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HERALD OF MEDICINE, 2018, 37(1): 67-70
doi: 10.3870/j.issn.1004-0781.2018.01.017
地佐辛与盐酸右美托咪定预防小儿术后躁动的效果比较
Comparison of Effects of Dezocine and Dexmedetomidine Hydrochloride on Prevention Pediatric Postoperative Agitation
魏会霞, 罗向红

摘要:

目的 探讨地佐辛与盐酸右美托咪定预防小儿术后躁动的效果及安全性。方法 择期行包皮套扎术患儿90例,随机分为地佐辛组、右美托咪定组和对照组,每组30例,均采用全身麻醉联合阴茎背神经阻滞麻醉。地佐辛组麻醉诱导后静脉泵注地佐辛0.1 mg·kg-1;右美托咪定组麻醉诱导后静脉泵注盐酸右美托咪定0.5 μg·kg-1;对照组麻醉诱导后静脉泵注等剂量0.9%氯化钠注射液。观察患儿躁动发生率、手术后苏醒时间、手术中追加丙泊酚的量及手术结束后6 h内的不良反应。结果 3组患儿均顺利完成手术,手术后苏醒时间差异无统计学意义(P>0.05);地佐辛组、右美托咪定组和对照组手术后躁动发生率分别为3.33%,0.00%和46.67%(P<0.05),3组患儿术中均未追加丙泊酚,术后6 h内均未见明显不良反应。结论 地佐辛与盐酸右美托咪定均可有效预防患儿术后躁动,无明显不良反应,临床可安全使用。

关键词: 地佐辛 ; 右美托咪定,盐酸 ; 躁动 ; 麻醉

Abstract:

Objective To evaluate the effects and safety of dezocine and dexmedetomidine hydrochloride on the prevention of the pediatric postoperative agitation. Methods A total of 90 pediatric patients undergoing prepuce cerclage were randomly divided into 3 groups(n=30):dezocine group( Group Dez ),dexmedetomidine group( Group Dex ) and control group( Group C ),all groups were implemented general anesthesia combining with penile dorsal nerve block anesthesia.After induction of anesthesia,Group Dez and Group Dex were given 0.1 mg·kg-1 of dezocine and 0.5 μg·kg-1 of dexmedetomidine hydrochloride,respectively,Group C was given 0.9% sodium chloride solution.The rate of pediatric agitation, the operating room,the recovery time,the amount of additional propofol during the operation and the adverse reaction incidence within 6 hours after the surgery(circulation and respiratory depression,drowsiness,headache,nausea and vomiting) were observed and recorded . Results All groups have the surgery successfully done.There were no significantly difference among the three groups on the recovery time( P>0.05) .The incidence of postoperative agitation was 3.33% in Group Dez,0.00% in Group Dex,46.67% in Group C ,respectively( P<0.05 ) .All of the pediatrics in three groups were not given additional propofol.There was no obvious adverse reaction at the time of 6 hours after surgery. Conclusion Dezocine and dexmedetomidine hydrochloride both can reduce the rate of postoperative agitation in pediatric patients and have no obvious side effects.Therefore,the clinical use of dezocine and dexmedetomidine hydrochloride are safe and effective.

Key words: Dezocine ; Dexmedetomidine,hydrochloride ; Agitation ; Anesthesia

小儿包皮套扎术是儿科常见手术,手术时间短,创伤小,多采阴茎背神经阻滞麻醉,但由于小儿难以配合,常常需要联合全身麻醉。全身麻醉苏醒期躁动(emergence agitation,EA)是全身麻醉苏醒期常见的并发症,有一定的自限性,但若不及时处理会引起严重的后果,如伤口裂开、出血等。给小儿留下不良的心理刺激,影响日后的恢复和精神发育,给家长及护士护理带来困难,降低了患儿家属的满意度[1-4]。因此小儿苏醒期躁动引起了麻醉医生关注,已证实多种药物可预防小儿苏醒期躁动如:阿片类药物、非甾体类药物、苯二氮 类药物、水合氯醛[1-7]等。1990年地佐辛在美国上市,随后广泛应用于术后镇痛和癌性镇痛[8-9]。盐酸右美托咪定是新型镇静、镇痛、抗焦虑药物[10-11]。2015年7月1日—8月1日,笔者比较地佐辛与盐酸右美托咪定用于预防小儿术后躁动的效果及安全性,为临床用药提供参考。

