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肌肉松弛药合理应用的专家共识

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肌肉松弛药合理应用的专家共识肌肉松弛药合理应用的专家共识 肌肉松弛药合理应用的专家共识(2009) 肌肉松弛药(肌松药)是作用于神经肌肉接头前膜及后膜(终板)烟碱样乙酰胆碱受体的药物。肌松药作用于神经肌肉接头后膜受体,阻滞了神经肌肉兴奋的正常传递,产生肌肉松弛。随着全身麻醉的增加,肌松药应用明显增加。为了肌松药的合理应用,确保患者安全,特制订肌松药临床应用的专家共识。 一、 使用肌松药的目的 1、为气管插管提供肌松条件。 2、满足各类手术或诊断、治疗对肌松的要求。 3、减弱或终止某些骨骼肌痉挛性疾病引起的肌肉僵直。 4、消除患者自主呼吸于机...
肌肉松弛药合理应用的专家共识
肌肉松弛药合理应用的专家共识 肌肉松弛药合理应用的专家共识(2009) 肌肉松弛药(肌松药)是作用于神经肌肉接头前膜及后膜(终板)烟碱样乙酰胆碱受体的药物。肌松药作用于神经肌肉接头后膜受体,阻滞了神经肌肉兴奋的正常传递,产生肌肉松弛。随着全身麻醉的增加,肌松药应用明显增加。为了肌松药的合理应用,确保患者安全,特制订肌松药临床应用的专家共识。 一、 使用肌松药的目的 1、为气管插管提供肌松条件。 2、满足各类手术或诊断、治疗对肌松的要求。 3、减弱或终止某些骨骼肌痉挛性疾病引起的肌肉僵直。 4、消除患者自主呼吸于机械通气的对抗。 二、肌松药的合理选择 (一)置入喉罩或气管插管 1、选用起效快的肌松药,缩短置入喉罩或气管插管的时间,维护气道通畅、防止返流误吸是麻醉重要的安全因素。 2、起效最快的去极化肌松药是琥珀胆碱,非去极化肌松药是罗库溴铵。应用琥珀胆碱时应权衡其产生去极化作用带来的不良反应并严格掌握其禁忌症。 3、常用去极化肌松药的置入喉罩剂量为1~2倍ED(肌颤搐被95抑制95%的剂量),气管插管剂量为2~3倍ED,增加剂量可适当缩95 短起效时间,但会延长时效肌增加不良反应。 integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, 4、常用肌松药ED及气管插管剂量、起效时间和临床作用时间95 间1,2。 表1 常用肌松药的ED (mg/kg) 95 肌松药 新生儿 婴儿 儿童 成人 琥珀胆碱 0.625 0.729 0.423 0.30 阿曲库铵 0.226 0.226 0.316 0.25 顺阿曲库铵 -- 0.043 0.047 0.05 罗库溴铵 -- 0.225 0.402 0.30 维库溴铵 0.047 0.048 0.081 0.05 哌库溴铵 -- 0.035 0.048 0.05 表2 常用肌松药的剂量和时效 气管插管剂量 起效时间 临床作用时间 追加剂量 肌松药 (mg/kg) (min) (min) (mg/kg) 琥珀胆碱 1.0-1.5 0.75-1.00 10-12 -- 阿曲库铵 0.50 2-4 40-50 0.10-0.20 顺阿曲库铵 0.15 2-4 50-60 0.05-0.10 罗库溴铵 0.60 1.0-1.5 40-60 0.15-0.20 维库溴铵 0.10 2-3 40-60 0.10-0.04 哌库溴铵 0.10 2-4 80-100 0.01-0.05 (二)麻醉维持期 1、更具肌松药特性、患者病理生理特点、药物的相互作用及手术不同阶段对肌松的要求,决定追加肌松药的时间和剂量。 2、手术期间多选用中、短时效肌松药,便于肌松程度的调节及神经肌肉传导功能的恢复。二对长时间手术、体外循环心内直视手术以及术后需行机械通气的患者可选用长时效肌松药。 3、整个手术期间没有必要保持同等深度的肌松。术中维持肌松最常用的方法是间断静注肌松药,不提倡持续静脉输注肌松药,长时效的非去极化肌松药更不应持续输注。通畅间隔30min追加中时效肌松药,间隔60min追加长时效肌松药,非去极化肌松药维持剂量一般 and-te. Low mountains and hills in the city landscape as the main ridgeEastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand2ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate aality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters - 为初量的1/5~1/3,应以最少量的肌松药达到临床肌松的要求。 4、麻醉维持期不主张多次静脉注射或持续静脉输注琥珀胆碱。 5、常用非去极化肌松药气管插管剂量,追加剂量和持续输注速率见表2,3。 表3 常用非去极化肌松药持续输注速率 1-1肌松药 持续输注速率(mg? kg- ?h) 阿曲库铵 0.3-0.6 顺阿曲库铵 0.10-0.15 罗库溴铵 0.3-0.6 维库溴铵 0.06-0.10 (三)ICU 1、ICU患者应给予镇静药和镇痛药,调整呼吸机通气模式和参数,如仍有自主呼吸于机械通气不同步才考虑使用肌松药。在给予镇静药后即可使用肌松药治疗破伤风或癫痫持续状态等痉挛疾病。 2、ICU患者应用肌松药主张小剂量间断静脉注射,当镇静药和镇痛药剂量不足或肺顺应性明显降低时,肌松药用量比术中增加。 3、ICU患者给予肌松药可降低机械通气时的气道峰压,减少气压上,但长期用药可产生耐药性,并可引起严重肌肉病变(肌肉萎缩和肌肉溶解),特别是复合应用大剂量激素时,以致脱机困难。 (四)影响ED的因素 95 1、年龄 不同年龄患者肌松药的ED有差别(见表1),老年95 患者非去极化肌松药的ED比青壮年患者低。 95 2、性别 非去极化肌松药的ED女性患者比男性患者低。 