婴幼儿活体肝移植术中静脉注射顺阿曲库铵的药效学研究

Pharmacodynamics of cisatracurium intravenously infused in infants and young children undergoing living donor liver transplantation

目的·观察婴幼儿活体肝移植术中静脉注射顺阿曲库铵的药效学变化。方法·选择终末肝病期需择期行活体肝移植术的婴幼儿16例,年龄6~24个月,美国麻醉师协会(American Society of Anesthesiologists,ASA)分级为Ⅲ级或Ⅳ级。采用TOF-Watch肌松监测仪对尺神经进行连续4个成串刺激(train-of-four,TOF),观察拇内收肌的加速度变化。静脉注射0.15 mg/kg顺阿曲库铵诱导,T1为最大抑制程度时,行气管插管。T1恢复至3%时,输注起始剂量为2μg/(kg·min)的顺阿曲库铵,调节速率,维持90%~95%肌松抑制程度。分别记录注射首剂量顺阿曲库铵后药物的起效时间、TOF无反应期、术中不同分期肌松药的用量;观察停药后患者的肌松恢复情况,包括停药后T1从10%恢复至25%时间、恢复指数(T1从25%恢复至75%的时间)以及4个成串刺激比值(TOFr)=0.9的时间。结果·肝移植术中顺阿曲库铵的平均输注速率为(1.37±0.46)μg/(kg·min);术中无肝前期、无肝期以及新肝期的药物平均输注速率呈现下降趋势,但差异无统计学意义(P=0.110)。顺阿曲库铵的起效时间为(242.63±46.74)s,TOF无反应期为(34.02±7.71)min。停药后,T1恢复至25%时间为(12.80±3.49)min,恢复指数为(15.12±4.59)min,TOFr=0.9的时间为(40.27±7.03)min。结论·终末肝病患儿行活体肝移植术时,应充分认识肌松药的药效学特征;使用0.15 mg/kg的顺阿曲库铵麻醉诱导时,应在用药4 min后进行气管插管。在麻醉维持阶段,顺阿曲库铵的用药量在3个不同时期基本保持不变,1.4μg/(kg·min)的药物输注速率能提供满意的肌松效果。

Objective·To observe pharmacodynamics of cisatracurium intravenously infused in infants and young children with end-stage liver disease during living donor liver transplantation.Methods·Sixteen patients of American Society of Anesthesiologists(ASA)physical statusⅢandⅣ,aged 6-24 months,with end-stage liver disease,undergoing liver transplantation were studied.Neuromuscular transmission was monitored by the responses of the adductor pollicis to train-of-four(TOF)stimulation of ulnar nerve,using the accelerography(TOF-Watch).Endotracheal intubation was performed after intravenous injection of 0.15 mg/kg cisatracurium,with T1 being the maximum inhibitory degree.After recovery of T1 to 3%,cisatracurium was infused at an initial rate of 2μg/(kg·min).The infusion rate was adjusted to maintain a constant 90%to 95%neuromuscular paralysis until the end of the operation.The onset time,no reaction period of TOF,the dosage of cisatracurium given during paleo-phepatic phase,an-hepatic phase and neo-hepatic phase,the time to 25%recovery of T1,recovery index(25%-75%),and the time for the TOF ratio(TOFr)to reach 0.9 were recorded respectively.Results·The infusion rate was(1.37±0.46)μg/(kg·min).The average infusion rate of drugs in the three different periods showed a downward trend,but there was no statistical difference(P=0.110).The onset time of cisatracurium was(242.63±46.74)s.The no reaction period of TOF was(34.02±7.71)min.Following termination of the infusion,the time to 25%recovery of T1 was(12.80±3.49)min,and the recovery index(25%-75%)was(15.12±4.59)min.The time of TOFr=0.9 was(40.27±7.03)min.Conclusion·The pharmacodynamical characteristics of muscle relaxants should be fully understood during living donor liver transplantation in infants and young children with end-liver disease.When cisatracurium(0.15 mg/kg)is used for anesthesia induction,endotracheal intubation should be performed 4 min after administration.In the maintenance stage of anesthesia,the infusion dose requirement of cisatracurium is basically unchanged in the three different periods,and the infusion rate of 1.4μg/(kg·min)can provide satisfactory muscle relaxation effect.