1 资料与方法
1.1 临床资料

选择在小儿外科手术室全身麻醉联合阴茎背神经阻滞麻醉下择期行包皮套扎术患儿90例,按照美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级为Ⅰ或Ⅱ级,年龄3~6岁。排除困难气道、手术复杂、体质量超出标准体质量±20%及严重心肺等并发症患儿。本研究通过本院伦理委员会批准,患儿家属同意并签署知情同意书。

1.2 分组与麻醉方法

使用随机数字表法,随机分为地佐辛组、右美托咪定组和对照组,每组30例。手术前1 d访视患儿,充分与患儿沟通并与患儿建立良好的关系,取得患儿的合作。3组患儿手术前常规禁食8 h、禁饮3 h,3组患儿均不使用术前药物,入手术室前30 min在病房建立静脉通道。患儿入手术室后给予面罩吸氧,监测心电图(ECG)、血压(BP)、心率(HR)、血氧饱和度(SpO2),保持手术室温度24~26 ℃。并以8~10 mL·kg-1·h-1速度静脉滴注复方林格溶液。麻醉诱导:3组患儿均经静脉给予丙泊酚(西安力邦制药有限公司,批准文号:国药准字H20010368,规格20 mL:200 mg)2.5 mg·kg-1,注射速度0.4 mL·s-1。地佐辛组静脉泵注地佐辛(扬子江药业集团有限公司,批准文号:国药准字H80932002,规格1 mL:5mg)0.1 mg·kg-1;右美托咪定组静脉泵注盐酸右美托咪定(江苏恒瑞医药股份有限公司,批准文号:国药准字H20090248,规格2 mL:200 μg)0.5 μg·kg-1;对照组静脉泵注等容量0.9%氯化钠注射液。3组患儿静脉泵注时间10 min,剂量10 mL。患儿入睡后静脉泵注药物的同时,开始外科消毒,铺无菌巾,阴茎背神经阻滞后给予包皮套扎术。维持心率、血压在麻醉前基础水平±20%。手术结束后将患儿转入麻醉恢复室,1 min轻拍患儿眉间呼唤患儿1次,待患儿睁眼后送回病房。

1.3 异常情况及处理

手术期间各组患儿若出现体动,则暂停手术,静脉追加丙泊酚2 mg·kg-1(注射速度0.4 mL·s-1);若心率低于基础水平±20%,静脉注射阿托品0.01 mg·kg-1;若出现呼吸抑制,给予球囊辅助呼吸(处理标准:呼吸频率<12次·min-1、SpO2<95%)。

1.4 观察指标

观察并记录患儿入室前、入室后、出手术前的配合情况,配合则无躁动,哭闹、躯体及四肢乱动则为躁动;手术后呼唤睁眼时间、术中追加丙泊酚的量及手术结束后6 h内由责任护士观察患儿不良反应(循环及呼吸抑制、嗜睡、头痛、恶心呕吐)的发生率。

1.5 统计学方法

采用SPSS16.0版统计学软件,计量资料以均数±标准差( x ¯ ±s)表示,计数资料均用率表示。计量资料采用单因素方差分析,计数资料采用卡方检验。以P<0.05为差异有统计学意义。

2 结果
2.1 临床资料比较

3组患儿年龄、体质量、手术时间及苏醒均差异无统计学意义(均P>0.05),见表1。

表1 3组患儿一般临床资料比较
Tab.1 Comparison of baseline data among three groups of pediatric patients x¯±s,n=30
组别 年龄/
体质量/
kg
手术时间 苏醒时间
min
对照组 5.18±0.74 18.07±1.36 8.03±0.49 11.70±0.75
地佐辛组 5.20±0.61 18.47±1.87 8.30±0.53 11.77±0.57
右美托咪定组 5.23±0.82 18.70±1.05 8.27±0.58 11.90±0.61

表1 3组患儿一般临床资料比较

Tab.1 Comparison of baseline data among three groups of pediatric patients x¯±s,n=30

2.2 患儿躁动情况

入手术室前及入手术室后3组患儿躁动发生率差异无统计学意义(P>0.05);地佐辛组与右美托咪定组手术结束后躁动发生率差异无统计学意义(P>0.05),均低于对照组(均P<0.05),见表2。

表2 3组患儿躁动发生率比较
Tab.2 Comparison of agitation rate among three groups of patients n=30
组别 入手术室前 入手术室后 手术结束后
% % %
对照组 9 30.00 10 33.33 14 46.67
地佐辛组 5 16.67 11 36.67 1 3.33*1
右美托咪定组 8 26.67 13 43.33 0 0.00*1
χ2 1.564 0.662 29.28
P 0.457 0.718 0.000

