《右旋美托嘧啶顾小萍》由会员分享，可在线阅读，更多相关《右旋美托嘧啶顾小萍（65页珍藏版）》请在金锄头文库上搜索。
1、右旋美托嘧啶的术后镇痛应用右旋美托嘧啶的术后镇痛应用南京大学医学院附属鼓楼医院麻醉科南京大学医学院附属鼓楼医院麻醉科 顾小萍顾小萍p镇痛p镇静p精准麻醉p可视化操作麻醉医师，是舒适化医疗的主要参与者麻醉医师，是舒适化医疗的主要参与者p刺激交感系统p增加心肌氧耗p延缓患者自主活动恢复p改变免疫系统p诱发慢性疼痛术后镇痛，是舒适化医疗的重要组成术后镇痛，是舒适化医疗的重要组成右旋美托咪啶右旋美托咪啶:D:Dexmedetomidineexmedetomidineq高效、高选择性和特异性高效、高选择性和特异性的的2受体激动剂受体激动剂q抑制交感神经活性抑制交感神经活性q镇静、催眠和麻醉作用镇静、催眠
2、和麻醉作用q镇痛作用镇痛作用镇静作用镇静作用p蓝斑是大脑内负责调解觉醒与睡眠的关键部位p蓝斑是下行延髓- 脊髓去甲肾上腺素能通路的起源，其在伤害性神经递质的调控中起重要作用l2-受体激动剂作用于去甲肾上腺素能神经元突触前膜2-受体，减少去甲肾上腺素释放，从而产生镇静作用。 2 2 激动剂激动剂初级传入纤维初级传入纤维皮层皮层丘脑丘脑中脑中脑延髓延髓p镇痛作用的位点可能位于脊髓，脊髓中存在肾上腺素能下行抑制系统。2-受体激动剂激动脊髓背角2-受体，产生镇痛作用。 镇痛作用镇痛作用对循环系统的影响对循环系统的影响p作用于中枢，抑制交感神经发放冲动，从而使血压下降、心率减慢。p作用于外周血管平滑肌的
3、2B-受体，可使血管收缩，出现一过性的血压升高，小剂量缓慢注射可避免这一现象的出现。 对其它系统的影响对其它系统的影响p呼吸系统 无明显呼吸抑制p肾脏功能 利尿作用p内分泌系统 减少去甲肾上腺素、胰岛 素、皮质醇的释放。pDEX作为关节腔的注射用药在术后镇痛中的应用pDEX作为神经阻滞的复合用药在术后镇痛中的应用pDEX作为阿片类药物的辅助用药术后镇痛中的应用DEX在术后镇痛中的应用在术后镇痛中的应用DEX作为关节腔的注射用药在术后作为关节腔的注射用药在术后镇痛中的应用镇痛中的应用Sixty patients ， double-blind placebo controlled . contro
4、l group: i.v. 20ml saline and intra-articular 20ml saline the intra-articular group: i.v. 20ml saline and intra-articular 20ml saline+dexmedetomidine1ug/kg the i.v. group : i.v. 20ml saline+dexmedetomidine1ug/kg and intra-articular 20ml saline. 1.significant reduction in pain scores for 6 h after op
5、eration in the intra-articular group but only for 1 h in the i.v. group. 2.The time to first postoperative analgesic request was longer in the intra-articular group 312.0 (SD 120.7) min compared with the control group 71.0 (50.1) min and the i.v. group 102.1 (54.4) min (P0.001). 3.total diclofenac r
6、equirement was significantly lower in the intra-articular group 90.0 (46.2) mg than in the control group 165.0 (52.2) mg and in the i.v. group 129.3 (54.3) mg (P4.Timeoffirstanalgesiarequestandtotalrescueanalgesicusedin24hourswerecalculated.RESULTS: Timeforrequirementoffirstpostoperativerescueanalge
7、siainGroupAwas380.6122.973min,inGroupBwas326.8217.131minandinGroupCwas244.0920.096minutes.TotalrescueanalgesiarequirementwaslessinGroupA(1.3940.496)comparedtoGroupB(1.7580.435)andGroupC(2.5460.546).GroupAhadhighermeanVASscoreat6(th)and24(th)postoperativehours.Nosideeffectsfoundamongthegroups.CONCLUS
8、ION: intra-articularropivacainegivesbetterpostoperativepainreliefincreasedtimeoffirstanalgesicrequestdecreasedneedoftotalpostoperativeanalgesiacomparedtofentanylanddexmedetomidine.DEX作为神经阻滞的复合用药作为神经阻滞的复合用药药在术后镇痛中的应用药在术后镇痛中的应用DEX作为阿片类药物的辅助用作为阿片类药物的辅助用药在术后镇痛中的应用药在术后镇痛中的应用Therewasalsoevidenceofadecreas
9、einpainintensityat24h;theweightedmeandifferencewas-0.7cm(-1.2to-0.1)ona10-cmvisualanalogscalewithclonidineand-0.6cm(-0.9to-0.2)withdexmedetomidine.Therewasalsoevidenceofadecreaseinpainintensityat12h;theweightedmeandifferencewas-1.5cm(-2.1to-1.0)ona10-cmvisualanalogscalewithclonidineand-1.4cm(-2.7to-
10、0.2)withdexmedetomidineat1h. Theincidenceofearlynauseawasdecreasedwithboth(numberneededtotreat,approximatelynine).Clonidineincreasedtheriskofintraoperative(numberneededtoharm,approximatelynine)andpostoperativehypotension(numberneededtoharm,20).Dexmedetomidineincreasedtheriskofpostoperativebradycardi
11、a(numberneededtoharm,three).RCONCLUSIONS:Perioperativesystemic2agonistsdecreasepostoperativeopioidconsumption,painintensity,andnausea.Recoverytimesarenotprolonged.Commonadverseeffectsarebradycardiaandarterialhypotension.Theimpactof2agonistsonchronicpainorhyperalgesiaremainsunclearbecausevaliddataare