95 3、血浆蛋白 各种肌松药在血液内与血浆蛋白结合的比率不相同,与血浆蛋白结合率低的肌松药,游离肌松药分子数量地增多, -ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand3, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city 该肌松药的ED低。药注意急性等容或高容血液稀释及低蛋白血症95 患者,游离肌松药分子数量增加,肌松作用增强。 三、肌松药的相互作用 (一)去极化肌松药与非去极化肌松药的相互作用 1、给予小剂量非去极化肌松药对琥珀胆碱作用的影响 临床上常预注小剂量非去极化肌松药以减少琥珀胆碱引起的不协调肌颤搐,但会削弱琥珀胆碱的肌松效应,延缓其起效时间,缩短其恢复时间。因此用小剂量非去极化肌松药作前处理时,琥珀胆碱剂量需增加70%,预注间隔时间以3min为宜。 2、作用消退中的非去极化肌松药对琥珀胆碱作用的影响 术中给予大剂量非去极化肌松药维持肌肉松弛,当其作用减弱时有人试图追加琥珀胆碱,期望获得很满意的肌松,以满足关腹的要求。但这种情况给予的琥珀胆碱可能产生难以预测地部分拮抗非去极化肌松药作用后,出现短暂肌松作用,甚至会出现?相阻滞。故不提倡此种给药方法,建议继续用小剂量同种非去极化肌松药。 (二)非去极化肌松药先后应用时的相互作用 1、诱导时采用预注法给予非去极化肌松药 预注法(Priming Principle)是先静注1/10 气管插管剂量的非去极化肌松药2~4min后,可使再静注9/10插管剂量该肌松药的起效时间显著缩短。 2、作用消退中的长时效肌松药对随后给予的中、短时效肌松药作用的影响 Eastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand4ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate aality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-te. Low mountains and hills in the city landscape as the main ridge 先用的肌松药可影响后用肌松药的药效学特性,后用肌松药的时效特性需待原先使用的肌松药3~5个半衰期之后才能表现出来。因此先用长、中时效肌松药,再给予中、短时效肌松药,后者临床作用时间延长。 (三)其他药物和不同病理生理状态对肌松药作用的影响 1、协同肌松药效应的药物及病理生理状态 卤族吸入性麻醉药、氨基糖甙类和酰胺类抗生素、抗癫痫药、氨茶碱衍生物、局麻药、速尿、β受体阻滞剂、钙通道阻滞剂、硝酸甘油、普鲁卡因酰胺、奎尼丁、锂制剂,酸中毒、低血钙、低血钾、高血镁及重症肌无力,在合用上述药物或有上述病理生理情况时,应适当减少肌松药的用量并加强监测。 2、拮抗非去极化肌松药效应的药物及病理生理状态 卡马西平、苯妥因、皮质激素、麻黄碱、去甲肾上腺素、雷尼替丁、氨茶碱;碱中毒、高血钙、高血钾、低血镁、烧伤,在合用上述药物或有上述病理生理情况时可能需要适当增加肌松药的用量。 总之,为减少肌松药联合应用出现的复杂相互作用,除麻醉诱导外,提倡根据手术需要,恰当地确定剂量和给药时间,始终使用单一的非去极化肌松药;在合并使用多种影响肌松药作用的药物和合并某些病理生理情况时,宜在监测肌松药效应指导下给予肌松药。 四、特殊患者肌松药的选择 (一)剖宫产孕妇 肌松药属于水溶性大分子药物,较少透过胎盘屏障。应选择起效 -tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city-ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand5, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu 快、时效短的肌松药,防止产妇返流误吸及对新生儿呼吸的影响。建议使用琥珀胆碱气管内插管,待胎儿取出后给予中时效肌松药。 (二)肝、肾功能衰竭患者 1、 肝、肾功能障碍时,由于体内水钠潴留导致分布容积增大,较高的γ球蛋白结合了大量的肌松药,血浆胆碱酯酶活性降低所致突触间隙乙酰胆碱清除速率下降,表现为肌松药起效时间延长,初始剂量增加。 2、主要经肝脏生物转化和肾脏排除的维库溴铵、经胆汁排泄的罗库溴铵、经肾脏排除的哌库溴铵和经血浆假性胆碱酯酶代谢的琥珀胆碱的清除半衰期将明显延长,应延长给药间隔时间。术前已完成透析的肾功能衰竭患者对肌松药的反应近于正常。 3、 经Hofmann消除(pH和温度依赖性降解)的阿曲库铵和顺阿曲库铵作用终止很少依赖肝、肾功能,在肝、肾功能障碍时最好选择顺阿曲库铵。但是在肝、肾功能衰竭存在严重的内环境紊乱会影响Hofmann消除。阿曲库铵和顺阿曲库铵必须低温保存,防止降解。 (三)神经肌肉疾病患者 1、琥珀胆碱可使脊髓损伤与中风引起肌肉无力或麻痹、严重创伤、大面积烧伤、脊髓性肌萎缩、肌萎缩性侧索硬化症、急性感染性神经炎、肌营养不良症和横纹肌溶解症等患者发生致命性高钾血症,这些患者禁用琥珀胆碱。 2、 重症肌无力患者对非去极化肌松药十分敏感,肌松作用增强,作用时间延长,用药剂量应减少至正常人的1/10,1/2。术后确定无 ality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-te. Low mountains and hills in the city landscape as the main ridgeEastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand6ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate a 肌松药残留作用,通气功能适当后方可停止辅助通气,拔出气管内导管。 3、 强直性肌营养不良患者对非去极化肌松药表现敏感,其它类型肌强直患者则表现耐药。一般认为可用中、短时效非去极化肌松药,但应在肌松药效应严密监测下给予肌松药。 五、肌松药残留阻滞作用 (一)肌松药残留阻滞作用 尽管临床上已广泛应用中、短时效肌松药,并对其药理作用的认识逐步深化,但术后肌松药残留阻滞作用仍时有发生,严重者可被致残或危及生命。 