警惕：阿片类诱发肌肉强直，可致患者窒息缺氧

本文由“小麻哥的日常”授权转载

昨天碰到一例特殊的情况：

一例成年男性舌根血管瘤患者拟上全身麻醉，判断为困难气道，采取半清醒经鼻纤支镜引导气管插管。插管前静脉推注舒芬太尼10ug，咪达唑仑1mg，静注后发现患者肌肉强直，氧饱和度下降，面罩供氧气道阻力非常大，所幸发现面罩供氧困难后立即纤支镜引导气管插管成功，然后给予丙泊酚和罗库溴铵后肌肉松弛，机控呼吸正常，氧合迅速上升，恢复正常。纤支镜插管期间发现舌根血管瘤没有阻塞气道，没有发现明显的气道阻塞情况，考虑面罩通气困难与肌肉强直有关。

查阅文献，阿片类导致肌肉强直的时有报道，分享一篇供参考和借鉴。

摘要译文（供参考）

危重病人芬太尼诱发的胸壁强直综合征

背景：

阿片类药物诱导的胸壁强直最早出现在20世纪50年代早期，被称为芬太尼诱导的胸壁强直综合症（fentanyl induced rigid chest syndrome，FIRCS）。

通常出现在程序性镇静和支气管镜检查中，以胸壁和腹肌强直、非同步通气和呼吸衰竭为特征。

在危重成人患者持续镇痛的情况下，FIRCS很少被描述。

我们假设FIRCS可发生在这种情况下，并且可能未被认识到，从而导致发病率和死亡率的增加。

方法：

回顾性分析重症监护病房疑似FIRCS患者的临床表现及治疗策略。

结果：

42例有FIRCS症状的患者。 42例有描述性记录的患者中，22例(52.4%)检查时有胸或腹肌强直的证据。 仅接受纳洛酮治疗的16名患者中有12名(75%)在干预后记录了呼吸机依从性，而仅接受顺阿曲库铵治疗的11名患者中有6名(55%)在干预后记录了呼吸机依从性。 在接受顺阿曲库铵初始治疗后最终接受纳洛酮治疗的12名患者中，9名患者在纳洛酮给药后记录了呼吸机依从性(75%)。 标准干预，包括镇静优化和呼吸机调整，尝试排除和治疗其他潜在的不同步原因。 在大多数情况下，纳洛酮给药导致呼吸机和患者自主呼吸的顺应性均适当，提示呼吸机不同步是由芬太尼引起的。

结论：

这是迄今为止描述重症监护环境中FIRCS的最大病例系列。 认识和及时管理是改善患者结局的必要条件。 需要开展研究以提高认识，识别患者风险因素，并分析干预措施的有效性和安全性。

关键词：

非同步步通气；芬太尼；胸壁强直；呼吸机不依从性。

原文摘要

Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

Background:  Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality. 

Methods:  Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS. 

Results:  Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl. Conclusions:  This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions. 

Keywords:  asynchronous ventilation; fentanyl; rigid chest; ventilator noncompliance. 

免责声明：

文中所涉及药物使用、疾病诊疗等内容仅供医学专业人士参考。

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编辑：MiSuper.米超

校对：Michel.米萱

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