Compared with control group,*1P<0.05

与对照组比较,*1P<0.05

表2 3组患儿躁动发生率比较

Tab.2 Comparison of agitation rate among three groups of patients n=30

2.3 手术中追加丙泊酚情况及手术后不良反应

3组患儿术中均未追加丙泊酚,术后6 h内3组患儿均未见循环及呼吸抑制、嗜睡、头痛、恶心呕吐等不良反应。

3 讨论

小儿包皮过长最有效的治疗方式是手术治疗,可有效预防包皮龟头炎、泌尿系统感染等疾病,传统的手术方式是采用包皮环切术,随着外科手术技术的进步,目前多采用套扎器套扎包皮,手术时间短(我院从患儿入手术室消毒、铺巾、阴茎背神经阻滞及手术的平均时间约为8.2 min)、疼痛刺激小、恢复快、便于患儿家属及护士术后护理。但由于患儿对手术存在恐惧,很难配合,常常需要全身麻醉复合阴茎背神经阻滞麻醉。患儿在术后苏醒期躁动,降低了患儿家属的满意度,影响了整个手术的效果,也给患儿留下了心理阴影,因此对麻醉医生提出了更高的要求。本研究中丙泊酚全身麻醉复合阴茎背神经阻滞麻醉,术中患儿安静无体动,镇痛作用完全。丙泊酚起效迅速,代谢完全,不良反应少,小儿单次按2.5 mg·kg-1给药,平均苏醒时间8 min[12]。这就要求麻醉医生使用长效的药物,使患儿安静的渡过苏醒期,临床上广泛应用的药物如:阿片类药物、非甾体类药物、苯二氮 类药物、水合氯醛等虽然达到了镇静的效果但也带来了安全隐患[13-15]。麻醉性镇痛药如吗啡、芬太尼等主要是通过激动 μ受体而发挥作用,镇痛疗效满意,但镇静作用强,易产生不同程度的呼吸、循环抑制及术后恶心、呕吐等不良反应[16-19]。地佐辛是一种新型强效阿片类镇痛药,1990年在美国上市。地佐辛是苯吗啡烷类衍生物,阿片受体部分激动剂,其主要分布于大脑、脑干和脊髓的κ受体而产生镇痛作用,镇静作用轻微。地佐辛拮抗 μ受体,依赖性小而列入非麻醉品范畴,广泛应用于术后镇痛和癌性镇痛[8-9]。盐酸右美托咪定1999年在美国批准用于重症监护病房患者的短期镇静。盐酸右美托咪定是一种新型的高选择性的α2肾上腺素能受体激动药,通过抑制去甲肾上腺素的释放而产生镇静、镇痛作用。盐酸右美托咪定有口内含化、口服、滴鼻、皮下注射、肌内注射、静脉注射等多种给药途径。因为静脉注射盐酸右美托咪定易引起心动过缓,一般要求给药时间大于10 min[20]。本研究中为保证双盲3组患儿均采用10 min的给药时间。研究表明盐酸右美托咪定因给药方式不同,其达峰时间、起效时间、峰浓度均有较大差异,且该药具有双相半衰期,分布半衰期为6 min,消除半衰期为2 h,然而盐酸右美托咪定在体内的清除率和代谢半衰期个体差异很小。符合本研究长效的镇静、镇痛要求。静脉输注盐酸右美托咪定剂量为0.2~0.7 μg·kg-1·h-1时,呼吸率和氧饱和度仍可保持在正常范围内,未见明显的呼吸抑制[10-11,19]。本研究表明地佐辛与盐酸右美托咪定均可用于预防小儿术后躁动,未见明显的不良反应,提高患儿围手术期的安全性和舒适度,为小儿安静的术后护理提供了一个全新的选择。

综上所述,地佐辛与盐酸右美托咪定均可有效预防小儿术后躁动,不延长术后苏醒的时间,无明显不良反应,可安全应用于小儿麻醉,值得临床推广。

The authors have declared that no competing interests exist.

