培训课件-张生锁主任右美托咪定在骨科手术麻醉的应用.pptVIP

讨论 近年来,通过许多研究逐渐认识到右美托咪定在改善病人术后认知功能改变方面有潜在优势,并在围术期的各个阶段试用“Shukry!等对接受全麻手术的儿童术前给予右美托咪定,发现术后急性谵妄的发生率降低”Maldonad“等比较了心脏手术后使用右美托咪定,丙泊酚和咪吟安定镇静,在术前和术中因素没有显著差异的情况下,右美托咪定可以减少术后澹妄的发生率(3%vs500kvs5090)”在ICU谵妄患者中使用右美托咪定可以满意的控制谵妄,并提供充分的镇静,且不影响呼吸。 随着对POD和POCD的不断地深入认识,右美托咪定被认为可能是一个对预防POD和POCD有利的药物“虽然以上研究都提示右美托咪定对术后认知功能有一定的改善作用 Takayuki Kunisawa, 0.1–2.5 μ g/kg/h 30 days 好处降低谵妄和昏睡发生，降低感染发生率，降低ICU费用，降低ICU住院天数， 未发现快速耐药、戒断反应和停药反跳 Kunisawa T .Dexmedetomidine hydrochloride as a long-term sedative. TherClin Risk Manag 2011;7:291-9. Tobias JD. Dexmedetomidine: Are there going to be issues with prolonged administration? J PediatrPharmacolTher 2010;15:4-9. 右美托咪定镇静的优点 有明确的量效关系 镇静过程容易被唤醒 病员合作 配合医护人员 有助于评估病人的全身状况：循环系统、呼吸系统等 减轻隔绝感 呼吸抑制轻微 镇痛药物的用量明显减少 可以逆转（atipamezole，阿替美唑） 正在进行的临床观察 右美托咪啶对脊柱术后病人舒芬太尼自控静脉 镇痛效果的影响 与复合氟比洛芬酯比较 PAIN 154 (2013) 1140–1149 Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials A. Schnabel a,?,1, C.H. Meyer-Frie遝m b,1, S.U. Reichl c, P.K. Zahn b, E.M. Pogatzki-Zahn a a Department of Anaesthesiology, Intensive Care and Pain medicine, University Hospital of Muenster, Muenster, Germany Conclusions There is ample evidence that intraoperative DEX administration significantly decreases postoperative pain intensity and has an opioid-sparing effect compared with placebo. Additionally, DEX reduces opioid-related adverse events, but this slightly failed significance in most outcomes (such as nausea and vomiting). In contrast, the comparison with opioids is currently less clear due to limited data. The most important adverse event is intraoperative bradycardia and possibly concomitant hypotension. Their possible hazardous consequences (increased incidence of stroke) are currently less clear from this meta-analysis and the literature. Therefore,in patients at risk, DEX should be administered with caution.Further trials focusing on long-term outcomes after DEX administration are warranted.