椎管内镇痛药物的应用.ppt
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椎管内镇痛药物的应用
天津医科大学总医院
王国林
2007-8-25山东
Neuraxial drug administration
Techniques that deliver drugs in close proximity to the spinal cord----intrathecally into CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion.
椎管内麻醉的机制
CNS drugs 2006;20(11):917-933
Spinal anaesthesisEpidural anaesthesia
椎管内麻醉应用的药物
> 局麻药 ：利多卡因、 布比卡因、 罗哌卡因、左旋布比卡因
> 阿片类：吗啡、哌替啶、芬太尼、苏芬太尼
> alpha-adrenergic receptors antagonist：可乐定、右旋美托咪啶
> 其他：新斯的明、氯胺酮、咪唑安定 ，腺苷、 ziconotide (齐考诺肽)
局麻药
> Produce reversibale blockade of sodium channels within nervous tissues hinder the transmission of peripheral nerve impulses.
-short-acting drug-------lidocaine
-three longer-acting structurally related compounds---
bupivacaine,levobupivacaine and ropivacaine
> Often co-administered with adjunctive agents(opioids and non-opioids)
-utilize the synergistic analgesic properties
-improve the quality and duration of sensory block
-limit adverse effects such as motor blockade
Carr DB,et al " Acute Pain" The LancetJune 1999
Indian J. Anaesth.2004:48(1):13-24
CURRENT CONCEPTS IN NEURAXIAL ADMINISTRATION OF OPIOIDS AND NON-OPIOIDS : AN OVERVIEW AND FUTURE PERSPECTIVES
椎管内阿片类药物的应用进展
> The identification of opioid receptors has opened new horizons in pain management.
> "Any opioid administered anywhere in the body will eventually produce analgesia" Benjamine Rush, 1818
> 1900 ----- N.Racoviceanu-pitesti of Romania. The first report of the use of opioids for the intrathecal route.
injected morphine and cocaine for intrathecal anaesthesia
> 1901 -----Katawata of Japan
used 10 mg intrathecal (IT) morphine with the local anaesthetic eucaine in two cancer patients.
> 1976 ----- Yaksh and Rudy were the first investigators to demonstrate direct opioid analgesia at the spinal cord level (rats experiment).
> 1979 ----- Wang et al. spinal morphine in patients.
> 1979 ----- Behar et al. epidural opioids to manage acute
postoperative pain.
阿片药应用于椎管内麻醉的优势
> Greater anaesthesia success rate
> Faster onset of surgical block than LA alone
> Improved intraoperative analgesia (enhances sensory block without increased motor block)
> Permits lower LA dose with faster recovery from spinal anaesthesia
> Postoperative analgesia beyond the duration of LA motor block
> Less nausea and/or vomiting during cesarean delivery
> Shorter time to extubation, significantly reduces MAC
阿片药应用于椎管内麻醉的作用机制
"The clinical practice of spinal morphine administration
for pain relief is based on observations in animals that
opioid receptors exist in the spinal cord and intrathecal
injections of opioids in those species (mostly rats) lead
to antinociceptive effects."
European Journal of Anaesthesiology 2004;21:179-185
Mechanism of Action: Reaching Receptors
? Epidurally administered drugs must travel through:
dura matter
arachnoid matter
CSF
pia matter
white matter
gray matterdorsal horn
? Competing pathways
Uptake into epidural fat
Uptake into systemic circulation
Anesth Analg 2005;101:S30 -S43
作用机制
> Universal molecular mechanism of opioids:
Binding to G-protein-coupled opioid receptor
Inhibition of adenylate cyclase and voltage-gated Ca++ channels
Decrease neuronal excitability, interruption of pain transmission
> 脊髓水平效应 - 脊髓背角胶质
- Highly selective nociceptive pathways
- Presynaptic receptor action - inhibition of substance P release
- Postsynaptic receptor action - modulation of pain transmission
> 脊髓以上作用 - inhibition of primary afferent transmission in the brainstem, thalamus and gray matter
Anesth Analg 2002;95:209 -13
Intrathecal Versus Intravenous Fentanyl for Supplementation
of Subarachnoid Block During Cesarean Delivery
副作用
> 瘙痒
> 呼吸抑制
> 恶性、呕吐
> 嗜睡
> 尿潴留
> 低血压
> 潜在神经毒性
> 引起异常性疼痛
> 耐受
椎管内阿片类药物在急性疼痛的应用
Indian J. Anaesth.2004:48(1):13-24
CURRENT CONCEPTS IN NEURAXIAL ADMINISTRATION OF OPIOIDS AND NON-OPIOIDS : AN OVERVIEW AND FUTURE PERSPECTIVES
Optimal Intrathecal (IT) Opioid Dose for Specific Surgical Procedures
morphine
> 第一个被报道应用于椎管内麻醉的阿片类镇痛药，研究最广泛
> 无论硬膜外给药还是蛛网膜下腔给药均能通过椎管内机制产生镇痛作用
> 椎管内给予阿片类镇痛药的?°金标准?±
Anesth Analg 1999;88:599-604
The Safety And Efficacy of Intrathecal Opioid Analgesia for Acute Postoperative Pain: Seven Years' Experience with 5969 Surgical Patients at Indiana University Hospital
? a combination of morphine plus fentanyl and bupivacaine (74%)
? morphine plus fentanyl (23%)
? morphine alone (1.5%)
? morphine as part of a standard spinal anesthetic(1.5%)
? Implications: Over a 7-yr period, intrathecal opioid analgesia was used to control acute postoperative pain on nearly 6000 patients, resulting in a high degree of patient satisfaction and a low incidence of side effects and complications.
