右旋美托嘧啶顾小萍.ppt

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顾小萍,镇痛镇静精准麻醉可视化操作,麻醉医师，是舒适化医疗的主要参与者,刺激交感系统增加心肌氧耗延缓患者自主活动恢复改变免疫系统诱发慢性疼痛,术后镇痛，是舒适化医疗的重要组成,右旋美托咪啶:Dexmedetomidine,高效、高选择性和特异性的2受体激动剂抑制交感神经活性镇静、催眠和麻醉作用镇痛作用,镇静作用,蓝斑是大脑内负责调解觉醒与睡眠的关键部位蓝斑是下行延髓-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,2-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。,皮层,丘脑,中脑,延髓,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,对循环系统的影响,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。作用于外周血管平滑肌的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,呼吸系统无明显呼吸抑制肾脏功能利尿作用内分泌系统减少去甲肾上腺素、胰岛素、皮质醇的释放。,DEX作为关节腔的注射用药在术后镇痛中的应用DEX作为神经阻滞的复合用药在术后镇痛中的应用DEX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,DEX作为关节腔的注射用药在术后镇痛中的应用,Sixtypatients，double-blindplacebocontrolled.controlgroup:i.v.20mlsalineandintra-articular20mlsalinetheintra-articulargroup:i.v.20mlsalineandintra-articular20mlsaline+dexmedetomidine1ug/kgthei.v.group:i.v.20mlsaline+dexmedetomidine1ug/kgandintra-articular20mlsaline.,significantreductioninpainscoresfor6hafteroperationintheintra-articulargroupbutonlyfor1hinthei.v.group.Thetimetofirstpostoperativeanalgesicrequestwaslongerintheintra-articulargroup312.0(SD120.7)mincomparedwiththecontrolgroup71.0(50.1)minandthei.v.group102.1(54.4)min(P0.001).totaldiclofenacrequirementwassignificantlylowerintheintra-articulargroup90.0(46.2)mgthaninthecontrolgroup165.0(52.2)mgandinthei.v.group129.3(54.3)mg(P4.Timeoffirstanalgesiarequestandtotalrescueanalgesicusedin24hourswerecalculated.,RESULTS:TimeforrequirementoffirstpostoperativerescueanalgesiainGroupAwas380.6122.973min,inGroupBwas326.8217.131minandinGroupCwas244.0920.096minutes.TotalrescueanalgesiarequirementwaslessinGroupA(1.3940.496)comparedtoGroupB(1.7580.435)andGroupC(2.5460.546).GroupAhadhighermeanVASscoreat6(th)and24(th)postoperativehours.Nosideeffectsfoundamongthegroups.,CONCLUSION:intra-articularropivacainegivesbetterpostoperativepainreliefincreasedtimeoffirstanalgesicrequestdecreasedneedoftotalpostoperativeanalgesiacomparedtofentanylanddexmedetomidine.,DEX作为神经阻滞的复合用药药在术后镇痛中的应用,DEX作为阿片类药物的辅助用药在术后镇痛中的应用,Therewasalsoevidenceofadecreaseinpainintensityat24h;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-0.2)withdexmedetomidineat1h.,Theincidenceofearlynauseawasdecreasedwithboth(numberneededtotreat,approximatelynine).,Clonidineincreasedtheriskofintraoperative(numberneededtoharm,approximatelynine)andpostoperativehypotension(numberneededtoharm,20).Dexmedetomidineincreasedtheriskofpostoperativebradycardia(numberneededtoharm,three).R,CONCLUSIONS:Perioperativesystemic2agonistsdecreasepostoperativeopioidconsumption,painintensity,andnausea.Recoverytimesarenotprolonged.Commonadverseeffectsarebradycardiaandarterialhypotension.Theimpactof2agonistsonchronicpainorhyperalgesiaremainsunclearbecausevaliddataarelacking.,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%,P0.05).Therewasnobradycardia,hypotension,oversedation,orrespiratorydepression,CONCLUSIONS:Theadditionofdexmedetomidinetoi.v.PCAmorphineresultedinsuperioranalgesiasignificantmorphinesparinglessmorphine-inducednauseadevoidofadditionalsedationanduntowardhaemodynamicchanges.,PATIENTS:Onehundredandtwentyparturients(AmericanSocietyofAnesthesiologistsclass1or2)scheduledforelectivecaesareandeliveryunderspinalanaesthesiarandomlyallocatedintothreegroups(n=40each).INTERVENTIONS:Group1:physiologicalsalinebolusafterdeliveryandsufentanilPCA,Group2:dexmedetomidinebolus(0.5gkg)afterdeliveryandsufentanilPCAGroup3:dexmedetomidinebolus(0.5gkg)afterdeliveryandsufentanilwithdexmedetomidinePCA(backgroundinfusionof0.045gkghwithabolusof0.07gkg).,PThandPTThweresignificantlyincreased1hafterdrugadministrationingroups2(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,VASwasincreasedat4,8and24haftersurgeryingroups1and2(P0.05);therewasnodifferencebetweengroups1and2,实验结果2,*,*,*,实验结果3,Proc(BaylUnivMedCent).2019Jan;27(1):3-10.,METHODS:Thirty-eightthoracotomypatientswereadministereddexmedetomidineintraoperativelyandovernightpostoperativelyandthenrandomizedtoreceiveplaceboordexmedetomidinetitratedfrom0.1to0.5gkgh(-1)thedayfollowingsurgeryforupto24hoursonatelemetryfloor.Opioidsviaapatient-controlledanalgesiapumpwereavailableforbothgroups,andvitalsignsincludingtranscutaneouscarbondioxide,pulseoximetry,respiratoryrate,andpainandsedationscoresweremonitored.,Thedexmedetomidinegroupused41%lessopioidsbutachievedpainscoresequaltothoseoftheplacebogroup.,Themeanrespiratoryrateandoxygensaturationweresimilarinthetwogroups.,Mildhypercarbiaoccurredinbothgroups,butperiodsofsignificantrespiratorydepressionwerenotedonlyintheplacebogroup.,Significanthypotensionwasnotedinonepatientinthedexmedetomidinegroupinconjunctionwithconcomitantadministrationofabeta-blockeragent.Theplacebogroupreportedahighernumberofopioid-relatedadverseevents.,结果4,*,*,Evaluationofdexmedetomidineandpostoperativepainmanagementinpatientswithadolescentidiopathicscoliosis:conclusionsbasedonaretrospectivestudyatatertiarypediatrichospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.PediatrCritCareMed.2019Jul;15(6):e247-52.,结果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,p0.001).,*,*,CONCLUSIONS:Therewasnodifferenceinopioiduserelatedtodexmedetomidineonanypostoperativeday.Theonlyvariableshowingasignificantopioidsparingeffectwastheuseoflocalanestheticinfusionsviaelastomericpumps.UsingcontinuouslocalanestheticinfusionsinsteadofdexmedetomidinecouldeliminatetheneedforICUadmission,requireshorterhospitalstays,andreducecostswhilestillprovidingsafeandeffectivepaincontrol.,*,*,Comparisonofpatient-controlledanalgesiawithandwithoutdexmedetomidinefollowingspinesurgeryinchildren.SadhasivamS1,BoatA,MahmoudM.JClinAnesth.2009Nov;21(7):493-501,*,*,DESIGN:Retrospectivecomparison.SETTING:University-affiliatedchildrenshospital.MEASUREMENTS:Themedicalchartsof131childrenwithidiopathicscoliosis(IS)andNMSwhohadmajorspinesurgerywerereviewed.Outof131,postoperatively94childrenreceivedPCAwithmorphinealone(PCAgroup)andtheremaining37children