右旋美托嘧啶顧小萍課件

右旋美托嘧啶的術后鎮(zhèn)痛應用鎮(zhèn)痛鎮(zhèn)靜精準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改變免疫系統(tǒng)誘發(fā)慢性疼痛術后鎮(zhèn)痛，是舒適化醫(yī)療的重要組成鎮(zhèn)靜作用藍斑是大腦內負責調解覺醒與睡眠的關鍵部位藍斑是下行延髓-脊髓去甲腎上腺素能通路的起源，其在傷害性神經(jīng)遞質的調控中起重要作用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作為關節(jié)腔的注射用藥在術后鎮(zhèn)痛中的應用DEX作為神經(jīng)阻滯的復合用藥在術后鎮(zhèn)痛中的應用DEX作為阿片類藥物的輔助用藥術后鎮(zhèn)痛中的應用DEX在術后鎮(zhèn)痛中的應用DEX作為關節(jié)腔的注射用藥在術后鎮(zhèn)痛中的應用

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)阻滯的復合用藥藥在術后鎮(zhèn)痛中的應用

DEX作為阿片類藥物的輔助用藥在術后鎮(zhèn)痛中的應用

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).實驗結果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實驗結果2***實驗結果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.結果4**Evaluationofdexmedetomidineandpostoperativepainmanagementinpatientswithadolescentidiopathicscoliosis:conclusionsbasedonaretrospectivestudyatatertiarypediatrichospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.

PediatrCritCareMed.2014Jul;15(6):e247-52.結果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