摘要/Abstract

摘要： 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2 μg/（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，1.4 μg/（kg·min）的药物输注速率能提供满意的肌松效果。
关键词: 肝移植, 婴幼儿, 顺阿曲库铵, 药效动力学
Abstract:
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 status Ⅲ and Ⅳ, 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 2 μg/(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 1.4 μg/(kg·min) can provide satisfactory muscle relaxation effect.

Key words: liver transplantation, infants and young children, cisatracurium, pharmacodynamics


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