Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,*,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,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,1,臨床試驗計劃:Dexmedetomidine對於止血帶所,Part,:,Introduction of Dexmedetomidine,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,2,Part:Introduction of Dexmed,Medetomidine,動物鎮靜麻醉,Ketamine(K他命）和 Midazolam 混合,Medetomidine,Medetomidine混合dextro-medetomidine levo-medetomidine,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,3,Medetomidine動物鎮靜麻醉Dexmedetomid,Dexmedetomidine,Alpha-2 Agonist,1999 美國FDA 核准使用,Drug,2/1,selectivity,Dexmedetomidine,1600,Medetomidine,1200,Clonidine,200,Dyck,Shafer.Aneasth Pharm Review.1993,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,4,DexmedetomidineAlpha-2 Agonist,Dexmedetomidine(,Precedex,),適應症：,適用於在加護病房中，插管且接受呼吸器治療的病患鎮靜用。Precedex應該以連續輸注的方式給予，連續輸注以24小時為限。,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,5,Dexmedetomidine(Precedex)適應症,自主神經系統,副交感,交感,新腎上腺素,乙醯膽鹼,腎上腺素接受器,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,6,自主神經系統副交感交感新腎上腺素乙醯膽鹼腎上腺素接受器Dex,腎上腺素接受器,Adrenergic receptors,a,1,b,1,平滑肌,節前Pre-,synaptic,氣管平滑肌,心臟,a,2,b,2,擴張,心跳,心搏量,收縮,抑制,新腎上腺素NE,分泌,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,7,腎上腺素接受器Adrenergic receptorsa1,a,2,腎上腺素接受器,負回饋,Regulate release of neurotransmitters,Control epinephrine,norepinephrine release,Modulate sympathetic response“negative feedback loop”,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,8,a2腎上腺素接受器負回饋Regulate release o,Dexmedetomidine作用機轉,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,9,Dexmedetomidine作用機轉Dexmedetomi,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,Dexmedetomidine,Spinal Cord,LOCUSCERULEUS,FOURTHVENTRICLE,PONS,CEREBRUM,CEREBELLUM,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,10,Dexmedetomidine作用部位作用部位Dexmede,2,-Receptor Subtypes,2C,2A,2A,a2A,利尿,止痛,鎮靜,心跳,抑制顫抖,血管,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,11,2-Receptor Subtypes2C2A2Aa,Mechanism for,2-induced sedation/hypnosis in the rat locus coeruleus,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,12,Mechanism for 2-induced sedat,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,13,Dexmedetomidine对於止血带所引起术中高血压的疗,Dexmedetomidine:Side Effects,Bradycardia,Hypotension,Transient hypertension,Dry mouth,Limited amnestic effect,Excessive sedation,Reduction in CBF/CMRO,2,in animal model,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,14,Dexmedetomidine:Side EffectsB,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,2B,-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,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,15,Dexmedetomidine 的使用(Adult)Hea,Tournique induced hypertension,Incidence:30%,Tourniquet time 60 min,Associated with severe pain and augmented sympathetic outflow,Difficult treatment,Unknown mechanism,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,16,Tournique induced hypertension,Previous study data,Ketamine,(Satsumae et al.A&A,2001),Clonidine,(Zalunardo et al.A&A,2002),Dextromethrophan,(Yamashita et al.A&A,2004),Stellate ganglion blockade,(Arai et al.Acta Anesthesiol Scand,2004),Dexmedetomidine?,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,17,Previous study dataKetamine(,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2 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,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,18,Exclusion and Inclusion Crietr,Grouping,Control group,Dexmedetomidine(continuous infusion),Loading:(0.8 g/kg),Continuous infusion rate:(0.4 g/kg/h),Dexmedetomidine(single dose),1ug/kg for over 10 mins,Dexmedetomidine(continuous infusion),Loading:(0.5 g/kg),Continuous infusion rate:(0.4 g/kg/h),Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,19,GroupingControl groupDexmedeto,Anesthetic standard procedure,General Anesthesia,Pre-op:IV 1.5-2 mg Midazolam,Induction medication:fentanyl 2 ug/ml,propofol 2mg/kg,and recuronium 0.6 mg/kg.,Maintenance medication:sevoflurane which concentration is adjusted to keep,BIS 40-45.,TOF,Rescue(BP,),:Perdipine 1ml/5min,Combined Spinal-Epidural Anesthesia,Pre-op:IV 1.5-2 mg Midazolam,Spinal bupivaccaine dosage:12-15 mg,Epidural dosage:0.25%bupivacaine with continuous rate of 4-8 ml/h.,Level 15 min,Rescue:fentanyl 1ml/15mn,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,20,Anesthetic standard procedure,Monitoring,血液,NE&Epi,濃度(2 times x 10 ml),Post-induction(1 MAC)&tourniquet inflation 60 min,Finometer and HRV recordings,preinduction,postinduction,inflation for 30 and 60 min,after deflation,and POR,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,21,Monitoring血液 NE&Epi 濃度(2 tim,Thank You!,We are small,but we think big!,Dexmedetomidine对於止血带所引起术中高血压的疗效及药理机转之探讨,22,Thank You!We are small,but we,