右旋美托嘧啶顧小萍課件

右旋美托嘧啶的術(shù)后鎮(zhèn)痛應(yīng)用鎮(zhèn)痛鎮(zhèn)靜精準(zhǔn)麻醉可視化操作麻醉醫(yī)師，是舒適化醫(yī)療的主要參與者刺激交感系統(tǒng)增加心肌氧耗延緩患者自主活動恢復(fù)改變免疫系統(tǒng)誘發(fā)慢性疼痛術(shù)后鎮(zhèn)痛，是舒適化醫(yī)療的重要組成鎮(zhèn)靜作用藍(lán)斑是大腦內(nèi)負(fù)責(zé)調(diào)解覺醒與睡眠的關(guān)鍵部位藍(lán)斑是下行延髓-脊髓去甲腎上腺素能通路的起源，其在傷害性神經(jīng)遞質(zhì)的調(diào)控中起重要作用2-受體激動劑作用于去甲腎上腺素能神經(jīng)元突觸前膜2-受體，減少去甲腎上腺素釋放，從而產(chǎn)生鎮(zhèn)靜作用。

2

激動劑初級傳入纖維皮層丘腦中腦延髓鎮(zhèn)痛作用的位點(diǎn)可能位于脊髓，脊髓中存在腎上腺素能下行抑制系統(tǒng)。2-受體激動劑激動脊髓背角2-受體，產(chǎn)生鎮(zhèn)痛作用。

鎮(zhèn)痛作用對循環(huán)系統(tǒng)的影響作用于中樞，抑制交感神經(jīng)發(fā)放沖動，從而使血壓下降、心率減慢。作用于外周血管平滑肌的2B-受體，可使血管收縮，出現(xiàn)一過性的血壓升高，小劑量緩慢注射可避免這一現(xiàn)象的出現(xiàn)。DEX作為關(guān)節(jié)腔的注射用藥在術(shù)后鎮(zhèn)痛中的應(yīng)用DEX作為神經(jīng)阻滯的復(fù)合用藥在術(shù)后鎮(zhèn)痛中的應(yīng)用DEX作為阿片類藥物的輔助用藥術(shù)后鎮(zhèn)痛中的應(yīng)用DEX在術(shù)后鎮(zhèn)痛中的應(yīng)用DEX作為關(guān)節(jié)腔的注射用藥在術(shù)后鎮(zhèn)痛中的應(yīng)用

Sixtypatients，double-blindplacebocontrolled.controlgroup:i.v.20mlsaline

andintra-articular20mlsalinetheintra-articulargroup:i.v.20mlsalineandintra-articular20mlsaline+dexmedetomidine1ug/kgthei.v.group:i.v.20mlsaline+dexmedetomidine1ug/kg

andintra-articular20mlsaline.significantreductioninpainscoresfor6hafteroperationintheintra-articulargroupbutonlyfor1hinthei.v.group.Thetimetofirstpostoperativeanalgesicrequestwaslongerintheintra-articulargroup[312.0(SD120.7)min]comparedwiththecontrolgroup[71.0(50.1)min]andthei.v.group[102.1(54.4)min](P<0.001).totaldiclofenacrequirementwassignificantlylowerintheintra-articulargroup[90.0(46.2)mg]thaninthecontrolgroup[165.0(52.2)mg]andinthei.v.group[129.3(54.3)mg](P<0.05).PainreliefafterArthroscopicKneeSurgery:Acomparisonofintra-articularropivacaine,fentanyl,anddexmedetomidine:Aprospective,double-blinded,randomizedcontrolledstudy.ManuarMB1,MajumdarS1,DasA2,HajraBK1,DuttaS3,MukherjeeD1,MitraT4,KunduR4.SaudiJAnaesth.2014Apr;8(2):233-7.RESULTS:TimeforrequirementoffirstpostoperativerescueanalgesiainGroupAwas380.61±22.973min,inGroupBwas326.82±17.131minandinGroupCwas244.09±20.096minutes.TotalrescueanalgesiarequirementwaslessinGroupA(1.394±0.496)comparedtoGroupB(1.758±0.435)andGroupC(2.546±0.546).GroupAhadhighermeanVASscoreat6(th)and24(th)postoperativehours.Nosideeffectsfoundamongthegroups.CONCLUSION:intra-articularropivacainegivesbetterpostoperativepainreliefincreasedtimeoffirstanalgesicrequestdecreasedneedoftotalpostoperativeanalgesiacomparedtofentanylanddexmedetomidine.DEX作為神經(jīng)阻滯的復(fù)合用藥藥在術(shù)后鎮(zhèn)痛中的應(yīng)用