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[7] ATASHKHOYI S,NEGARGAR S,HATAMI-MARANDI P.Effects of the addition of low-dose ketamine to propofol-fentanyl anaesthesia during diagnostic gynaecological laparoscopy[J].Eur J Obstet Gynecol Reprod Biol,2013,170(1):247-250.
Diagnostic gynaecological laparoscopy (DGL) is a brief procedure, generally performed on an outpatient basis. Propofol-fentanyl is often used for anaesthesia in minor outpatient procedures because of its rapid onset, short duration of action and smooth patient awakening. However, propofol has various cardiovascular effects such as reduced arterial pressure, cardiac output and cardiac index. Ketamine is an intravenous anaesthetic and short-acting analgesic that could alleviate the haemodynamic effects of propofol due to its sympathomimetic activity. The aim of this placebo-controlled trial was to evaluate the effects of the addition of low-dose ketamine to propofol-fentanyl anaesthesia in DGL.In this double-blind randomized trial, 60 healthy women undergoing gynaecological laparoscopy to investigate infertility were studied. Following injection of midazolam and fentanyl in all patients, the study group (n=30) received ketamine 0.5 mg/kg and propofol 1-2.5 mg/kg, and the placebo group (n=30) received saline 0.9% and propofol 1-2.5 mg/kg. Propofol was subsequently infused for the maintenance of anaesthesia.Patients in the study group had a significantly lower incidence of pain than patients in the placebo group during propofol injection (13% vs 87%, respectively; p<0.0001). After induction of anaesthesia, 16 (53%) patients in the placebo group and three (10%) patients in the study group had a decreased heart rate (p<0.001). The decrease in mean arterial pressure was greater in the placebo group compared with the study group (37% vs 7%, respectively; p<0.001). During the procedure, the total mean standard deviation dose of propofol was 420卤65 mg in the placebo group and 330卤35 mg in the study group (p<0.001). Pain scores for the first 3h after the operation were significantly lower in the study group (p<0.001).Use of low-dose ketamine with propofol-fentanyl anaesthesia in patients undergoing DGL was associated with less pain during propofol injection, lower incidence of haemodynamic changes, lower total dose of propofol and improved postoperative analgesia.
DOI:10.1016/j.ejogrb.2013.06.026      PMID:23870189      URL    
[本文引用:1]
[8] THESBJERG S E,HARBOE K M,BARDRAM L,et al.Sex differences in laparoscopic cholecystectomy[J].Surg Endosc,2010,24(12):3068-3072.
Background Conversion from laparoscopic to open cholecystectomy may not be desirable due to the increased complication rate and prolonged convalescence. In Denmark, nationwide data show that 7.7% of the laparoscopic cholecystectomies are converted to open surgery. This article aims to document the relationship of gender to conversion rate and length of hospital stay after laparoscopic cholecystectomy in a national cohort of patients. Methods The gender of 5,951 patients from the 2007 National Danish Cholecystectomy Database was compared with conversion rate, length of hospital stay, and various risk factors using multivariate analyses. Results The findings showed that 14.3% of the patients had acute cholecystitis and that men had the highest risk (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.66–2.27). The operative findings for the men included sequelae from previous acute cholecystitis more frequently than the findings for the women (OR, 1.89; 95% CI, 1.67–2.15). The rate for conversion from laparoscopic to open surgery was 7.7%, and male sex was highly associated with conversion (OR, 2.48; 95% CI, 2.04–3.01). Thus, 259 (5.8%) of the 4,451 operations for women were converted to laparotomy compared with 199 (13.3%) of the 1,500 operations for men. No significant sex differences were found in the proportion of bile duct lesions (those requiring reconstructive surgery as well as those that could be handled by endoscopy or T-tube drainage, suturing, or both) or in the 30-day mortality rate. The multivariate analyses showed that male sex was a significant factor for conversion but not for length of postoperative stay or readmission. Conclusion Men showed a significantly higher risk of the operation being converted from laparoscopic to open cholecystectomy than women (OR, 2.48; 95% CI, 2.04–3.01). The main reason for this may be that men more frequently had acute cholecystitis or sequelae from previous acute cholecystitis. These results can be used to give patients a better basis for their informed consent and better resource management in connection with the operation.
