右旋美托嘧啶顧小萍

右旋美托嘧啶顧小萍第1頁/共66頁鎮(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)療的主要參與者第2頁/共66頁刺激交感系統(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)療的重要組成第3頁/共66頁右旋美托咪啶:Dexmedetomidine高效、高選擇性和特異性的α2受體激動劑抑制交感神經(jīng)活性鎮(zhèn)靜、催眠和麻醉作用鎮(zhèn)痛作用第4頁/共66頁鎮(zhèn)靜作用藍斑是大腦內(nèi)負責(zé)調(diào)解覺醒與睡眠的關(guān)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(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。第5頁/共66頁

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(chǎn)生鎮(zhèn)痛作用。

鎮(zhèn)痛作用第6頁/共66頁對循環(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)。第7頁/共66頁對其它系統(tǒng)的影響呼吸系統(tǒng)無明顯呼吸抑制腎臟功能利尿作用內(nèi)分泌系統(tǒng)減少去甲腎上腺素、胰島

素、皮質(zhì)醇的釋放。第8頁/共66頁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)用第9頁/共66頁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

第10頁/共66頁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.第11頁/共66頁第12頁/共66頁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).第13頁/共66頁第14頁/共66頁PainreliefafterArthroscopicKneeSurgery:Acomparisonofintra-articularropivacaine,fentanyl,anddexmedetomidine:Aprospective,double-blinded,randomizedcontrolledstudy.ManuarMB1,MajumdarS1,DasA2,HajraBK1,DuttaS3,MukherjeeD1,MitraT4,KunduR4.SaudiJAnaesth.2014Apr;8(2):233-7.第15頁/共66頁MATERIALSANDMETHODS:March2008toJuly2010,

inaprospectivedouble-blindedfashion.GroupAreceived10mlof0.75%ropivacaineGroupBreceived50μgfentanylGroupCreceived100μgofdexmedetomidinethroughtheintra-articularrouteattheendofprocedure.PainassessedusingvisualanalogscaleanddiclofenacsodiumgivenasrescueanalgesiawhenVAS>4.Timeoffirstanalgesiarequestandtotalrescueanalgesicusedin24hourswerecalculated.第16頁/共66頁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.第17頁/共66頁CONCLUSION:intra-articularropivacainegivesbetterpostoperativepainreliefincreasedtimeoffirstanalgesicrequestdecreasedneedoftotalpostoperativeanalgesiacomparedtofentanylanddexmedetomidine.第18頁/共66頁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)用第19頁/共66頁第20頁/共66頁第21頁/共66頁第22頁/共66頁

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

第23頁/共66頁第24頁/共66頁第25頁/共66頁第26頁/共66頁第27頁/共66頁Therewasalsoevidenceofadecreasein

pain

intensity

at24h;theweightedmeandifferencewas-0.7cm(-1.2to-0.1)ona10-cmvisualanalogscalewithclonidineand-0.6cm(-0.9to-0.2)withdexmedetomidine.Therewasalsoevidenceofadecreasein

pain

intensity

at12h;theweightedmeandifferencewas-1.5cm(-2.1to-1.0)ona10-cmvisualanalogscalewithclonidineand-1.4cm(-2.7to-0.2)withdexmedetomidineat1h.第28頁/共66頁

Theincidenceofearlynauseawasdecreasedwithboth(numberneededtotreat,approximatelynine).第29頁/共66頁Clonidineincreasedtheriskofintraoperative(numberneededtoharm,approximatelynine)andpostoperative

hypotension(numberneededtoharm,20).Dexmedetomidineincreasedtheriskof

postoperative

bradycardia(numberneededtoharm,three).R第30頁/共66頁CONCLUSIONS:Perioperative

systemic

α2

agonists

decrease

postoperative

opioid

consumption,

pain

intensity,andnausea.Recoverytimesarenotprolonged.Commonadverseeffectsarebradycardiaandarterialhypotension.Theimpactofα2

agonists

onchronic

pain

orhyperalgesiaremainsunclearbecausevaliddataarelacking.第31頁/共66頁第32頁/共66頁第33頁/共66頁第34頁/共66頁METHODS:double-blinded,randomized,controlledstudy,100womenundergoingabdominaltotalhysterectomywereallocatedGroupM：receiveeithermorphine1mg/mlGroupD:morphine1mg/mlplusdexmedetomidine5ug/mlpostoperativei.v.PCA,whichwasprogrammedtodeliver1mlperdemandwitha5minlockoutintervalandnobackgroundinfusion.