DEX作為阿片類藥物的輔助用藥在術(shù)后鎮(zhèn)痛中的應(yīng)用

Theincidenceofearlynauseawasdecreasedwithboth(numberneededtotreat,approximatelynine).Clonidineincreasedtheriskofintraoperative(numberneededtoharm,approximatelynine)andpostoperative

hypotension(numberneededtoharm,20).Dexmedetomidineincreasedtheriskof

postoperative

bradycardia(numberneededtoharm,three).RCONCLUSIONS:Perioperative

systemic

α2

agonists

decrease

postoperative

opioid

consumption,

pain

intensity,andnausea.Recoverytimesarenotprolonged.Commonadverseeffectsarebradycardiaandarterialhypotension.Theimpactofα2

agonists

onchronic

pain

orhyperalgesiaremainsunclearbecausevaliddataarelacking.METHODS:double-blinded,randomized,controlledstudy,100womenundergoingabdominaltotalhysterectomywereallocatedGroupM：receiveeithermorphine1mg/mlGroupD:morphine1mg/mlplusdexmedetomidine5ug/mlpostoperativei.v.PCA,whichwasprogrammedtodeliver1mlperdemandwitha5minlockoutintervalandnobackgroundinfusion.

CumulativePCArequirementspainintensitiescardiovascularandrespiratoryvariablesPCA-relatedadverseeventswererecordedfor24hafteroperation.ComparedwithGroupM,patientsinGroupDrequired29%lessmorphineduringthe0-24hpostoperativeperiodandreportedsignificantlylowerpainlevelsfromthesecondpostoperativehouronwardsandthroughoutthestudy..decreasesinheartratefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byarangeof5-7beatsmin(-1)respectively).decreasesinmeanbloodpressurefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byarangeof10-13%,respectively).Whereaslevelsofsedationweresimilarbetweenthegroupsateachobservationaltimepoint,The4-24hincidenceofnauseawassignificantlylowerinGroupD(34%vs56.3%,P<0.05).Therewasnobradycardia,hypotension,oversedation,orrespiratorydepressionCONCLUSIONS:Theadditionofdexmedetomidinetoi.v.PCAmorphineresultedinsuperioranalgesiasignificantmorphinesparinglessmorphine-inducednauseadevoidofadditionalsedationanduntowardhaemodynamicchanges.PATIENTS:Onehundredandtwentyparturients(AmericanSocietyofAnesthesiologistsclass1or2)scheduledforelectivecaesareandeliveryunderspinalanaesthesiarandomlyallocatedintothreegroups(n?=?40each).INTERVENTIONS:Group1:physiologicalsalinebolusafterdeliveryandsufentanilPCA,Group2:

dexmedetomidine

bolus(0.5?μg?kg)afterdeliveryandsufentanilPCAGroup3:

dexmedetomidine

bolus(0.5?μg?kg)afterdeliveryandsufentanilwith

dexmedetomidine

PCA(backgroundinfusionof0.045?μg?kg?hwithabolusof0.07?μg?kg)..PThandPTThweresignificantlyincreased1?hafterdrugadministrationingroups2(1.59?±?0.45,2.57?±?0.46?mA)and3(1.74?±?0.37,2.56?±?0.48?mA)comparedwithgroup1(1.49?±?0.49,2.42?±?0.62?mA)(P?<?0.05).實(shí)驗(yàn)結(jié)果1