DOI:10.1007/s00464-010-1091-1      PMID:20449610      URL    
[本文引用:2]
[9] ZHU Y M,JING G X,YUAN W.Preoperative administra-tion of intramuscular dezocine reduces postoperative pain for laparoscopic cholecystectomy[J].J Biomed Res,2011,25(5):356-361.
Postoperative pain is the most common complaint after laparoscopic cholecystectomy.This study was carried out to evaluate whether preoperative administration of intramuscular dezocine can provide postoperative analgesia and reduce postoperative opioid consumption in patients undergoing laparoscopic cholecystectomy.Patients (ASA or ) scheduled for laparoscopic cholecystectomy were randomly assigned into intramuscular dezocine group (group 1) or intramuscular normal saline group (group 2).Dezocine and equal volume normal saline were administered intramuscularly 10 min before the induction of anesthesia.After operation,the severity of postoperative pain,postoperative fentanyl requirement,incidence and severity of side-effects were assessed.Postoperative pain and postoperative patient-controlled fentanyl consumption were reduced significantly in group 1 compared with group 2.The incidence and severity of side effects were similar between the two groups.Preoperative single-dose administration of intramuscular dezocine 0.1 mg/kg was effective in reducing postoperative pain and postoperative patient-controlled fentanyl requirement in patients undergoing laparoscopic cholecystectomy.
DOI:10.1016/S1674-8301(11)60047-X      PMID:23554711      URL    
[本文引用:2]
[10] YUEN V M,HUI T W,IRWIN M G,et al.A randomised comparison of two intranasal dexmedetomidine doses for premedication in children[J].Anaesthesia,2012,67(11):1210-1216.
Abstract We compared sedation levels in children following administration of intranasal dexmedetomidine. One hundred and sixteen children aged between 1 and 8 years were enrolled in this prospective, randomised trial. Children were assigned to receive either intranasal dexmedetomidine 1 0204g.kg(-1) (Group 1) or 2 0204g.kg(-1) (Group 2). Thirty-one (53%) patients from Group 1 and 38 (66%) patients from Group 2 were satisfactorily sedated at the time of anaesthetic induction. Logistic regression showed a significant interaction effect (p=0.049), with the odds ratio between Group 2 over Group 1 estimated as 1.1 (95% CI 0.5-2.7) for the 1-4 year age group, and 10.5 (95% CI 1.4-80.2) for the 5-8 year age group. Both doses produced a similar level of satisfactory sedation in children aged 1-4 years, whereas 2 0204g.kg(-1) resulted in a higher proportion of satisfactory sedation in children aged 5-8 years. There were no adverse haemodynamic effects. We conclude that intranasal dexmedetomidine in a premedication dose of 2 0204g.kg(-1) resulted in excellent sedation in children. Anaesthesia 0008 2012 The Association of Anaesthetists of Great Britain and Ireland.
DOI:10.1111/j.1365-2044.2012.07309.x      PMID:22950484      URL    
[本文引用:2]
[11] MEKITARIAN F E,ROBINSON F, DE CARVALHO W B, et al.Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging[J].J Pediatr,2015,166(5):1313-1315.
Abstract This prospective observational pilot study evaluated the aerosolized intranasal route for dexmedetomidine as a safe, effective, and efficient option for infant and pediatric sedation for computed tomography imaging. The mean time to sedation was 13.402minutes, with excellent image quality, no failed sedations, or significant adverse events. TRIAL REGISTRATION: Registered with ClinicalTrials.gov: NCT01900405. Copyright 08 2015 Elsevier Inc. All rights reserved.
DOI:10.1016/j.jpeds.2015.01.036      PMID:25748567      URL    
[本文引用:2]
[12] MASON K P,TURNER D P,HOULE T T,et al.Hemody-namic response to fluid management in children undergoing dexmedetomidine sedation for MRI[J].AJR Am J Roentgenol,2014,202(6):W574-579.
