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右美托咪定在剖宫产术后多模式镇痛中的应用

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简介:本文是右美托咪定和剖腹产方面参考文献格式范文与模式相关毕业论文格式范文.

右美托咪定和剖腹产论文范文

摘 要:右美托咪定是一种新型高选择性的α2受体激动剂,主要通过作用于中枢神经系统和外周神经系统的α2受体产生相应的药理作用,因其具有镇静催眠、抗焦虑、降低应激反应、稳定血流动力学、镇痛、抗寒战和利尿等作用,从而普遍运用于临床中.在剖宫产术后镇痛中,右美托咪定的不同给药方式以及与其他镇痛药物和局麻药联合使用,在起到镇静、抗焦虑等作用的同时,还可以起到减少镇痛药物剂量、加强镇痛效果、延长镇痛时间及减少不良反应的效果.本文就右美托咪定如何在剖宫产术后多模式镇痛中应用、镇痛优势及其注意事项予以综述.

关键词:右美托咪定;剖宫产;术后镇痛;多模式镇痛

中图分类号:R614 文献标识码:ADOI:10.3969/j.issn.1006-1959.2020.23.017

文章編号:1006-1959(2020)23-0057-04

Abstract:Dexmedetomidine is a new type of high selectivity of alpha 2 agonists,mainly through the central nervous system and peripheral nervous system α2 receptors of the corresponding pharmacological effects,because of its sedative hypnotic,anxiety,reduce stress reaction, stabilize hemodynamics,analgesia,cold resistance and diuresis effect,thus widely used in clinical. In the postoperative analgesia after cesarean section,dexmedetomidine was administered in different ways and used in combination with other analgesics and local anesthetics, which not only had the effects of sedation and anti-anxiety,but also had the effects of reducing the dosage of analgesics,enhancing the analgesic effect,prolonging the analgesic time and reducing the adverse reactions. This paper reviews the application of dexmedetomidine in multi-mode analgesia after cesarean section,its analgesic advantages and points for attention.

Key words:Dexmedetomidine;Cesarean section;Postoperative analgesia;Multi-mode analgesia

疼痛使交感神经兴奋,导致机体耗氧量增加,对产妇体力恢复及消化功能恢复有一定影响,间接导致产妇忧郁、烦躁等不良情绪,甚至可以发展为慢性疼痛,严重影响产妇术后康复的进度[1].术后有效镇痛不仅可以减轻产妇的疼痛,还可有效地减少应激反应、抑制交感神经兴奋,促进催乳素分泌,有助于早期哺乳[2].剖宫产术后镇痛方案还要考虑对产妇泌乳的影响以及对新生儿的影响等.多模式镇痛是指在整个围术期联合应用作用不同的镇痛药、辅助药和镇痛技术,作用于疼痛传导通路的不同靶点,发挥镇痛的相加或协同作用,以应对不同机制产生的术后疼痛,达到最佳的减轻术后疼痛的疗效[3].常用的镇痛方式有患者自控静脉镇痛(PCIA)、患者自控硬膜外镇痛、神经阻滞等,具有呼吸抑制、瘙痒、尿储留、运动阻滞等不良反应.多模式镇痛的方式可制定个体化的镇痛配方,有效减少不良反应的发生.右美托咪定是一种高选择性的α2受体激动剂,广泛用于围手术期及ICU治疗中,越来越多的研究发现它是良好的麻醉镇痛的辅助药物,可起到加强镇痛效果、减少镇痛药物剂量、减少不良反应的发生等作用.现就右美托咪定在剖宫产患者术后多模式镇痛中的应用、镇痛优势及其注意事项作一综述.

1在PCIA中的应用

PCIA是目前术后镇痛最常用和理想的方法,因其具有起效快、镇痛效果明确、血药浓度稳定、可通过冲击剂量及时控制爆发痛,并有用药个体化、患者满意度高等优点[3].剖宫产术后PCIA大多数采用阿片类药物复合NSAIDs类药物及其他辅助药物如托烷司琼、地塞米松等止吐药,法旨在提高镇痛效果,减少术后阿片类药物的需求,进而减少阿片类药物相关的不良反应.右美托咪定是一类辅助镇痛药物运用于PCIA中也能产生这种效果.

