Dexmedetomidine对於止血带所引起术中高血压的疗效与药理机转之探讨.pptVIP

臨床試驗計劃:Dexmedetomidine對於止血帶所引起術中高血壓的療效及藥理機轉之探討 Presenter:勞萱之醫師 Correspondence: 黃俊仁主任 Part Ⅰ:Introduction of Dexmedetomidine Medetomidine 動物鎮靜麻醉 Ketamine (K他命）和 Midazolam 混合 Medetomidine Medetomidine混合dextro-medetomidine levo-medetomidine Dexmedetomidine Alpha-2 Agonist 1999 美國FDA 核准使用 Dexmedetomidine (Precedex?) a2腎上腺素接受器 Regulate release of neurotransmitters Control epinephrine, norepinephrine release Modulate sympathetic response “negative feedback loop” Dexmedetomidine作用機轉 Dexmedetomidine作用部位 作用部位 Brain (locus ceruleus)第4腦室底上角之色素隆凸 Spinal cord 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 ? Sympathetic activity ? BP, ? HR Mechanism for α2-induced sedation/ hypnosis in the rat locus coeruleus Dexmedetomidine: Side Effects Bradycardia Hypotension Transient hypertension Dry mouth Limited amnestic effect Excessive sedation Reduction in CBF/CMRO2 in animal model Dexmedetomidine 的使用 (Adult) Heart block 心房心室傳導阻滯的病患，要小心使用 Administer loading dose slowly 第1個劑量要慢慢給 Transient vasoconstriction mediated by α2B-adrenoceptors will ↑ BP loading : 1 mcg/kg over 10 min maintenance : 0.2 to 0.7 mcg/kg/hr Onset: 5 -10 min Reduced effect: 30 min Duration: 2 hour Tournique induced hypertension Incidence: 30% Tourniquet time 60 min Associated with severe pain and augmented sympathetic outflow Difficult treatment Unknown mechanism Previous study data Ketamine ( Satsumae et al. AA, 2001) Clonidine ( Zalunardo et al. AA, 2002) Dextromethrophan ( Yamashita et al. AA, 2004) Stellate ganglion blockade ( Arai et al. Acta Anesthesiol Scand, 2004) Dexmedetomidine? Exclusion and Inclusion Crietria Exclusion Criteria 貧血 (Hct ? 20) 肥胖 (BMI ? 40) 肝或腎功能異常者 心律不整,AV Block,或是心臟鬱血性衰竭 對dexmedetomidine或其他α2 agonist過敏者 預期下肢止血帶使用會超過150分鐘或低於60分鐘 Inclusion criteria ASA I-II 20 至75 歲 預期接受骨科下肢常規手術而會打止血帶超過60分鐘者 不論半身或全身麻醉 Grouping Control group Dexmedetomidine (continuous infusion) Loading:(0.8 μg/kg) Continuous infusion rate:(0.4 μg/kg/h) Dexmedetomidine (single