UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

神经肌肉阻滞剂用于成人快速顺序插管

Author
David Caro, MD
Section Editor
Ron M Walls, MD, FRCPC, FAAEM
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
王儒蓉, 主任医师，教授

引言

任何一位临床医生在处理危急、病情不稳定患者时的首要任务是保证气道通畅。在大多数情况下，当需要人工气道管理时，急诊科医生采用快速顺序插管(rapid sequence intubation, RSI)的方法。RSI联合使用神经肌肉阻滞剂(Neuromuscular blocking agents, NMBAs)和快速起效的镇静剂(即诱导)，以创造最佳的插管条件。

本专题将讨论NMBA用于RSI的基础临床药理学及药物选择。RSI的实施、RSI的其他用药及气道管理的其他方面将在别处讨论。 (参见“手术室外成人快速诱导气管插管”和“成人快速诱导插管的镇静或诱导药物”和“成人快速诱导插管的预处理药物”和“成人基础气道管理”)

神经肌肉阻滞剂(NMBA)在快速顺序插管(RSI)中的应用

在紧急气道管理中，RSI是预期无困难插管的的标准治疗[1-4]。RSI使用1种镇静剂和1种NMBA，以使患者迅速进入无意识及肌肉松弛的状态，从而利于紧急气管内插管，并减少喉镜置入及气管插管引起的不利生理反应，同时将误吸的风险降到最低。大量的前瞻性观察性研究证实：在急诊科(emergency department, ED)联合应用1种镇静剂和1种NMBA可使RSI获得极高的成功率[2-4]。 (参见“手术室外成人快速诱导气管插管”和“儿童的快速顺序插管”)

NMBA对RSI的实施是必不可少的。许多观察性研究显示，NMBA的使用可以提高急诊气管插管的成功率，并降低并发症的风险[1,5-9]。一项使用交叉设计在院前气道管理情况中进行的前瞻性试验发现：在进行直接喉镜检查时，使用NMBA可以将大多数患者的喉部视野提高整整1个等级[6]。

在RSI中，通常将1种NMBA与1种镇静剂联合使用。接受RSI的患者可能能够充分感知自己的处境与疼痛刺激，但无法做出反应[10,11]。这类患者如果没有充分镇静，则可能对气道处理产生不良生理反应，包括心动过速、高血压及颅内压 (intracranial pressure, ICP)增高[12]。使用镇静剂可预防这些不良反应或将其减到最小，也可能改善神经肌肉麻痹后获取的喉镜检查视野[13,14]。 (参见“成人快速诱导插管的镇静或诱导药物”)

                    

