右旋美托嘧啶顾小萍

右旋美托嘧啶顾小萍第1页/共66页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第2页/共66页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第3页/共66页右旋美托咪啶:Dexmedetomidine高效、高选择性和特异性的α2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第4页/共66页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。第5页/共66页

2

激动剂初级传入纤维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。

镇痛作用第6页/共66页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。第7页/共66页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。第8页/共66页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第9页/共66页DEX作为关节腔的注射用药在术后镇痛中的应用

第10页/共66页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页/共66页第12页/共66页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页/共66页第14页/共66页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页/共66页MATERIALSANDMETHODS:March2008toJuly2010,

inaprospectivedouble-blindedfashion.GroupAreceived10mlof0.75%ropivacaineGroupBreceived50μgfentanylGroupCreceived100μgofdexmedetomidinethroughtheintra-articularrouteattheendofprocedure.PainassessedusingvisualanalogscaleanddiclofenacsodiumgivenasrescueanalgesiawhenVAS>4.Timeoffirstanalgesiarequestandtotalrescueanalgesicusedin24hourswerecalculated.第16页/共66页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页/共66页CONCLUSION:intra-articularropivacainegivesbetterpostoperativepainreliefincreasedtimeoffirstanalgesicrequestdecreasedneedoftotalpostoperativeanalgesiacomparedtofentanylanddexmedetomidine.第18页/共66页DEX作为神经阻滞的复合用药药在术后镇痛中的应用第19页/共66页第20页/共66页第21页/共66页第22页/共66页

DEX作为阿片类药物的辅助用药在术后镇痛中的应用

第23页/共66页第24页/共66页第25页/共66页第26页/共66页第27页/共66页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页/共66页

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

hypotension(numberneededtoharm,20).Dexmedetomidineincreasedtheriskof

postoperative

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

systemic

α2

agonists

decrease

postoperative

opioid

consumption,

pain

intensity,andnausea.Recoverytimesarenotprolonged.Commonadverseeffectsarebradycardiaandarterialhypotension.Theimpactofα2

agonists

onchronic

pain

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

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

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