12、lacking.METHODS:double-blinded,randomized,controlledstudy,100womenundergoingabdominaltotalhysterectomywereallocatedGroupM：receiveeithermorphine1mg/mlGroupD:morphine1mg/mlplusdexmedetomidine5ug/mlpostoperative i.v. PCA, which was programmed to deliver 1 ml per demand with a 5 min lockout interval and
13、 no background infusion.CumulativePCArequirementspainintensitiescardiovascularandrespiratoryvariablesPCA-relatedadverseeventswererecordedfor24hafteroperation.ComparedwithGroupM,patientsinGroupDrequired29%lessmorphineduringthe0-24hpostoperativeperiodandreportedsignificantlylowerpainlevelsfromthesecon
14、dpostoperativehouronwardsandthroughoutthestudy.decreasesinheartratefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byarangeof5-7beatsmin(-1)respectively).decreasesinmeanbloodpressurefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byaran
15、geof10-13%,respectively).Whereaslevelsofsedationweresimilarbetweenthegroupsateachobservationaltimepoint,The4-24hincidenceofnauseawassignificantlylowerinGroupD(34%vs56.3%,P0.05).Therewasnobradycardia,hypotension,oversedation,orrespiratorydepressionCONCLUSIONS:Theadditionofdexmedetomidinetoi.v.PCAmorp
16、hineresultedinsuperioranalgesiasignificantmorphinesparinglessmorphine-inducednauseadevoidofadditionalsedationanduntowardhaemodynamicchanges.PATIENTS:Onehundredandtwentyparturients(AmericanSocietyofAnesthesiologistsclass1or2)scheduledforelectivecaesareandeliveryunderspinalanaesthesiarandomlyallocated
17、intothreegroups(n=40each).INTERVENTIONS:Group1:physiologicalsalinebolusafterdeliveryandsufentanilPCA,Group2:dexmedetomidinebolus(0.5gkg)afterdeliveryandsufentanilPCAGroup3:dexmedetomidinebolus(0.5gkg)afterdeliveryandsufentanilwithdexmedetomidinePCA(backgroundinfusionof0.045gkghwithabolusof0.07gkg).P
18、ThandPTThweresignificantlyincreased1hafterdrugadministrationingroups2(1.590.45,2.570.46mA)and3(1.740.37,2.560.48mA)comparedwithgroup1(1.490.49,2.420.62mA)(P0.05).实验结果1 Sufentanilconsumptioningroup3was43.919.2g,significantlylowerthaningroup1(54.523.9g)andgroup2(56.320.6g)(P0.05).Comparedwithgroup3,VA
19、Swasincreasedat4,8and24haftersurgeryingroups1and2(P0.05);therewasnodifferencebetweengroups1and2实验结果实验结果2 2*实验结果3Proc(BaylUnivMedCent).2014Jan;27(1):3-10.METHODS:Thirty-eightthoracotomypatientswereadministereddexmedetomidineintraoperativelyandovernightpostoperativelyandthenrandomizedtoreceiveplaceboo
20、rdexmedetomidinetitratedfrom0.1to0.5gkgh(-1)thedayfollowingsurgeryforupto24hoursonatelemetryfloor.Opioidsviaapatient-controlledanalgesiapumpwereavailableforbothgroups,andvitalsignsincludingtranscutaneouscarbondioxide,pulseoximetry,respiratoryrate,andpainandsedationscoresweremonitored.Thedexmedetomid
21、inegroupused41%lessopioidsbutachievedpainscoresequaltothoseoftheplacebogroup.Themeanrespiratoryrateandoxygensaturationweresimilarinthetwogroups.Mildhypercarbiaoccurredinbothgroups,butperiodsofsignificantrespiratorydepressionwerenotedonlyintheplacebogroup.Significanthypotensionwasnotedinonepatientint
22、hedexmedetomidinegroupinconjunctionwithconcomitantadministrationofabeta-blockeragent.Theplacebogroupreportedahighernumberofopioid-relatedadverseevents.结果4*Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospe
23、ctive study at a tertiary pediatric hospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.PediatrCritCareMed.2014Jul;15(6):e247-52.结果4*DESIGN: Thiswasaretrospectivechartreview.Patientswereseparatedintotwogroups:thosethatreceivedopioidviapatient-controlledanalgesiapai
24、ntherapyalonethosethatreceivedopioidviapatient-controlledanalgesiapaintherapywithdexmedetomidine.PATIENTS: Onehundredsixty-threechildrenwithadolescentidiopathicscoliosis.*MEASUREMENTS AND MAIN RESULTS: Measurementsincludedpatientdemographics,AmericanSocietyofAnesthesiologistsPhysicalStatusClassifica
25、tionSystem,levelsofspinalfusion,lengthofhospitalstay,complications,numericpainscores,opioidrequirement,elastomericpainpumpuse,lengthoftimeuntilambulation,adverseeffects,andnaloxoneuse.Datawerecollectedthroughthefirst72hoursoftheperioperativeperiod.Onehundredsixpatientsreceivedopioidsviapatient-contr
26、olledanalgesiatherapywithdexmedetomidineand57receivedopioidsviapatient-controlledanalgesiaalone.Withinthegroups,therewere46patientswhoreceivedlocalanestheticinfusionsviaelastomericpumpsinthepatient-controlledanalgesiawithdexmedetomidinegroupand16patientshadpumpsinthepatient-controlledanalgesia-alone
27、group.Therewasnooveralldifferenceinpostoperativeuseofmorphine(orequivalents)betweenthetwogroups.However,theuseofelastomericpainpumpsdemonstratedastatisticallysignificantdecreaseinmeanoverallopioidconsumption(42.6mgvs63.1mg,p0.001).*CONCLUSIONS: Therewasnodifferenceinopioiduserelatedtodexmedetomidine
28、onanypostoperativeday.Theonlyvariableshowingasignificantopioidsparingeffectwastheuseoflocalanestheticinfusionsviaelastomericpumps.UsingcontinuouslocalanestheticinfusionsinsteadofdexmedetomidinecouldeliminatetheneedforICUadmission,requireshorterhospitalstays,andreducecostswhilestillprovidingsafeandef
29、fectivepaincontrol.*Comparison of patient-controlled analgesia with and without dexmedetomidine following spine surgery in children.SadhasivamS1,BoatA,MahmoudM.JClinAnesth.2009Nov;21(7):493-501*DESIGN: Retrospectivecomparison.SETTING: University-affiliatedchildrenshospital.MEASUREMENTS: Themedicalch
30、artsof131childrenwithidiopathicscoliosis(IS)andNMSwhohadmajorspinesurgerywerereviewed.Outof131,postoperatively94childrenreceivedPCAwithmorphinealone(PCAgroup)andtheremaining37childrenreceivedPCAmorphineanddexmedetomidineinfusionat0.4mcg/kg/hourfor24hours(PCA+Dexgroup).Preoperative,intraoperative,and
31、postoperativemorphineusedatawerecollected.*MAIN RESULTS: IntraoperativeuseofmorphinewassimilarinchildrenwithISandNMS.However,patientswithISusedmoremorphinethanpatientswithNMSonthefirst,secondandthirdpostoperativedaysinbothgroups.InchildrenwithIS,useofmorphineonthesecondpostoperativedaywassignificant
32、lyhigherinthePCA+Dexgroup(73mg50.5,110.5)thanthePCAalonegroup(54mg36,69,P=0.03).TheoverallfrequencyofallperioperativecomplicationswasmoreinthePCAalonegroup(40%vs.32%)thanthePCA+Dexgroup.*CONCLUSION: Postoperative24-hourdexmedetomidineinfusionasanadjuncttoPCAwithopioidsmighthaveamorphine-sparingeffectasevidencedbytheincreaseinmorphineuseonpostoperativeday2afterthedexmedetomidineinfusionwasstopped.DEX具有的镇静、镇痛、抗焦虑、抗交感兴奋作用且对呼吸系统的抑制作用轻微，其在围麻醉期的应用越来越广。关注DEX的临床优越性的同时，其尚未明确的作用机制及安全剂量范围仍需探索，有关副作用仍需提防，以便为临床应用提供更好的基础。展 望