Anesth Analg 2005;101:S30 -S43
The Role of Intrathecal Drugs in the Treatment of Acute Pain
Anaesthesia,2006,61: 838-844
The use of pre-operative intrathecal morphine for analgesia following coronary artery bypass
fentanyl
> 脂溶性高，更易为血管吸收
> Bolus 或"short term"给药比持续给药更易通过脊髓内机制发挥镇痛效应
Anesth Analg 2002;95:209 -13
> intrathecally 12 mg of bupivacaine plus 12.5 μg of fentanyl vs bupivacaine alone plus IV 12.5μ g of fentanyl during Cesarean
? IT fentanyl produces a better quality of spinal anesthesia
? a lack of need for additional intraoperative analgesia
? a lower VAS before delivery
? a longer time to first request for analgesia
? a less frequent incidence of side effects, such as severe hypotension,nausea, and vomiting
Reg Anesth Pain Med 2000；25(3): 235-239......（后略) ......
椎管内镇痛药物的应用
天津医科大学总医院
王国林
2007-8-25山东
Neuraxial drug administration
Techniques that deliver drugs in close proximity to the spinal cord----intrathecally into CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion.
椎管内麻醉的机制
CNS drugs 2006;20(11):917-933
Spinal anaesthesisEpidural anaesthesia
椎管内麻醉应用的药物
> 局麻药 ：利多卡因、 布比卡因、 罗哌卡因、左旋布比卡因
> 阿片类：吗啡、哌替啶、芬太尼、苏芬太尼
> alpha-adrenergic receptors antagonist：可乐定、右旋美托咪啶
> 其他：新斯的明、氯胺酮、咪唑安定 ，腺苷、 ziconotide (齐考诺肽)
局麻药
> Produce reversibale blockade of sodium channels within nervous tissues hinder the transmission of peripheral nerve impulses.
-short-acting drug-------lidocaine
-three longer-acting structurally related compounds---
bupivacaine,levobupivacaine and ropivacaine
> Often co-administered with adjunctive agents(opioids and non-opioids)
-utilize the synergistic analgesic properties
-improve the quality and duration of sensory block
-limit adverse effects such as motor blockade
Carr DB,et al " Acute Pain" The LancetJune 1999
Indian J. Anaesth.2004:48(1):13-24
CURRENT CONCEPTS IN NEURAXIAL ADMINISTRATION OF OPIOIDS AND NON-OPIOIDS : AN OVERVIEW AND FUTURE PERSPECTIVES
椎管内阿片类药物的应用进展
> The identification of opioid receptors has opened new horizons in pain management.
> "Any opioid administered anywhere in the body will eventually produce analgesia" Benjamine Rush, 1818
> 1900 ----- N.Racoviceanu-pitesti of Romania. The first report of the use of opioids for the intrathecal route.
injected morphine and cocaine for intrathecal anaesthesia
> 1901 -----Katawata of Japan
used 10 mg intrathecal (IT) morphine with the local anaesthetic eucaine in two cancer patients.
> 1976 ----- Yaksh and Rudy were the first investigators to demonstrate direct opioid analgesia at the spinal cord level (rats experiment).
