Dexmedetomidine 用於降低小儿Sevoflurane麻醉后躁动.ppt

Dexmedetomidine用於降低小兒Sevoflurane麻醉後躁動 徐永偉醫師馬偕紀念醫院麻醉科2006 12 1 2of23 LearningObjectives學習目標 什麼是DexmedetomidineDexmedetomidine的藥理作用Dexmedetomidine用於麻醉的臨床報告Dexmedetomidine用於降低小兒Sevoflurane麻醉後躁動的研究 實證醫學的應用 3of23 Medetomidine 動物鎮靜麻醉Ketamine K他命 和Midazolam混合MedetomidineMedetomidine混合dextro medetomidinelevo medetomidine 4of23 Dexmedetomidine Precedex CH3 CH3 N N CH3 H Dexmedetomidine Alpha 2Agonist 1999美國FDA核准使用 5of23 Dexmedetomidine Precedex 適應症 適用於在加護病房中 插管且接受呼吸器治療的病患鎮靜用 Precedex應該以連續輸注的方式給予 連續輸注以24小時為限 6of23 有關Dexmedetomidine的研究 2005 242006 25 自主神經系統 副交感 交感 新腎上腺素 乙醯膽鹼 腎上腺素接受器 8of23 腎上腺素接受器Adrenergicreceptors a1 b1 平滑肌 節前Pre synaptic 氣管平滑肌 心臟 a2 b2 擴張 心跳心搏量 收縮 抑制新腎上腺素NE分泌 9of23 a2腎上腺素接受器 負回饋 RegulatereleaseofneurotransmittersControlepinephrine norepinephrinereleaseModulatesympatheticresponse negativefeedbackloop 10of23 Dexmedetomidine作用機轉 11of23 Dexmedetomidine作用部位 作用部位Brain locusceruleus 第4腦室底上角之色素隆凸Spinalcord脊髓交感神經中樞神經之作用Sedation鎮靜Anxiolysis抗焦慮Analgesia止痛交感神經之作用 Sympatheticactivity BP HR SpinalCord LOCUSCERULEUS FOURTHVENTRICLE PONS CEREBRUM CEREBELLUM 13of23 Precedex在呼吸以及止痛方面的研究 Anesthesiology November2004 14of23 Dexmedetomidine的使用 Adult Heartblock心房心室傳導阻滯的病患 要小心使用Administerloadingdoseslowly第1個劑量要慢慢給Transientvasoconstrictionmediatedby 2B adrenoceptorswill BPloading 1mcg kgover10minmaintenance 0 2to0 7mcg kg hrOnset 5 10minReducedeffect 30minDuration 2hour 15of23 Dexmedetomidine使用於麻醉 SevererespiratorycompromiseObesity cooperativesedation CraniotomyInterventionalproceduresunderLAe g vascularPainfulproceduresFiberopticintubationDecreasecoughduringemergenceStablehemodynamicwithpronepositionEffectonemergenceagitation 16of23 實證醫學 實證醫學在Dexmedetomidinem預防emergenceagitation的應用 Dexmedetomidineforemergenceagitation Double blindedRandomizedCase controlStudies LevelofEvidenceIb LevelofEvidence 19of23 WhatDidTheySaidAboutDexmedetomidineforemergenceagitation 0 3 0 5 1ug kgDexmedetomidineaftersevofluraneinductionDecreaseemergenceagitationtoabout5 10 TimeatPACU POR Nodelay 20of23 Dexmedetomidineforemergenceagitation AnesthAnalg2004 98 60 3 Group1 SalineGroup2 0 15ug kgGroup3 0 3ug kg 21of23 Askingananswerablequestion提出可回答的臨床問題Trackingdownthebestevidence搜尋最佳實證文獻資料Criticalappraisal謹慎的文獻評讀Integratingtheappraisalwithclinicalexpertiseandpatients preference臨床應用Evaluationtheeffectivenessandefficiencyinexecutingsteps1 4評估改善 實證醫學的實行 五個步驟FivestepstopracticeEBM 22of23 馬偕經驗Dexmedetomidineforemergenceagitation 0 5ug kgDexmedetomidine 稀釋成10cc afterse