Sufentanilconsumptioningroup3was43.9?±?19.2μg,significantlylowerthaningroup1(54.5?±?23.9?μg)andgroup2(56.3?±?20.6?μg)(P?<?0.05).Comparedwithgroup3,VASwasincreasedat4,8and24?haftersurgeryingroups1and2(P?<?0.05);therewasnodifferencebetweengroups1and2實(shí)驗(yàn)結(jié)果2***實(shí)驗(yàn)結(jié)果3Proc(BaylUnivMedCent).2014Jan;27(1):3-10.METHODS:Thirty-eightthoracotomypatientswereadministereddexmedetomidineintraoperativelyandovernightpostoperativelyandthenrandomizedtoreceiveplaceboordexmedetomidinetitratedfrom0.1to0.5μg·kg·h(-1)thedayfollowingsurgeryforupto24hoursonatelemetryfloor.Opioidsviaapatient-controlledanalgesiapumpwereavailableforbothgroups,andvitalsignsincludingtranscutaneouscarbondioxide,pulseoximetry,respiratoryrate,andpainandsedationscoresweremonitored..Thedexmedetomidinegroupused41%lessopioidsbutachievedpainscoresequaltothoseoftheplacebogroup.Themeanrespiratoryrateandoxygensaturationweresimilarinthetwogroups.Mildhypercarbiaoccurredinbothgroups,butperiodsofsignificantrespiratorydepressionwerenotedonlyintheplacebogroup.Significanthypotensionwasnotedinonepatientinthedexmedetomidinegroupinconjunctionwithconcomitantadministrationofabeta-blockeragent.Theplacebogroupreportedahighernumberofopioid-relatedadverseevents.結(jié)果4**Evaluationofdexmedetomidineandpostoperativepainmanagementinpatientswithadolescentidiopathicscoliosis:conclusionsbasedonaretrospectivestudyatatertiarypediatrichospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.

PediatrCritCareMed.2014Jul;15(6):e247-52.結(jié)果4**DESIGN:Thiswasaretrospectivechartreview.Patientswereseparatedintotwogroups:thosethatreceivedopioidviapatient-controlledanalgesiapaintherapyalonethosethatreceivedopioidviapatient-controlledanalgesiapaintherapywithdexmedetomidine.PATIENTS:Onehundredsixty-threechildrenwithadolescentidiopathicscoliosis.**MEASUREMENTSANDMAINRESULTS:Measurementsincludedpatientdemographics,AmericanSocietyofAnesthesiologistsPhysicalStatusClassificationSystem,levelsofspinalfusion,lengthofhospitalstay,complications,numericpainscores,opioidrequirement,elastomericpainpumpuse,lengthoftimeuntilambulation,adverseeffects,andnaloxoneuse.Datawerecollectedthroughthefirst72hoursoftheperioperativeperiod.Onehundredsixpatientsreceivedopioidsviapatient-controlledanalgesiatherapywithdexmedetomidineand57receivedopioidsviapatient-controlledanalgesiaalone.Withinthegroups,therewere46patientswhoreceivedlocalanestheticinfusionsviaelastomericpumpsinthepatient-controlledanalgesiawithdexmedetomidinegroupand16patientshadpumpsinthepatient-controlledanalgesia-alonegroup.Therewasnooveralldifferenceinpostoperativeuseofmorphine(orequivalents)betweenthetwogroups.However,theuseofelastomericpainpumpsdemonstratedastatisticallysignificantdecreaseinmeanoverallopioidconsumption(42.6mgvs63.1mg,p<0.001).**CONCLUSIONS:Therewasnodifferenceinopioiduserelatedtodexmedetomidineonanypostoperativeday.Theonlyvariableshowingasignificantopioidsparingeffectwastheuseoflocalanestheticinfusionsviaelastomericpumps.UsingcontinuouslocalanestheticinfusionsinsteadofdexmedetomidinecouldeliminatetheneedforICUadmission,requireshorterhospitalstays,andreducecostswhilestillprovidingsafeandeffectivepaincontrol.**Comparisonofpatient-controlledanalgesiawithandwithoutdexmedetomidinefollowingspinesurgeryinchildren.SadhasivamS1,BoatA,MahmoudM.JClinAnesth.2009Nov;21(7):493-501**DESIGN:Retrospectivecomparison.SETTING:University-affiliatedchildren'shospital.MEASUREMENTS:Themedicalchartsof131childrenwithidiopathicscoliosis(IS)andNMSwhohadmajorspinesurgerywerereviewed.Outof131,postoperatively94childrenreceivedPCAwithmorphinealone(PCAgroup)andtheremaining37childrenreceivedPCAmorphineanddexm