1、肌松药残留阻滞作用的危害 (1)呼吸无力,肺泡有效通气量不足,导致低氧血症和高碳酸血症。 (2)咽喉部肌无力,导致上呼吸道梗阻,增加返流误吸的风险。 (3)咳嗽无力,无法有效排出起到分泌物,引起术后肺部并发症。 (4)颈动脉体缺氧性通气反应受抑制,引发低氧血症。 2、肌松药残余阻滞作用的原因 (1)未针对患者病情特点,合理选用和科学使用肌松药。 (2)给予长时效肌松药或多次应用肌松药,术后肌松药阻滞作用仍存在。 (3)肌松药作用开始消退,肌力开始恢复时还有75%左右烟碱 State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand7, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city-ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and- 样乙酰胆碱受体被肌松药分子占据,合并其他影响因素时,出现肌松残留阻滞作用。 (4)个体差异,老龄、女性、肌肉不发达和慢性消耗患者肌松药时间延长。 (5)低体温、水电解质紊乱及酸碱平衡失调,延长肌松药的代谢和排泄,乙酰胆碱的合成和释放受损。 (6)复合应用肌松药有协同作用的药物,时肌松药阻滞作用时间异常延长。 (7)肝、肾功能受损,使依赖肝脏代谢和肾脏排泄的肌松药阻滞作用延长。 (8)神经肌肉疾病。 3、肌松药残留阻滞作用的评估 (1)肌松监测仪:观察刺激尺神经时拇内收肌的颤搐反应,如TOF比值,0.9提示存在肌松药残留阻滞作用。 (2)临床指征 ?清醒、呛咳和吞咽反射恢复。 ?头能持续抬离枕头5s以上。 ?呼吸平稳、呼吸频率10~20次,min,最大吸气压?,50cmHO2(1 cmHO=0.098kPa)。 2 ?呼气末二氧化碳分压和动脉血二氧化碳分压?45mmHg(1mmHg=0.133Kpa). 上述指征表明不存在肌松药残留阻滞作用。 -te. Low mountains and hills in the city landscape as the main ridgeEastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand8ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate aality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and 4、肌松药残留阻滞作用的预防 (1)根据患者病情特点和手术需要,合理选择和使用肌松药。 (2)改善患者全身情况,维持电解质正常和酸碱平衡。 (3)拮抗肌松药的残留阻滞作用。术毕无明确指征显示肌松药阻滞作用已完全消退,应进行肌松药残留阻滞作用的拮抗。 (4)拔除气管内导管后,应在手术室或恢复室严密观测患者的神志、保护性反射状态、呼吸道通畅度、肺泡通气量及氧合状态,至少30min,确保患者安全。 (二)肌松药残留阻滞作用的拮抗 1、琥珀胆碱残留阻滞作用的拮抗 并无特异的琥珀胆碱拮抗药。反复或大剂量使用琥珀胆碱发生自主呼吸恢复延迟时,应进行有效的辅助通气或控制通气,直至自主呼吸恢复正常。同时改善患者全身情况,纠正电解质与酸碱平衡紊乱,尤其是纠正低血钾,给予钙剂和利尿剂,维持循环稳定;对胆碱酯酶功能异常者可输注新鲜冰冻血浆。 2、非去极化肌松药残留阻滞作用的拮抗 (1)拮抗药——胆碱酯酶抑制剂 胆碱酯酶抑制剂——新斯的明可抑制乙酰胆碱酶,增加神经肌肉结合部乙酰胆碱的浓度,竞争性拮抗非去极化肌松药的残留阻滞作用;但同时会出现肠蠕动增强、分泌物增多、支气管平滑肌收缩和心率减慢等毒蕈碱样乙酰胆碱受体兴奋的副反应。因此需同时给予阿托品。胆碱酯酶抑制剂拮抗残留肌松作用的效果与其剂量和拮抗时肌松 -tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city-ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand9, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu 程度密切相关。 ?拮抗时机:TOF出现2个反应或开始有自主呼吸时拮抗肌松药残留阻滞作用。 ?拮抗药剂量:新斯的明静脉注射0.04~0.07mg,kg,总量不应超过5mg。新斯的明起效时间2min,达峰时间7~15min,作用时间2h。用量偏小,难以达到满意的拮抗效果,肌力恢复不充分。新斯的明的拮抗作用有封顶效应,如果已达到最大剂量,拮抗效果仍不满意时,不宜在给予拮抗药,应进行有效的人工通气,认真分析影响肌松药拮抗效果的原因,采取必要的措施。 需同一注射器给予阿托品,阿托品的剂量一般为新斯的明的半量,需根据患者心率调整阿托品的剂量。静脉注射阿托品后10~30s起效,达峰时间12~16min(尽管注药后8~10min阿托品血药浓度迅速下降,但阿托品引起心率最大变化与血药浓度无相关性,而与其组织水平明显相关),作用时间可达4~6h,故给予拮抗药后患者心率通常会增快。 (2)拮抗药使用注意事项 ?下列情况下禁用或慎用新斯的明:支气管哮喘;心律失常、心动过缓,尤其是房室传导阻滞,心肌缺血、瓣膜严重狭窄;机械性肠梗阻;尿路感染或尿路梗阻;妊娠;对溴化物过敏等。 ?下列情况下禁用或慎用阿托品:婴幼儿,特别是痉挛性麻痹与脑损伤的婴幼儿;心脏疾病,特别是心律失常、充血性心力衰竭、冠心病、二尖瓣狭窄;返流性食管炎;食管与胃的运动减弱;青光眼; ality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-te. Low mountains and hills in the city landscape as the main ridgeEastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand10ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate a 溃疡性结肠炎;前列腺肥大及尿路阻塞性疾患。 ?酸碱和电解质失衡、肾功能衰竭、高龄和复合应用肌松协同作用药物患者,新斯的明拮抗残留肌松作用不理想。 ?胆碱酯酶抑制剂拮抗婴幼儿残留肌松作用较成人好。 ?胆碱酯酶抑制剂拮抗长时效肌松药残留阻滞作用,肌力恢复后发生再箭毒化几率较拮抗中、短时效肌松药多,给予拮抗药后须严密监测患者的肌力恢复情况,严防出现再箭毒化。 ?凡禁用拮抗药者,须进行有效的人工通气,直至自主呼吸恢复满意。 (六)肌力监测 (一)应采取骨骼肌收缩力监测的患者 1、术中多次给予大剂量非去极化肌松药。 2、肝、肾疾患及重症肌无力。 3、神经外科、显微外科等要求绝对无体动的精细手术。 4、需要拔出气管内导管而不宜用拮抗药或合并电解质失衡。 5、手术结束无法确定肌松药肌松作用已完全消退。 (二)神经肌肉传导检测仪和神经刺激模式 临床上常采用加速度测定仪或肌肉收缩力测定仪了解肌松药肌松作用起效、维持和消退情况。神经刺激的模式有单次颤搐刺激、四个成串刺激、强直刺激、强直刺激后计数和双短强直刺激。强直刺激后计数主要监测深度阻滞,四个成串刺激和双短强直刺激主要监测是否存在肌松药残留阻滞作用。 tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city-ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand11, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu- 七、肌松药不良反应的防治 1、琥珀胆碱主要不良反应的防治 (1)心律紊乱:可以出现窦性心动过缓或室性逸搏心律,可预防性静脉注射阿托品。婴幼儿不主张使用琥珀胆碱。 (2)肌束震颤:预先给予小剂量非去极化肌松药。 (3)高钾血症:烧伤、大面积创伤、上运动神经元损伤患者可发生危及生命的血清钾浓度升高。高钾血症及上述患者禁用琥珀胆碱。 (4)眼内压、颅内压、胃内压升高:闭角型青光眼和颅内压升高患者禁用琥珀胆碱。 (5)恶性高热:恶性高热家族史或易感者禁用琥珀胆碱。 2、非去极化肌松药常见不良反应的防治 阿曲库铵大剂量及快速注射时,引起组胺释放,可诱发支气管痉挛、心率增快、血压下降。诱导剂量不适宜超过3倍的,且应粉刺、缓慢静脉注射。 我国外文献报道肌松药过敏反应较高,但国内文献报道甚少。对一种肌松药过敏的患者有可能亦对另一种肌松药产生过敏。 八、肌松药临床应用的注意事项 1、严格掌握肌松药临床应用的适应证和禁忌证。 2、应用肌松药前必须准备人工通气设备,术毕也必须进行人工通气直至肌松药作用消退,呼吸功能恢复正常。 3、高度重视术后肌松药残留阻滞作用,术毕无明确指征表明肌 ality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-n, "old townbuilding situatio-cities in building with an area of about 76.2km2. From city-s, and spatial structure of typical zonal group, 2012%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationabove sea level in the city, low mountain, 46.6% hills 45.3Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-te. Low mountains and hills in the city landscape as the main ridgeEastern Sta-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-high ry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independentliquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industvalue to 73.58 billion yuan, the city's integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand12ities have been expanding, centripetal city traffic organization has not changed,ies, cnting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cited, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accouality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-old townbuilding situation, "-cities in building with an area of about 76.2km2. From city-nd spatial structure of typical zonal group, 2012ingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, aabove sea level in the city, low mountain, 46.6% hills 45.3%, pValley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-Low mountains and hills in the city landscape as the main ridgeEastern