DRUGSUSEDFORANESTHESIA,MUSCLERELAXATION1DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛A.LocalanesthesiaAsthenameimplies,localanestheticsareappliedlocallyandfunctiontoblocknerveconduction.2DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛1.GeneralinformationThemechanismbywhichlocalanestheticsworkiswellknown3DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Recallthattheconcentrationofsodiumionsisnormallyhigherontheoutsideofneuronsthanontheinside.4DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Arapidfloodofsodiumionsintocellsisnecessaryforneuronstofireandconductanactionpotential.5DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛6DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Localanestheticsactbyblockingsodiumchannels.7DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisblockingisnonselective,whichmeansthatbothsensoryandmotorimpulsesareaffected.8DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisblockingisbroughtaboutbytheanestheticreversiblybindingtoandinactivatingsodiumchannels.9DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Sodiuminfluxthroughthesechannelsisnecessaryforthedepolarizationofnervecellmembranesandsubsequentpropagationofimpulsesalongthecourseofthenerve.10DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Whenanervelosesdepolarizationandcapacitytopropagateanimpulse,theindividuallosessensationintheareasuppliedbythenerve.11DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Example:AninjectablelocalanestheticwhichcombinescapsaicinwithQX-314,avariationoflidocaine12DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Alllocalanestheticshaveanaminefunctionalgroup,anaromaticring,andeitheranesteroramidegrouplinkingthem.13DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛amine14DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛aromaticring15DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ester16DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛amide17DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Therefore,alllocalanestheticsareclassifiedasestersoramides.18DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisisimportantbecausetheamidesarechemicallystablein vivo,whereastheestersaresubjecttohydrolysis.19DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,thehydrolysisofanesterlocalanestheticleadstotheformationofPABA,whichcausesanallergicresponseinsomeindividuals.20DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Localanestheticsmaybeadministeredtopically(i.e.nasalmucosa);21DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛throughinfiltration(injectionintothedermisandsofttissueslocatednearperipheralnerveendings);22DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛andin/nearthespinalcord(includescaudalblock,epiduralblock,andspinalnerveblock).23DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Whichlocalanestheticshouldbeusedgenerallydependsonthedurationofactionoftheprocedure.24DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Forshortprocedures,procainewouldberecommended.25DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Anintermediatedurationofactionisfoundwithcocaine,lidocaine,andmepivacaine.26DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Long-actinglocalanestheticsincludebupivacaine(andlevobupivacaine),ropivacaine,andtetracaine.27DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛2.EsterlocalanestheticsCommonlyusedlocalanestheticscontainingtheesterfunctionalgrouparebenzocaine,cocaine,procaine,andtetracaine.28DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.procaine(Novocain)Procaineistheprototypedrugofthelocalanesthetics.Ithasthelowestpotency(exceptforBenzocaine).29DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisusedfornerveblock,epiduralandspinalanesthesia.Novocaineisgenerallynotusedindentistryanymore.30DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛31DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.benzocaineTopicaluseonlybenzocaine(Solarcaine,Orajel,Lanacaineetc)32DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisusedforminormouthconditions(i.eteething,cankersores)sorethroat,sunburn,andotherminorskinconditions33DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛34DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.cocaineCocaineis2timesaspotentasprocaine.Itisusedforear,noseandthroatprocedures.35DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛36DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛d.tetracaine(Pontocaine)37DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Usedfor:spinalanesthesiarequiring2to3hoursofanesthesiasurfaceanesthesiaoftheeye,noseandthroat.38DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itis16timesaspotentasprocaine.39DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛3.AmidelocalanestheticsCommonlyusedlocalanestheticscontainingtheamidefunctionalgrouparebupivacaine,lidocaine,mepivacaine,andropivacaine.40DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.bupivacaine(Marcaine)andlevobupivacaine(Chirocaine)41DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theseareusedininfiltrationandepiduralanesthesia.Theyare16timesmorepotentthanprocaine.42DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Generally,theyaremorecardiotoxicthantheotherlongactinglocalanesthetics.43DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.lidocaine44DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Usedtopicallyforminordermatologicalprocedures(i.eskintagremoval)45DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itis4timesmorepotentthanprocaineandhasreplacedprocaineintheareaofdentalanesthesia.46DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.mepivacaine(Carbocaine)Thislocalanestheticisusedfordentalprocedures,surgicalproceduresandduringlaboranddelivery.47DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛d.ropivacaine(Naropin)Thisisusedforsurgicalprocedures,includingcaesariansections.Althoughitissimilarpharmacologicallytobupivacaine,itislesscardiotoxic.48DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛4.Adverseeffectsa.Lowconcentrationdosages:dizzinesssleepinessrestlessness49DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.Higherconcentrationdosages:musculartwitchingseizures50DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛andhypotension(exceptforcocaine,whichcanresultinvasoconstrictionandhypertension,aswellascardiacarrhythmias).51DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛B.Generalanesthesia52DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛1.generalinformationGeneralanesthesiaprovidesrapidandcompletelossofsensation.53DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itischaracterizedby:totalanalgesia(nopain)unconsciousnessdeeperthansleeplossofmemorycompletemusclerelaxation.54DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛55DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Althoughsimilartosleepthereareprofounddifferences:56DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereisthelossofthe“fightorflightresponse”,whichisnotlostduringsleep.57DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Generalanestheticsstopmostnervousactivityinthebrain,sleeponlystopsactivityinveryspecificareas,andincreasesactivityinotherareas.58DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itistheultimate“alteredstate”,likeflippingaswitchtotemporarilyturnoffthenervoussystem.59DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛InthepastdecadeithasbecomeapparentthattheGABAreceptor-chloridechannelisthetargetofmanygeneralanesthetics(inhaledanesthetics,BZs,barbiturates,propofol).60DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛TheGABAreceptorcomplexconsistsofalpha,beta,andgammasubunitssurroundingandcontrollingacentralchlorideionchannel.61DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Allanestheticsbindatsitesintheandsubunits,whichareremovedfromtheGABAbindingsite.62DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛63DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ThebindingofGABA(gammaaminobutyricacid)toitsreceptorcausesanopeningofthechlorideionchannel.64DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theincreaseofchlorideionleadstoahyperpolarizationofthecell.65DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ForIVbenzodiazepineanestheticsandtheinhalationanesthetics,bindingtotheGABAreceptorcomplex,concurrentwithGABAbinding,resultsinagreaterdurationofchloridechannelopening.66DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛67DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisincreasestheentryofchlorideionintothecell.Theincreasedhyperpolarizationreducesneuralexcitabilitybymakingitmoredifficultforthecelltodepolarize.68DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛69DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thismeansthatamuchlargerthannormalstimulusisrequiredtoreachthethreshholdpotentialandgenerateanactionpotential.70DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛IVbarbituratebindingtotheGABAreceptorcomplexalsoincreasesthedurationofGABA-activatedchloridechannelopening.71DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛72DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,higherconcentrationsofbarbituratesmaydirectlyactivatechloridechannelopeningevenintheabsenceofGABA,leadingtobarbiturateanesthesia”.73DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inadditiontotheiractionsonthesechloridechannels,generalanestheticsalsodecreasethedurationofopeningofvariouscationchannels(K1+,Ca2+).74DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisenhancesthehyperpolarizationofthemembrane.75DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Generalanesthesiausuallyrequiresmorethanonedrug.Multiplemedicationsareusedtorapidlycauseunconsciousnessandmusclerelaxationandtomaintaindeepanesthesia.76DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛IVagentsareusuallyadministeredfirstbecausetheyactwithinafewseconds.77DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Afterthepatientlosesconsciousness,inhaledagentsareusedtomaintaintheanesthesia.78DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisapproachallowsthedoseofinhalationanesthetictobelowersothattheprocedureissaferforthepatient79DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Generalanesthesiaoccursindistinctstepsorstages:80DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Stage1Lossofpain,lossofgeneralsensation,butthepatientmaybeawake81DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Stage2ExcitementandhyperactivityThepatientmaytrytoresist,theirheartbeatandbreathingmaybecomeirregularandbloodpressurecanincrease.82DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theanesthesiologistwilltrytoquicklymovethroughstage2.OftenanIVagentwillbegiventocalmthepatientduringthisstage.83DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Stage3CalledsurgicalanesthesiaSkeletalmusclesbecomerelaxed,cardiovascularandbreathingactivitiesstabilize84DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Eyemovementsslowdownandthepatientbecomesverystill.Thisisthestagewhensurgerybeginsandremainsuntiltheprocedureends.85DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Stage4,oroverdoseThisismarkedbyhypotensionorcirculatoryfailure.Deathmayresultifthepatientcannotberevivedquickly.86DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛2.InhaledgeneralanestheticsTheseagentsarenonflammable,nonexplosivegasesorvolatileliquids.87DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Oneoftheirmajoradvantagesisthatthedepthofanesthesiamaybeveryquicklychangedbyalteringtheconcentrationoftheagent.88DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Themedianalveolarconcentration(MAC)isatermusedtodeterminethepotencyofvariousinhalationanesthetics.89DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisthemedianeffectivedose(ED50)oftheanesthetic,andisexpressedasthe%ofthegasinthemixturenecessarytoachieveananestheticeffect.90DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ThesmallertheMAC,themorelipidsolubleistheanesthetic,andthelowertheconcentrationoftheanestheticneededtoproduceanesthesia.Therefore,themorepotentistheanesthetic.91DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Anesthetic MAC value, in %Isoflurane1.2Sevoflurane2.0Desflurane6.0Nitrousoxide10092DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Alloftheinhalationanesthetics(exceptnitrousoxide)arerespiratorydepressants.93DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Isofluraneismoredepressantthandesfluraneandsevoflurane94DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛All3increasetherestingpartialpressureofCO2inarterialblood(PaCO2),increasetheapneicthreshold,anddecreasetheventilatorresponsetohypoxia.95DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theseeffectscanbemitigatedbymechanicallyassistingventilation.96DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.Nitrousoxide(laughinggas)Thisistheonlygasusedroutinelyforanesthesia.97DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisnotverysolubleinbloodandtissues,whichenablesittomoveinandoutofthebodyveryrapidly98DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Usedfordentalproceduresandbriefobstetricalandsurgicalprocedures99DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛SeeYoutubevideofromthePinkPantherStrikesagain(GooglevideoPeterSellers;Clouseau,Dentist)100DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itmayalsobeusedtogetherwithothergeneralanesthetics.101DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Nitrousoxideinhigherdoseshasbeenfoundtodepresstheheart.102DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛3.VolatileanestheticsTheseareliquidatroomtemperature,convertedintoavaporandinhaled103DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ThemostcommonlyadministeredliquidvolatileagentsintheU.S.are:desflurane(Suprane)Sevoflurane(Ultane)Isoflurane(Forane)104DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.desfluraneAdvantages:rapidonsetandrecoveryofanesthesia(usefulforoutpatientprocedures)oneofleastmetabolizedtotoxicbyproducts105DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Disadvantages:lowvolatility,sorequiresaspecialvaporizerpungentandirritatingtotheairway(leadingtomorecoughing,laryngospasm,soitisnotasusefulforextendedsurgicalprocedures)106DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,whenhighinspiredgasconcentrationsareadministered,thereisasignificantincreaseinthepatientsbloodpressureandheartrate.107DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛sevoflurane:Advantages:rapidonsetandveryrapidrecoveryofanesthesia(usefulwithchildren)Notaspungentasdesflurane(alsousefulwithchildren)108DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Hasgoodbronchodilatingpropertiesandistheagentofchoiceinpatientswithasthma,bronchitis,andCOPD.Ithaslittleeffectontheheartrate.109DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Disadvantages:ItsmetabolismresultsinF1-whichmayreachtoxiclevelsinkidneys110DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,carbondioxideabsorbentsinanesthesiamachinesdegradesevofluranetoafluorinatedhydrocarbon,whichisdegradedbyrenallyaseenzymestoathioacylhalide.111DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thiscompoundhasbeenobservedtocausenecrosisoftheproximaltubuleinrats.112DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛isoflurane:Advantages:Itcausesperipheralvasodilationandincreasedcoronarybloodflow(usefulinpatientswithischemicheartdisease)oneofleastmetabolizedtoF1-113DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Disadvantages:moderatesolubility,sorecoveryfromanesthesiamaybedelayed114DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Isofluranecanmaketheheart“moresensitive”tocirculatingcatecholamines(likeepinephrine).115DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thiscouldleadtoaventriculararrhythmiainpatientswithheartdiseasewhoaregivenepinephrineincombinationwithananesthetic,orinchronicallyanxious,“TypeA”patients(theyhavehighercirculatinglevelsofendogenousepinephrine).116DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛C.IntravenousanesthesiaIntravenousanesthesiaisusedfortherapidinductionof,butnotthemaintenanceofanesthesia.117DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Themaintenanceofanesthesiaiswithaninhalationanesthetic.118DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereare5categoriesofdrugsusedasintravenousanesthetics:119DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛1.Benzodiazepines(BZ)The3maindrugsusedinthiscategoryarediazepam,lorazepamandmidazolam.120DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theysedate,relieveanxiety,andcontrolacuteagitation,thereforetheirprimaryindicationisforpremedication.121DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theyareinadequateforuseinsurgicalanesthesia“ontheirown”,andmustthereforebeusedwithanotheranestheticagent(i.e.aninhalationanesthetic).122DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.diazepam(Valium)ThisistheprototypedrugoftheBZs123DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itiswater-insoluble,soIVuserequiresanonaqueousvehiclewhichcancauselocalirritation/pain124DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.midazolam(Versed)Midazolamiswatersoluble,sodrugofchoiceforIVadministration125DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛IthasamorerapidonsetandmorerapideliminationthantheotherBZs.126DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,midazolamisthemostpotentamnestic127DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.lorazepam(Ativan)Itiswater-insoluble,soIVuserequiresanonaqueousvehiclewhichcancauselocalirritation/pain128DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisalesspotentamnesticthanmidazolam,butamorepotentamnesticthandiazepam.129DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛2.BarbituratesThe3maindrugsusedinthiscategoryarethiopental,thiamylal,andmethohexital.130DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theirhypnoticactivityisduetosidechainsatposition5(especiallyifoneofthemisbranched).131DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereisamorerapidonsetandshorterdurationofactionifthereisasulfurinsteadofoxygenatomatposition2(so,thiamylalandthiopentalhavemorerapidonsetandshorterdurationofactionthanmethohexital).132DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Noneofthesedrugsprovidesanalgesiaorsignificantmusclerelaxation.133DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Likemostofthe“older”drugs,barbiturateshaveaworsetoxicologicalprothebenzodiazepines134DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theyallmaycausecoughing,laryngospasm,bronchospasm,orapnea.135DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛136DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.ThiopentalThiopental,theflagshipofthebarbiturateanestheticgroup,hasbeenastandardanestheticinductionagentformorethan60yearsandisthedruginthiscategory,towhichallothersarecompared.137DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.Thiamylal138DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.Methohexitol139DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thiamylalisnotsignificantlydifferentfromthiopentalinpotency,incidenceoflaryngospasm,respiratorydepression,cardiotoxicityorrecoverytime.140DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛3.OpioidsThetermsopioidandopiateareoftenusedinterchangeably,buthavedifferentmeanings.141DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Anopiateisderivedfromthejuiceoftheopiumpoppy,Papaver