13例胸腺瘤合并重症肌无力手术的异丙酚—阿曲库铵麻醉

The Study of the Anesthesia with Propofol-Atracurium in Operations on the Patients with Thymoma Combining Myasthenia Gravis

目的:探讨胸腺瘤合并重症肌无力的患者手术麻醉中,应用非去极化肌松剂-阿曲库铵的可行性剂量及恢复程度。方法:13例胸腺瘤合并明显重症肌无力患者,为实验组(I组)。术前口服抗胆碱酯酶药物及激素预处理。入手术室后在肌松监测仪监测下静注阿曲库铵0.5m g/kg,并记录4个串刺激完全消失时间,后维持追加阿曲库铵0.2m g/kg。手术结束后均用新斯的明拮抗。无合并重症肌无力的胸腺瘤患者14例为对照组(Ⅱ组)。结果:Ⅰ组患者给肌松药后起效时间为下降至20%以下为1m in50s,维持时间25～35m in。Ⅱ组起效时间为2m in5s,维持时间为约20～30m in。能达到肌松较完全(T1<25%)者,Ⅰ组约为96%～98%,Ⅱ组为80%～90%。手术结束后Ⅰ组用新斯的明0.05m g/kg、阿托品0.02m g/kg拮抗残余肌松作用,效果不明显者10m in再追加1次。Ⅱ组用同样剂量拮抗10m in内T4/T1比值达到0.75,达到拔管标准,不需再追加拮抗剂。结论:术前应用激素及抗胆碱酯酶药物作为预处理,对控制症状、改善全身情况、有积极作用。术前虽然使用抗胆碱酯酶物治疗,但并未明显降低阿曲库铵的敏感性。此外,手术后用新斯的明拮抗残余肌松时需仔细监测,并酌情增大拮抗药剂量才能完全恢复以保证患者安全。

Objective: To investigated the feasible dose and the recovery degree of non-depolarized muscle relaxant atracurium in the patients with thymoma combining myasthenia gravis during anesthesia course. Methods: Twenty-seven patients were selected and divided into two groups at random. GroupⅠwas the trial group, in which 13 cases had obvious myasthenia gravis symptom. These patients received anti-cholinesterase drug orally and hormone treatment before operation. In operation room atracurium 0.5mg/kg was injected in vein under the muscle relaxant monitoring and the time for the 4 trains to disappear thoroughly was recorded, soon after atracurium 0.2mg/kg was injected in vein to maintain the muscle relaxed. Neostigmine was injected in vein to suppress the relaxed muscle after operation. Group Ⅱ was the control group, in which 14 cases had no myasthenia gravis symptom. Results: In groupⅠ, the onset time was 1 min 50 s and the holding time was about 25 to 35 min, after atracurium was injected in vein. In groupⅡ, the onset time was 2 min 5 s and the holding time was 20 to 30 min. For those whose muscle-relax was fairly completed, the rate was 96% to 98% in groupⅠand 80% to 90% in groupⅡ. In groupⅠ, neostigmine 0.05mg/kg and atropine 0.02mg/kg were injected in vein respectively to antagnize the remnant effect of muscle-relax after operation. If the effect was not obvious, the same dose of neostigmine and atropine were given 10 min later. In groupⅡ, the same dose of neostigmine and atropine were used and the ratio of T4/T1 amounted to 0.75 within 10 min, thus meeting the requirement of extubation. It is not necessary to administrate again. Conclusion: The application of hormone and anticholinesterase drug pretreatment before operation results in a positive role on controlling the symptom and improving the general condition of the body. Though the anticholinesterase drug therapy has been used before operation, it fails to decrease the sensibitity of atracurium obviously. In addtion, it needs careful monitoring for use of neostigmine to antagnize the muscle relax, and increase the dosage according to circumstance to achieve complete recovery of the muscular strength, thus ensuring the patients's safety.