Dexmedetomidine is administered for pediatric sedation for MRI studies. It has the advantage of preserving respiratory function and producing a sedation state identical to that of natural sleep. It can, however, cause a dose-dependent decrease in systemic blood pressure in children. The purpose of this study was to investigate whether i.v. fluid loading with normal saline solution before the initiation of dexmedetomidine administration would affect the frequency of hypotension.Quality assurance data on consecutively registered children who were sedated with dexmedetomidine for MRI were reviewed. All children received a bolus of 3 g/kg dexmedetomidine followed by a continuous infusion of 2 mg/ kg/h. A normal saline fluid bolus consisting of 0, 10, or 20 mL/kg was administered to each child within 1 hour before initiation of dexmedetomidine administration. Hypotension was defined as a greater than 20% decrease in mean arterial blood pressure from baseline.Sedation was administered to 1692 children. Data on fluid administration were missing in three cases. In the other cases, 252 (14.9%) children received 0 mL/kg of normal saline solution, 598 (35.3%) received 10 mL/kg, and 839 (49.6%) received 20 mL/kg. In a multiple logistic regression model controlled for confounding variables, the odds of development of hypotension with 10 mL/kg of fluid decreased 53% (odds ratio, 0.47; 95% CI, 0.28-0.79; p = 0.004) compared with 0 mL/kg.Administration of 10 mL/kg of normal saline solution before the initiation of dexmedetomidine administration for pediatric MRI sedation is effective in decreasing the incidence of observed hypotension.
DOI:10.2214/AJR.13.11580      PMID:24848852      URL    
[本文引用:1]
[13] BISGAARD T,ROSENBERG J,KEHLET H.From acute to chronic pain after laparoscopic cholecystectomy:a prospective follow-up analysis[J].Scand J Gastroenterol,2005,40(11):1358-1364.
Abstract OBJECTIVE: The pathogenesis and risk of chronic pain after cholecystectomy are unknown. In this prospective study of 150 consecutive patients undergoing laparoscopic cholecystectomy, the preoperative clinical data, cold pressor test, state of neuroticism and early postoperative pain intensity were assessed. MATERIAL AND METHODS: Follow-up questionnaires were sent to all patients 1 year after surgery. Patients with moderate/severe chronic pain were interviewed and invited to participate in a structured examination programme. RESULTS: The questionnaire response rate was 100%. Twenty patients reported moderate or severe chronic pain. The 1-year in-office interview revealed that two patients without chronic pain had misinterpreted the questionnaire. Sixteen patients were enrolled for the examination programme. Demonstrable pathology explained the aetiology of chronic pain in 8 patients (5%); another 8 patients with moderate (n=6) or severe (n=2) chronic pain were without pathological findings. In total, 132 patients had no chronic pain. Chronic pain patients suffered significantly more intense acute postoperative pain compared with those without chronic pain (p < or =0.05). The incidence of chronic pain patients was higher in the group of patients with intense acute postoperative pain than in patients with low acute postoperative pain (p = 0.030-0.063). Development of chronic pain was not statistically related to a preoperative cold pressor nociceptive stimulus, preoperative state of neuroticism or to any other variables examined. CONCLUSIONS: The risk of significant chronic pain after laparoscopic cholecystectomy for symptomatic cholecystolithiasis is low but was significantly associated with the intensity of acute postoperative pain. Patients should be carefully examined to exclude somatic causes of chronic pain after laparoscopic cholecystectomy.
DOI:10.1080/00365520510023675      PMID:16334446      URL    
[本文引用:1]
[14] GARG P,THAKUR J D,SINGH I.Lower abdominal wall pain and contusion in single-incision laparoscopic cholecystectomy[J].J Laparoendosc Adv Surg Tech A,2010,20(8):713-715.
Abstract There is a surge in interest in single-incision laparoscopic surgery in the recent years. Due to entry of all the ports and instruments from the same incision and obliquity of the instruments, the lowermost port exerts repeated pressure on the infraumbilical abdominal wall. We are reporting 2 cases of single-incision laparoscopic surgery cholecystectomy who presented with lower abdominal pain and contusion in the post operative period.
DOI:10.1089/lap.2010.0285      PMID:20874236      URL    
[本文引用:0]
[15] SMITH H,BRUCKENTHAL P.Implications of opioid anal-gesia for medically complicated patients[J].Drugs Aging,2010,27(5):417-433.