State. -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-d wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1yiel-hchangning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent higor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, s lique Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textilcitie ccounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion offormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate a 松作用已消退,应进行残留肌松作用的拮抗。 4、对不能进行面罩通气的困难气道患者禁止使用肌松药。 -and-State. Low mountains and hills in the city landscape as the main ridgeEastern -4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-ghent hiustry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independ's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing indvalue to 73.58 billion yuan, the city integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand13, cities have been expanding, centripetal city traffic organization has not changed,citiescounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of ormed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate acality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been fthe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-, "old townbuilding situation-cities in building with an area of about 76.2km2. From city-, and spatial structure of typical zonal group, 2012, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitationsabove sea level in the city, low mountain, 46.6% hills 45.3%Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters -and-e. Low mountains and hills in the city landscape as the main ridgeEastern Stat-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-3 GDP growth figure 2.1-ield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1y-highy, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent iquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industrty's ltile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and texof ci e accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansionen formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequatality public service resources are still heavily concentrated in the old town together. Southbank Centre has not bethe South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, qu-tion, "old townbuilding situa-cities in building with an area of about 76.2km2. From city-ions, and spatial structure of typical zonal group, 20125.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitatabove sea level in the city, low mountain, 46.6% hills 4Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters
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