CumulativePCArequirementspainintensitiescardiovascularandrespiratoryvariablesPCA-relatedadverseeventswererecordedfor24hafteroperation.第35頁/共66頁ComparedwithGroupM,patientsinGroupDrequired29%lessmorphineduringthe0-24hpostoperativeperiodandreportedsignificantlylowerpainlevelsfromthesecondpostoperativehouronwardsandthroughoutthestudy..第36頁/共66頁decreasesinheartratefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byarangeof5-7beatsmin(-1)respectively).第37頁/共66頁decreasesinmeanbloodpressurefrompresurgerybaselineat1,2,and4hafteroperationweresignificantlygreaterinGroupD(byarangeof10-13%,respectively).第38頁/共66頁Whereaslevelsofsedationweresimilarbetweenthegroupsateachobservationaltimepoint,The4-24hincidenceofnauseawassignificantlylowerinGroupD(34%vs56.3%,P<0.05).Therewasnobradycardia,hypotension,oversedation,orrespiratorydepression第39頁/共66頁CONCLUSIONS:Theadditionofdexmedetomidinetoi.v.PCAmorphineresultedinsuperioranalgesiasignificantmorphinesparinglessmorphine-inducednauseadevoidofadditionalsedationanduntowardhaemodynamicchanges.第40頁/共66頁第41頁/共66頁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)..第42頁/共66頁第43頁/共66頁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).第44頁/共66頁實驗結(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第45頁/共66頁實驗結(jié)果2***第46頁/共66頁實驗結(jié)果3第47頁/共66頁Proc(BaylUnivMedCent).2014Jan;27(1):3-10.第48頁/共66頁METHODS:Thirty-eightthoracotomypatientswereadministereddexmedetomidineintraoperativelyandovernightpostoperativelyandthenrandomizedtoreceiveplaceboordexmedetomidinetitratedfrom0.1to0.5μg·kg·h(-1)thedayfollowingsurgeryforupto24hoursonatelemetryfloor.Opioidsviaapatient-controlledanalgesiapumpwereavailableforbothgroups,andvitalsignsincludingtranscutaneouscarbondioxide,pulseoximetry,respiratoryrate,andpainandsedationscoresweremonitored..第49頁/共66頁第50頁/共66頁Thedexmedetomidinegroupused41%lessopioidsbutachievedpainscoresequaltothoseoftheplacebogroup.第51頁/共66頁Themeanrespiratoryrateandoxygensaturationweresimilarinthetwogroups.第52頁/共66頁Mildhypercarbiaoccurredinbothgroups,butperiodsofsignificantrespiratorydepressionwerenotedonlyintheplacebogroup.第53頁/共66頁Significanthypotensionwasnotedinonepatientinthedexmedetomidinegroupinconjunctionwithconcomitantadministrationofabeta-blockeragent.Theplacebogroupreportedahighernumberofopioid-relatedadverseevents.第54頁/共66頁第55頁/共66頁結(jié)果4**Evaluationofdexmedetomidineandpostoperativepainmanagementinpatientswithadolescentidiopathicscoliosis:conclusionsbasedonaretrospectivestudyatatertiarypediatrichospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.

PediatrCritCareMed.2014Jul;15(6):e247-52.第56頁/共66頁結(jié)果4**DESIGN:Thiswasaretrospectivechartreview.Patientswereseparatedintotwogroups:thosethatreceivedopioidviapatient-controlledanalgesiapaintherapyalonethosethatreceivedopioidviapatient-controlledanalgesiapaintherapywithdexmedetomidine.PATIENTS:Onehundredsixty-threechildrenwithadolescentidiopathicscoliosis.第57頁/共66頁**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).第58頁/共66頁**CONCLUSIONS:Therewasnodifferenceinopioiduserelatedtodexmedetomidineonanypostoperativeday.Theonlyvariableshowingasignificantopioidsparingeffectwastheuseoflocalanestheticinfusionsviaelastomericpumps.UsingcontinuouslocalanestheticinfusionsinsteadofdexmedetomidinecouldeliminatetheneedforICUadmission,requireshorterhospitalstays,andreducecostswhilestillprovidingsafeandeffectivepaincontrol.第59頁/共66頁**Comparisonofpatient-controlledanalgesiawithandwithoutdexmedetomidinefollowingspinesurgeryinchildren.SadhasivamS1,BoatA,MahmoudM.JClinAnesth.2009Nov;21(7):493-501第60頁/共66頁**DESIGN:Retrospectivecomparison.SETTING:University-affiliatedchildren'shospital.MEASUREMENTS:Themedicalchartsof131childrenwithidiopathicscoliosis(IS)andNMSwhohadmajorspinesurgerywerereviewed.Outof131,postoperatively94chi