaluated. Results: The times to return of T2,T3,T4 and durations of action after first repeated administration were longer at the thumb in Group cGEA than in Group GA, while there was no difference at the toe. The times to return of T1,T2,T3,T4,and the times of TOFR recovering to 25% and 90% were longer at the thumb in Group cGEA than in Group GA. And in two muscle groups, TOFR and T1/Tc were smaller in in Group cGEA than in Group GA all times. Conclusions: Epidural anesthesia can accelerate the onset, and delay the recovery of neuromuscular function, but cannot change the relationship between thumb and toe.

 

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