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-06-22.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999; 17:141.
  2. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
  3. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
  4. Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999; 6:31.
  5. Cicala R, Westbrook L. An alternative method of paralysis for rapid-sequence induction. Anesthesiology 1988; 69:983.
  6. Bozeman WP, Kleiner DM, Huggett V. A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care 2006; 10:8.
  7. Ma OJ, Atchley RB, Hatley T, et al. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Am J Emerg Med 1998; 16:125.
  8. Vijayakumar E, Bosscher H, Renzi FP, et al. The use of neuromuscular blocking agents in the emergency department to facilitate tracheal intubation in the trauma patient: help or hindrance? J Crit Care 1998; 13:1.
  9. Wilcox SR, Bittner EA, Elmer J, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 2012; 40:1808.
  10. Topulos GP, Lansing RW, Banzett RB. The experience of complete neuromuscular blockade in awake humans. J Clin Anesth 1993; 5:369.
  11. Wagner BK, Zavotsky KE, Sweeney JB, et al. Patient recall of therapeutic paralysis in a surgical critical care unit. Pharmacotherapy 1998; 18:358.
  12. Sivilotti ML, Ducharme J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med 1998; 31:313.
  13. El-Orbany MI, Wafai Y, Joseph NJ, Salem MR. Does the choice of intravenous induction drug affect intubation conditions after a fast-onset neuromuscular blocker? J Clin Anesth 2003; 15:9.
  14. Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med 2003; 10:612.
  15. Caro DA, Andescavage S, Akhlaghi M, et al. Pupillary response to light is preserved in the majority of patients undergoing rapid sequence intubation. Ann Emerg Med 2011; 57:234.
  16. Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF (Eds), Lippincott Williams & Wilkins, Philadelphia 2012.
  17. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151.
  18. Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2008; :CD002788.
  19. Herbstritt A, Amarakone K. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? Emerg Med J 2012; 29:256.
  20. Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438.
  21. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483.
  22. Levitan R. Safety of succinylcholine in myasthenia gravis. Ann Emerg Med 2005; 45:225.
  23. Boehm JJ, Dutton DM, Poust RI. Shelf life of unrefrigerated succinylcholine chloride injection. Am J Hosp Pharm 1984; 41:300.
  24. Gronert GA. Cardiac arrest after succinylcholine: mortality greater with rhabdomyolysis than receptor upregulation. Anesthesiology 2001; 94:523.
  25. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006; 104:158.
  26. Miller R. Miller's Anesthesia, 6th, Elsevier Churchill Livingstone, Philadelphia 2005.
  27. Kolb ME, Horne ML, Martz R. Dantrolene in human malignant hyperthermia. Anesthesiology 1982; 56:254.
  28. Magee DA, Gallagher EG. "Self-taming" of suxamethonium and serum potassium concentration. Br J Anaesth 1984; 56:977.
  29. Zink BJ, Snyder HS, Raccio-Robak N. Lack of a hyperkalemic response in emergency department patients receiving succinylcholine. Acad Emerg Med 1995; 2:974.
  30. Raman SK, San WM. Fasciculations, myalgia and biochemical changes following succinylcholine with atracurium and lidocaine pretreatment. Can J Anaesth 1997; 44:498.
  31. Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anesth Analg 2000; 91:237.
  32. Carroll JB. Increased incidence of masseter spasm in children with strabismus anesthetized with halothane and succinylcholine. Anesthesiology 1987; 67:559.
  33. Sims C. Masseter spasm after suxamethonium in children. Br J Hosp Med 1992; 47:139.
  34. Bauer SJ, Orio K, Adams BD. Succinylcholine induced masseter spasm during rapid sequence intubation may require a surgical airway: case report. Emerg Med J 2005; 22:456.
  35. Gill M, Graeme K, Guenterberg K. Masseter spasm after succinylcholine administration. J Emerg Med 2005; 29:167.
  36. Rosenberg H, Fletcher JE. Masseter muscle rigidity and malignant hyperthermia susceptibility. Anesth Analg 1986; 65:161.
  37. Harvey SC, Roland P, Bailey MK, et al. A randomized, double-blind comparison of rocuronium, d-tubocurarine, and "mini-dose" succinylcholine for preventing succinylcholine-induced muscle fasciculations. Anesth Analg 1998; 87:719.
  38. Larach MG, Rosenberg H, Gronert GA, Allen GC. Hyperkalemic cardiac arrest during anesthesia in infants and children with occult myopathies. Clin Pediatr (Phila) 1997; 36:9.
  39. Yasuda I, Hirano T, Amaha K, et al. Chronotropic effects of succinylcholine and succinylmonocholine on the sinoatrial node. Anesthesiology 1982; 57:289.
  40. Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Tracing the teaching. Anesthesiology 2003; 99:220.
  41. Chidiac EJ, Raiskin AO. Succinylcholine and the open eye. Ophthalmol Clin North Am 2006; 19:279.
  42. Perry JJ, Lee J, Wells G. Are intubation conditions using rocuronium equivalent to those using succinylcholine? Acad Emerg Med 2002; 9:813.
  43. Nava-Ocampo AA, Velázquez-Armenta Y, Moyao-García D, Salmerón J. Meta-analysis of the differences in the time to onset of action between rocuronium and vecuronium. Clin Exp Pharmacol Physiol 2006; 33:125.
  44. Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med 2011; 18:10.
  45. Na HS, Hwang JW, Park SH, et al. Drug-administration sequence of target-controlled propofol and remifentanil influences the onset of rocuronium. A double-blind, randomized trial. Acta Anaesthesiol Scand 2012; 56:558.
  46. Hans GA, Bosenge B, Bonhomme VL, et al. Intravenous magnesium re-establishes neuromuscular block after spontaneous recovery from an intubating dose of rocuronium: a randomised controlled trial. Eur J Anaesthesiol 2012; 29:95.
  47. Czarnetzki C, Lysakowski C, Elia N, Tramèr MR. Intravenous lidocaine has no impact on rocuronium-induced neuromuscular block. Randomised study. Acta Anaesthesiol Scand 2012; 56:474.
  48. Baumgarten RK, Carter CE, Reynolds WJ, et al. Priming with nondepolarizing relaxants for rapid tracheal intubation: a double-blind evaluation. Can J Anaesth 1988; 35:5.
  49. Sparr HJ, Vermeyen KM, Beaufort AM, et al. Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex in a randomized multicenter study: efficacy, safety, and pharmacokinetics. Anesthesiology 2007; 106:935.
  50. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg 2007; 104:575.
  51. Plaud B, Meretoja O, Hofmockel R, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology 2009; 110:284.
  52. Sørensen MK, Bretlau C, Gätke MR, et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth 2012; 108:682.
  53. Van Gestel L, Cammu G. Is the effect of sugammadex always rapid in onset? Acta Anaesthesiol Belg 2013; 64:41.
  54. Lee C, Jahr JS, Candiotti KA, et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology 2009; 110:1020.
  55. Gaszynski T, Szewczyk T, Gaszynski W. Randomized comparison of sugammadex and neostigmine for reversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia. Br J Anaesth 2012; 108:236.
  56. Geldner G, Niskanen M, Laurila P, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67:991.
  57. Pongrácz A, Szatmári S, Nemes R, et al. Reversal of neuromuscular blockade with sugammadex at the reappearance of four twitches to train-of-four stimulation. Anesthesiology 2013; 119:36.
  58. Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology 2008; 109:816.
  59. Abrishami A, Ho J, Wong J, et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Database Syst Rev 2009; :CD007362.
  60. Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core Evid 2013; 8:57.