> 1979 ----- Wang et al. spinal morphine in patients.
> 1979 ----- Behar et al. epidural opioids to manage acute
postoperative pain.
阿片药应用于椎管内麻醉的优势
> Greater anaesthesia success rate
> Faster onset of surgical block than LA alone
> Improved intraoperative analgesia (enhances sensory block without increased motor block)
> Permits lower LA dose with faster recovery from spinal anaesthesia
> Postoperative analgesia beyond the duration of LA motor block
> Less nausea and/or vomiting during cesarean delivery
> Shorter time to extubation, significantly reduces MAC
阿片药应用于椎管内麻醉的作用机制
"The clinical practice of spinal morphine administration
for pain relief is based on observations in animals that
opioid receptors exist in the spinal cord and intrathecal
injections of opioids in those species (mostly rats) lead
to antinociceptive effects."
European Journal of Anaesthesiology 2004;21:179-185
Mechanism of Action: Reaching Receptors
? Epidurally administered drugs must travel through:
dura matter
arachnoid matter
CSF
pia matter
white matter
gray matterdorsal horn
? Competing pathways
Uptake into epidural fat
Uptake into systemic circulation
Anesth Analg 2005;101:S30 -S43
作用机制
> Universal molecular mechanism of opioids:
Binding to G-protein-coupled opioid receptor
Inhibition of adenylate cyclase and voltage-gated Ca++ channels
Decrease neuronal excitability, interruption of pain transmission
> 脊髓水平效应 - 脊髓背角胶质
- Highly selective nociceptive pathways
- Presynaptic receptor action - inhibition of substance P release
- Postsynaptic receptor action - modulation of pain transmission
> 脊髓以上作用 - inhibition of primary afferent transmission in the brainstem, thalamus and gray matter
Anesth Analg 2002;95:209 -13
Intrathecal Versus Intravenous Fentanyl for Supplementation
of Subarachnoid Block During Cesarean Delivery
副作用
> 瘙痒
> 呼吸抑制
> 恶性、呕吐
> 嗜睡
> 尿潴留
> 低血压
> 潜在神经毒性
> 引起异常性疼痛
> 耐受
椎管内阿片类药物在急性疼痛的应用
Indian J. Anaesth.2004:48(1):13-24
CURRENT CONCEPTS IN NEURAXIAL ADMINISTRATION OF OPIOIDS AND NON-OPIOIDS : AN OVERVIEW AND FUTURE PERSPECTIVES
Optimal Intrathecal (IT) Opioid Dose for Specific Surgical Procedures
morphine
> 第一个被报道应用于椎管内麻醉的阿片类镇痛药，研究最广泛
> 无论硬膜外给药还是蛛网膜下腔给药均能通过椎管内机制产生镇痛作用
> 椎管内给予阿片类镇痛药的?°金标准?±
Anesth Analg 1999;88:599-604
The Safety And Efficacy of Intrathecal Opioid Analgesia for Acute Postoperative Pain: Seven Years' Experience with 5969 Surgical Patients at Indiana University Hospital
? a combination of morphine plus fentanyl and bupivacaine (74%)
? morphine plus fentanyl (23%)
? morphine alone (1.5%)
? morphine as part of a standard spinal anesthetic(1.5%)
? Implications: Over a 7-yr period, intrathecal opioid analgesia was used to control acute postoperative pain on nearly 6000 patients, resulting in a high degree of patient satisfaction and a low incidence of side effects and complications.
Anesth Analg 2005;101:S30 -S43
The Role of Intrathecal Drugs in the Treatment of Acute Pain
Anaesthesia,2006,61: 838-844
The use of pre-operative intrathecal morphine for analgesia following coronary artery bypass
fentanyl
> 脂溶性高，更易为血管吸收
> Bolus 或"short term"给药比持续给药更易通过脊髓内机制发挥镇痛效应
Anesth Analg 2002;95:209 -13
> intrathecally 12 mg of bupivacaine plus 12.5 μg of fentanyl vs bupivacaine alone plus IV 12.5μ g of fentanyl during Cesarean
? IT fentanyl produces a better quality of spinal anesthesia
? a lack of need for additional intraoperative analgesia
? a lower VAS before delivery
? a longer time to first request for analgesia
? a less frequent incidence of side effects, such as severe hypotension,nausea, and vomiting
Reg Anesth Pain Med 2000；25(3): 235-239......（后略) ......
附件资料：
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