Somniferum,whichiscommonlycalledWhitePoppyandHerbofJoy.142DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛143DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Anopioidisacompound,eithersynthetic,oranaturalproductwhichhasmorphine-likeeffects.144DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Opioidsproducemoderatesedationandprofoundanalgesia.Theyexerttheireffectsbybindingwithopioidreceptorsinthecentralnervoussystem.145DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛146DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereare3majoropioidreceptorsclassified,functionally,as(mu),(kappa),and(delta).147DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereispharmacologicalevidenceforsubtypesofeachreceptorinadditiontoother,lesswell-knownopioidreceptors,epsilon(),zeta(),iota()andlambda().148DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereisacommongeneralstructurefoundinallopioidreceptorsembeddedinplasmamembranes.Theyare,usually,linkedtoaGprotein.149DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Oncethereceptorsarebound,aportionoftheGproteinisactivated,allowingittodiffusewithintheplasmamembrane.150DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛TheGproteinmoveslaterallywithinthemembraneuntilitreachesitstarget,anionchannel.151DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛TheionchannelsareinvolvedwitheitherareductionofCa2+influxoranincreaseinK1+efflux.152DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Eitheroftheseresultsinhyperpolarization(becomingmorenegative)whichimpairsthefiringofneuronsandneurotransmitterrelease.153DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Opioidsmaybeusedtosupplementanesthesiawhenotheranestheticdrugsdontadequatelycontrolpainreactions.154DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theymaybeusedasinductionagentsorastheprimarydrugforthemaintenanceofanesthesiawhenhemodynamicstabilityisessential155DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thehighdosesrequiredtoproduceunconsciousnessdonotdepressthemyocardium,nordotheycauseasignificantreductioninbloodpressure.156DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Dosesmustbeatleast10timesthedoseusedforcontrolofpaininambulatorypatients,thusthisisreferredtoashighdoseopioid.157DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛OpioidsdepressrespirationbyinhibitingtheresponsivenessofthemedullaryrespiratorycentertoPCO2andaltertherhythmofbreathing.158DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Consequently,itisnecessarytoassistventilation.159DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Sincerespiratorydepressionmayextendintothepost-operativeperiodasaresultofdrugaccumulationinthetissues,theuseofopioidswhoseclearancesareslowremainmostappropriateforpatientswhoareexpectedtorequirep.o.ventilatorycare.160DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theopioidsmostcommonlyusedarefentanyl(Sublimaze)sufentanilcitrate(Sufenta)alfentanil(Alfenta)remifentanil(Ultiva)161DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.fentanyl(Sublimaze)Oneofthemostfrequentlyusedbecauseofhowquicklyitproducesanalgesia162DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Fentanylisapotentsyntheticopioidagonistwithbetween50-100timestheanalgesicpotencyofmorphine.163DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Fentanylisusedtoaidinductionandmaintenanceofgeneralanesthesiaandtosupplementregionalandspinalanesthesia.164DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Fentanylispreferredtomorphineinanesthesiaduetoitsabilitytomaintaincardiacstability.165DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Fentanylmaybeadministeredaloneorincombinationwithinhalationanesthetics,localanesthetics,orbenzodiazepines.166DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.sufentanilcitrate(Sufenta)Rapidinductionofanalgesia(similartoFentanyl)167DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.alfentanil(Alfenta)168DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Comparedtofentanylandsufentanil,alfentanilhasashorterdurationofactionbecauseitshighproteinbindingandrelativelylowlipidsolubilityfavoritssequestrationinplasma169DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛d.remifentanil(Ultiva)170DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛RemifentanilisultrashortactingandrapidlyclearedbecauseitsesterlinkagesaresusceptibletohydrolysisbyesterasesintissuesandRBCs.171DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisconvertstheesterfunctionalgroupintoaninactivecarboxylicacidmetabolite.172DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisparticularopioidisusefulwhendealingwithpatientswithliverorkidneyfailure.173DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Lesspotentopioidssuchasmorphineanddemerolhavefallenintodisfavorbecauseoftheiradverseeffectswhengiveninhighdoses.174DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛DemerolmaycauseV-tach175DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Morphinemayproducehypotensionandbronchoconstrictionasaconsequenceofitshistamine-releasingaction.176DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Oneofthemostseriousdrawbacksoftheopioidanestheticsoverall,isthepossibilityofinadequateanestheticdepth.177DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Signsofthisincludesweating,wrinklingoftheforehead,andopeningoftheeyes.178DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Topreventthis,thehighdoseopioidtechniquesmaybesupplementedwithinhalationanestheticsorhypnoticssuchasbenzodiazepines(midazolamforshortercases,lorazepamforcaseslongerthan4hours),ormorerecently,propofol.179DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛However,theuseofthesemayresultinsomelossofcardiovascularstability.180DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛4.DissociativeanestheticsThisrelatestoatypeofgeneralanesthesiathatischaracterizedbyamnesia,sedation,andanalgesia,althoughthepatientappearstobeawake.181DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Oneofthedissociativeanestheticscommonlyusedisketamine(Vetalar,Ketaset).182DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ketamine,isanN-methyl-D-aspartate(NMDA)receptorantagonist.183DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ketamineblockstheionchannelinthefollowingdiagram184DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itincreasesbloodpressureandincreasescardiacoutput(usefulinpatientsexperiencingshock)185DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ketaminehasbothverypoormusclerelaxationandanalgesicactivity.186DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ketaminemaybeused,alongwithdiazepamforcosmetic/reconstructivesurgeryanesthesia.187DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisnotwidelyusedforanesthesiaasittendstoinducepostoperativehallucinations.188DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itissometimesusedasarecreationaldrug,butithasanumberofadverseeffects:189DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛lossofcoordination190DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛exaggeratedsenseofstrength191DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛blankstare192DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛slurredspeech193DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ABBCreportinMay2000claimedthatmedicalresearchhadshownthatcontrolledtestsonketamineusershadrevealedimpairedmemoryandmildschizophreniaseveraldaysaftertakingthedrug.194DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛KetaminewasclassifiedasaClassCdrugin2005.OtherclassCdrugsincludecannabisandanabolicsteroids 195DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ketamineplaysanextensiveroleintheseason2finaleofHouse,M.D,titled“Noreason”196DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛5.Propofol(Diprivan)FromDI-isoPRopyl IV ANestheticchemicalname:2,6-diisopropylphenol197DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Propofolisasedative/hypnoticthatcanbeusedforinductionormaintenanceofgeneralanesthesia.198DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisalsousedforsedatingintubated,mechanicallyventilatedpatients.199DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Analgesiceffectispoorandadditionofananalgesictotheanestheticregimenisnecessaryforsurgery.200DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Advantages:RapidinductionandrecoverytimesItcanbegivenforprolongedperiodswithoutresultinginprolongedrecovery201DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Disadvantages:apneabradycardiaandhypotension.202DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Propofolsabuseasarecreationaldrug(itproduceseuphoria)hasbeenseen,insomeanesthesiologistswhohaveaccesstothedrug.203DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Inaddition,MichaelJacksonsdeathinJune2009hasbeenattributedtoa“cocktail”ofpropofolandotherdrugs204DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Jacksonscardiologist,Dr.ConradMurrayhadbeenadministeringtoJackson50mgofpropofolIV,nightlyfor6weeksforhisinsomnia.205DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛FearingthatJacksonwasforminganaddictiontotheanesthetic,heattemptedtoweanhimbyloweringthedoseto25milligramsandaddingthesedativeslorazepamandmidazolam.206DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛AccordingtotheMSNBCnewsservice,thesequenceofdrugsgiven,onthedayofhisdeathwere:1:30 