Opioid analgesics have an established role in the management of postoperative pain and cancer pain, and are gaining acceptance for the management of moderate to severe chronic noncancer pain, most notably chronic low back pain and osteoarthritis, that does not respond to other interventions. Many patients with chronic pain have co-morbid medical conditions that may complicate opioid therapy. Selecting the appropriate opioid requires knowledge of how individual opioids differ with respect to metabolism and interaction with concurrent medications, as well as the reasons why specific medical conditions may influence their efficacy and tolerability. Polypharmacy is a common complicating condition in the elderly and in patients with psychiatric illness, cancer, cardiovascular disease, diabetes mellitus or other chronic illnesses. Polypharmacy, though often necessary for patients with multiple medical conditions, also multiplies the risk of drug interactions. Pharmacokinetic drug interactions can increase or reduce exposure to the opioid or concurrent medications, reducing efficacy and/or tolerability and increasing toxicity. Pharmacodynamic interactions can enhance the depressive effects of opioids, compromising safety. Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events. Patients with cardiovascular, cerebrovascular or respiratory disease (including smokers of 2 packs/day with no other diagnosis) may be more susceptible to respiratory depression, bradycardia and hypotension with any opioid, and a few specific opioids pose additional risks. Patients with cerebrovascular disease, dementia, brain injury or psychiatric illness are more susceptible to opioid effects on the CNS, which can include euphoria, cognitive impairment and sedation. Appropriate opioid selection may mitigate these effects. Even in older patients, addiction, abuse and misdirection of prescribed opioids are of concern. Higher risk exists for patients with psychiatric illness, history of substance abuse, and identifiable substance abuse risk factors. Screening for abuse potential and vigilant patient monitoring should be routine. Opioids differ in their ability to produce euphoria, based on opioid receptor agonism, but substance abusers may be more influenced by availability, familiarity and cost factors. Consequently, opioid selection has limited influence on abuse potential but can facilitate ease of monitoring. This review provides an overview of opioid use in medically complicated patients and recommendations on how to optimize analgesia while avoiding adverse events and drug interactions in the clinical setting. Articles cited in this review were identified via a search of EMBASE and PubMed. Articles selected for inclusion discussed characteristics of specific opioids and general physiological aspects of opioid therapy in important patient populations.
DOI:10.2165/11536540-000000000-00000      PMID:20450239      URL    
[本文引用:1]
[16] HOLZER P.Opioid antagonists for prevention and treatment of opioid-induced gastrointestinal effects[J].Curr Opin Anaesthesiol,2010,23(5):616-622.
The therapeutic action of opioid analgesics is compromised by peripheral adverse effects, among which constipation is the most disabling as laxatives often fail to provide satisfactory relief. This review highlights recent advances in the specific control of opioid-induced constipation by opioid receptor antagonists with limited systemic bioavailability or a peripherally restricted site of action.The specific management of opioid-induced bowel dysfunction is currently based on three drug entities: oral alvimopan for the shortening of postoperative ileus associated with opioid-induced pain control after bowel resection, subcutaneous methylnaltrexone for the reduction of opioid-induced constipation in patients with advanced illness, and a fixed combination of oral prolonged-release naloxone with prolonged-release oxycodone for the treatment of noncancer and cancer pain. All three drug entities have been shown to attenuate opioid-induced motor stasis in the gut with a favorable adverse effect profile, while the analgesic effect of opioids remains unabated.The availability of opioid receptor antagonists with restricted access to the central nervous system provides a novel opportunity to specifically control opioid-induced constipation and other peripheral adverse effects of opioid analgesics. Further studies are needed to evaluate the long-term efficacy, safety and cost-effectiveness of this approach.
DOI:10.1097/ACO.0b013e32833c3473      PMID:20543677      URL    
[本文引用:1]
[17] MILIC M,GORANOVIC T,KNEZEVIC P,et al.Complica-tions of sevoflurane-fentanyl versus midazolam-fentanyl anesthesia in pediatric cleft lip and palate surgery:a randomized comparison study[J].Int J Oral Maxillofac Surg,2010,39(1):5-9.