Nie Y等[4]研究报道,在208例择期椎管内麻醉下行剖宫产手术中,研究组在胎儿剖出后静脉泵注0.5 μg/kg的右美托咪定,手术结束后使用配方为右美托咪定300μg+100μg的PCIA泵,与单纯使用相同剂量的对照组相比,更能有效缓解术后疼痛,减少术后的消耗量和补救镇痛次数,增加产后的镇痛满意度,减少术后恶心呕吐(PONV)的发生率,且有益于肠道功能恢复.可能与该药使蓝斑核以及投射到脊髓的下行去甲肾上腺素能通路突触前膜去极化,抑制突触前膜P物质和其他伤害性肽类的释放,抑制脊髓突触前膜和后膜上的α2A 受体,使细胞产生超极化,抑制疼痛信号的传递有关[5].Bao Z等[6]的研究也有报道,在手术过程中静脉泵注右美托咪定[1 μg/(kg·h)]可以减少术后镇痛的药量,减少PONV的发生率,以及剖宫产术后寒战的发生,但不会减少瘙痒和低血压的发生率,增加心动过缓的发生率.低剂量右美托咪定通过激活起源于桥脑蓝斑的降肾上腺素能抑制系统,促进脊髓背角的抑制性突触传递,这一新的抗伤害性机制使得右美托咪啶在低于正常镇静范围的剂量下就可以有效地产生镇痛作用,这种抑制性突触传递的增强也可能部分解释了麻醉剂本身增强抑制性突触传递(通过GABAA受体介导的机制)和右美托咪定之间已知的协同作用[7].低血压是PONV的最重要原因之一.右美托咪定通过作用于蓝斑并控制延髓下游抑制中枢神经系统能显著减少PONV的发生[8].同时,右美托咪定的稳定血流动力学作用主要与增强交感肾上腺素能系统的稳定性有关,稳定的血流动力学可以减少呕吐和呕吐的发生[6].

6剖宮产术后镇痛的优点与不足

右美托咪定可与阿片类药物、局麻药起协同作用,可减少镇痛药物剂量从而减少镇痛药物带来不良反应,加强镇痛效果和延长镇痛时间;同时,其镇静、抗焦虑作用可以使产妇在术后恢复过程中更加舒适,利于术后心理健康,改善睡眠质量,其抗寒战作用还可以预防椎管内麻醉后的寒战症状.剖宫产术后早期产妇乳汁分泌量少,右美托咪定具有分子量较大、血浆蛋白结合率高、口服生物利用度低等特性,这就决定了它从血浆向乳汁转移的量非常少,且产妇术后早期泌乳量少,故经乳汁分泌的右美托咪定对新生儿的影响微乎其微[37].右美托咪定具有高度的亲脂性,因此它被保留在胎盘组织中,少量转移到胎儿体内,对胎儿的风险很小[38].在全身麻醉术中输注右美托咪定还有心脏保护作用.右美托咪定对健康患者心脏收缩或舒张功能没有损害,对有心脏疾病患者的心脏可通过诱导了环磷酸腺苷和腺苷诱导的冠状动脉舒张,还可降低血浆去甲肾上腺素浓度,降低心肌耗氧量,并有抗炎作用,如细胞因子减少[39].

右美托咪定最常见的不良反应是心动过缓和血压变化,且与给药剂量和输注速度相关,应严格掌握药物的用法用量,避免一次大剂量静脉注射.对有心脏传导阻滞、心室功能不全、迷走神经张力高、糖尿病、髙血压和肝功能严重受损的孕妇使用右美托咪定后更易发生心动过缓,甚至有可能导致窦性停搏,以上类型患者应谨慎使用[37].右美托咪定用于术后镇痛中应加强监护,如出现心动过缓应及时给予阿托品纠正,必要时停药.

综上所述,右美托咪定用于剖宫产术后多模式镇痛的效果是肯定的,它能增强镇痛效果、减少阿片类药物的使用以及阿片类药物相关的不良反应、延长神经阻滞时间;同时它具有镇静催眠、抗焦虑、改善睡眠质量、减少术后恶心呕吐及抗寒战等作用,有利于产妇术后快速康复及心理健康.此外,它在乳汁中分布极少,对胎儿的风险很小.

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收稿日期:2020-07-10;修回日期:2020-08-24

编辑/肖婷婷

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