a.m. 10 mg tablet of diazepam2 a.m. 2 mg, IV of lorazepam 3 a.m. 2 mg, IV of midazolam5 a.m. 2 mg, IV of lorazepam 7:30 a.m. 2 mg, IV of midazolam 10:40 a.m. 25 mg, IV of propofol diluted with lidocaine 10:50 a.m. Dr leaves Jacksons room; returns minutes later to him not breathing. Administers 0.2 mg of flumazenil (a BZ antagonist)207DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛D.NeuromuscularblockingdrugsThesedrugsareusedduringsurgery(especiallyintra-abdominalandintra-thoracic),andtoaidintubationforsurgicalanddiagnosticprocedures(endoscopy).208DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Previously,adequatemusclerelaxationwasonlypossiblewithdeepanesthesia(whichleadstoCNSdepressanteffects).209DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛ContractionofskeletalmusclesisvoluntarilycontrolledbyimpulsesthatoriginateintheCNS.210DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Impulsesfromthebrainareconductedthroughthespinalcordtothesomaticmotorneutrons.211DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Somaticmotorneuronseventuallyconnectwithskeletalmusclefibersforminganeuromuscularjunction(NMJ).212DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theneuronalendingsofthesomaticmotorfiberscontaintheneurotransmitteracetylcholine(ACH).213DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛WhenACHisreleasedintotheneuromuscularsynapses,itbindstoreceptorsknownasnicotinic-II(NII)receptors.214DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛215DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛NeuromuscularblockersinhibitskeletalmusclecontractionbyinterferingwiththeNIIreceptors.216DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thereare2typesofneuromuscularblockers:nondepolarizingdepolarizing217DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛1.NondepolarizingblockersThesebindtothereceptorsbutdonotstimulatethereceptors.TheyarestructurallysimilartoACHandfunctionasacompetitiveinhibitor.218DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Bybindingtothenicotinicreceptor,theypreventACHfrombindingandinhibitmuscularcontraction.219DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theydonotcausethesodiumchannelsinthemembranetoopen,thereforenodepolarizationofthereceptoroccurs.220DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Remember,therestingmembranepotential(ontheinsideofthecellmembrane)istypically70mV,withclosedsodiumchannels.Anyshiftfromtherestingpotentialtoward0mViscalledadepolarization.221DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛AfterI.V.injection,thereisgenerally,arapidonsetofeffects:1st:Finemusclesaffected(thoseofeyes&fingers)222DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛2nd:limbs,neck&trunk223DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛3rd:intercostalmuscles4th:diaphragm224DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Recoveryisinthereverseorder225DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛a.TubocurarineThisistheprototypeofthenon-depolarizingneuromuscularblockers.Itisfoundincurare,whichderivesfromtheSouthAmericanplantgenusStrychnos.226DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛227DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Ithasaslowonset(5min)andalongdurationofaction(1-2hours),anditisnotcommonlyusedanymore.228DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛b.Pancuroniumbromide(Pavulon)Fullmuscleparalysisformajorsurgeryisachievedinabout24minutes,recoveryisabout2-3hours229DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itisalsofoundasoneofthecomponentsinlethalinjections.AmnestyInternationalhasobjectedtothisusestatingthatitmaymaskthecondemnedprisonerssufferingduringtheexecution”.230DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛PancuroniumbromidewasoneofthecompoundsusedbyEfrenSaldivar,theAngelofDeath”.231DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Hewasaserialkillerwhomurderedpatientswhileworkingasarespiratorytherapist.232DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛HewasemployedbytheGlendaleAdventistMedicalCenter,workingthenightshift,whentherewerefewerstaffonduty.233DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thepolice,insearchingforevidencestrongenoughtoobtainacourtconviction,exhumedtheremainsof20patientswhohaddiedduringthetimeSaldivarwasonduty.234DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛TheywerespecificallylookingforunusuallyhighlevelsofPavuloninthecadaver,asthisdrugremainsidentifiableformanymonths.235DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛6ofthe20cadavershadevidenceofalethalconcentrationofPancuroniumbromide.236DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛In2002,Saldivarpleadedguiltytosixcountsofmurderandreceivedsixconsecutivelifesentenceswithoutthepossibilityofparole.237DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛c.Atracuriumbesylate(Tracrium)anditsisomercisatricuriumbesylate(Nimbex)238DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theyarewidelyusedandhaveanintermediateduration(recoveryis95%completeonehourafterinjection).239DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛However,abreakdownproductofatracurium,laudanosinemayaccumulateduetoveryslowhepaticmetabolismanduponcrossingintothebrainmaycauseseizures240DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Cisatracuriumhaslesslaudanosineformedandlesshistaminereleasedthanatracurium.241DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛FederalregulatorshavecitedSt.MargaretMercyHealthcareCentersinIndianafordispensingTracriumtoHammondFireDepartmentCapt.MichaelMagdziarzinJanuary2002.242DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Magdziarzhadunderwentasuccessfulbypasssurgeryandwasrecovering.Hissurgeonhadorderedapenicillintofightinfection.Instead,thenurseadministeredTracrium.243DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Hebecamerestless,complainedofshortnessofbreath,stoppedbreathingandsufferedcardiacarrest.244DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛d.Vecuroniumbromide(Norcuron)Thishasashorterdurationofactionthanpancuronium(recoveryis95%complete45minutestoonehourafterinjection).245DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Itslackofsignificantcardiovasculareffectsandlackofdependenceongoodkidneyfunctionforeliminationprovideadvantagesoverotherneuromuscularblockingagents.246DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Overall,theextentofadverseeffectsonthenondepolarizingneuromuscularblockersdependsonthespecificagent.247DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Theolderdrugs(i.e.tubocurarine,pancuronium)tendtohavemorecardiovascularactions(bloodpressureandheartratechanges)aswellashistaminerelease,andmoredifficultywiththeircontrolledreversal.248DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thenewerdrugs(i.e.vercuronium)tendtohaveminimaltonocardiaceffects,slighttonohistaminerelease,andaneasierreversal.249DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛2.DepolarizingDepolarizingagentsarealsostructurallysimilartoacetylcholineandfunctionascompetitiveinhibitors.250DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛However,whentheybindtothenicotinicreceptor,theycausethesodiumchannelsinthemembranetoopen,leadingtodepolarizationofthereceptor.251DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thesesodiumchannelsonlyopenbrieflyandcannotbeopenedagainuntilthemembraneisrepolarized.252DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Depolarizingneuromuscularblockersactaspersistentagonistsatnicotinereceptors,butunlikeacetylcholine,theirrelativelyslowerdegradationrateresultsinparalysis.253DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Generationofanactionpotentialrequiresarapidchange (increase)ofmembranepotentialfromanegativestate.254DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Asthesedrugsareeventuallyclearedandreceptorsbecomeunoccupied,theyreverttotheoriginalactivestate.255DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Succinycholineistheonlydruginthisclassthatisusedbyanesthesiaproviderstoday.256DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛257DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thedurationofactionofsuccinylcholineisveryshort,becauseitismetabolizedinthebodyveryquicklybyanenzymecalledplasmacholinesterase.258DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thisshortdurationofactionmakessuccinylcholineausefuldruginsituationswheremusclerelaxationisneededforonlyashorttimesuchastofacilitateintubation.259DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Sideeffectsofsuccinycholineinclude:fasciculations(smallmusclemovementscausedwhenthedrugbindstoreceptors)260DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛myalgias(musclesorenesswhichmaybetheresultofthefasciculations)261DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛cardiacrhythmdisturbancesincreasesinocularandgastricpressure,262DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛hyperkalemiainat-riskpatients263DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛malignanthyperthermia:adramaticincreaseinbodytemperature,acidosis,electrolyteimbalanceandshock264DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛Thesyndromeisthoughtobeduetoareductioninthereuptakeofcalcium,whichisnecessaryforterminationofmusclecontraction.Consequently,musclecontractionissustained.265DRUGSUSEDFORANESTHESIAMUSCLERELAXATION用于麻醉的药物肌肉松弛