Careful choice of anesthetic agents in pediatric patients reduces the frequency of anesthesia-related complications. The frequency and type of intraoperative and postoperative complications of sevoflurane–fentanyl versus midazolam–fentanyl anesthesia were compared in 140 consecutive children (aged 3 months to 10 years) undergoing cleft lip and palate repair. Midazolam–fentanyl anesthesia was induced with midazolam (0.05 mg/kg), fentanyl (0.005 mg/kg) and vecuronium (0.1 mg/kg), and maintained with the same agents according to the defined parametars. Sevoflurane–fentanyl anesthesia was induced and maintained with sevoflurane (5–8 vol% and 0.8–1 vol%, respectively) in an oxygen/air mixture and supplemented with fentanyl (0.005 mg/kg). Both groups were comparable in basic demographic data, hemodynamic and respiratory parameters. Difficult intubation occurred in 6 of 76 children (midazolam–fentanyl group) and 4 of 64 children (sevoflurane–fentanyl group) ( P = 0.754). Ventricular extrasystole and bronchospasm occurred in one patient each in the sevoflurane–fentanyl group. Postoperatively, emergence agitation was observed in the sevoflurane–fentanyl group (17 cases; P < 0.001); postoperative nausea and vomiting occurred in 2 children (midazolam–fentanyl group) and 3 children (sevoflurane–fentanyl group) ( P = 0.660). Midazolam-based anesthesia in children is safer than sevoflurane-based anesthesia regarding occurrence of emergence agitation.
DOI:10.1016/j.ijom.2009.09.007      PMID:19854614      URL    
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[18] SAPATE M,ANDURKAR U,MARKANDEYA M,et al.To study the effect of injection dexmedetomidine for prevention of pain due to propofol injection and to compare it with injection lignocaine[J].Rev Bras Anestesiol,2015,65(6):466-469.
DOI:10.1016/j.bjan.2013.10.006      URL    
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[19] 魏会霞,王玉佩.地佐辛用于小儿唇腭裂修复术围拔管期的镇痛效果[J].重庆医学,2014,43(27):3570-3572.
目的观察地佐辛用于小儿全身麻 醉下唇腭裂修复术围拔管期的镇痛效果及安全性。方法选择于2013年1月1日至8月1日,在湖北医药学院附属太和医院麻醉科全身麻醉下择期行唇腭裂修复术 患儿60例,美国麻醉医师协会(ASA)Ⅰ~Ⅱ级,分为D、F、N组,每组20例。所有患儿均实施气管内插管全身麻醉,术毕前15min D组静脉注射地佐辛0.10mg/kg;F组静脉注射芬太尼1.00μg/kg;N组给予等剂量生理盐水。观察并记录插管前、拔管时、拔管后5min的平 均动脉压(MAP)、心率(HR);术毕至拔管时间;苏醒期Riker镇静躁动评分;拔管后30min儿童行为量表疼痛程度(FIACC)评分及拔管后 30min内各种不良反应(呼吸、循环抑制、恶心、呕吐、嗜睡、头痛、锥体外系反应)的发生率。结果 3组患儿全部顺利完成手术,3组患儿年龄、体质量、手术时间、七氟醚吸入浓度比较差异无统计学意义(P0.05);D组患儿拔管时及拔管后5min的 MAP、HR均显著低于N组、F组(P0.05),而D组、F组拔管时、拔管后5min的MAP、HR比较差异均无统计学意义(P0.05);3组患儿术 毕至拔管时间比较差异无统计学意义(P0.05);D组患儿苏醒期Riker镇静躁动评分及拔管后30min FLACC评分明显低于N组、F组(P0.01);3组患儿拔管后30min均未见呼吸、循环抑制、恶心、呕吐、嗜睡、头痛、锥体外系反应等明显的不良反 应。结论地佐辛用于小儿全身麻醉唇腭裂修复术围拔管期镇痛,安全有效。
[本文引用:2]
[20] CIMEN Z S,HANCI A,SIVRIKAYA G U,et al.Compari-son of buccal and nasal dexmedetomidine premedication for pediatric patients[J].Pediatr Anesth,2013,23(2):134-138.
Abstract BACKGROUND: Alpha-2 adrenergic agonists are used to premedicate pediatric patients to reduce separation anxiety and achieve calm induction. The clinical effects of clonidine are similar whether via the oral or nasal route. However, oral dexmedetomidine is not preferred because of its poor bioavailability. The objective of this study was to evaluate the effects of nasal versus buccal dexmedetomidine used for premedication in children. METHODS: Sixty-two patients, aged 2-6 years, undergoing minor elective surgery were randomly assigned to two groups to receive dexmedetomidine, either 1 0204g00·kg(-1) buccally (group B) or 1 0204g00·kg(-1) intranasally (group N) for premedication 45 min before the induction of anesthesia. Heart rate, peripheral oxygen saturation, and respiratory rate were measured before and every 10 min after administering dexmedetomidine in all children. Level of sedation was assessed every 10 min until transport to operating room. Drug acceptance, parental separation, and face mask acceptance scores were recorded. RESULTS: There was no significant difference between the two groups in patient characteristics, nor was there any significant difference between the two groups in heart rate, respiratory rate, or SpO(2) values at all times after premedication. Levels of sedation, parental separation, and mask acceptance scores were significantly higher in group N than in group B at the various times. CONCLUSIONS: These results suggest that intranasal administration of 1 0204g00·kg(-1) dexmedetomidine is more effective than buccal administration of 1 0204g00·kg(-1) dexmedetomidine for premedication in children. 0008 2012 Blackwell Publishing Ltd.
DOI:10.1111/pan.12025      PMID:22985207      URL    
[本文引用:1]
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关键词(key words)
地佐辛
右美托咪定,盐酸
躁动
麻醉

Dezocine
Dexmedetomidine,hydrochlo...
Agitation
Anesthesia

作者
魏会霞
罗向红

WEI Huixia
LUO Xianghong