右旋美托嘧啶顾小萍课件

右旋美托嘧啶的术后镇痛应用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。

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。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.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

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).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实验结果2***实验结果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.结果4**Evaluationofdexmedetomidineandpostoperativepainmanagementinpatientswithadolescentidiopathicscoliosis:conclusionsbasedonaretrospectivestudyatatertiarypediatrichospital.JonesJS1,CotugnoRE,SinghalNR,SoaresN,SemenovaJ,NebarS,ParkeEJ,ShraderMW,HotzJ.

PediatrCritCareMed.2014Jul;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,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