Neil S. Bailard, M.D., is Assistant Professor; Jaime Ortiz, M.D., is Assistant Professor; and Roland A. Flores, M.D., is Assistant Professor, Department of Anesthesiology, Baylor College of Medicine, Houston, TX.
Am J Health Syst Pharm. 2014 Mar 1;71(5):373-85. doi: 10.2146/ajhp130336.
The therapeutic rationale, clinical effectiveness, and potential adverse effects of medications used in combination with local anesthetics for peripheral nerve block therapy are reviewed.
A wide range of agents have been tested as adjuncts to peripheral nerve blocks, which are commonly performed for regional anesthesia during or after hand or arm surgery, neck or spine surgery, and other procedures. Studies to determine the comparative merits of nerve block adjuncts are complicated by the wide variety of coadministered local anesthetics and sites of administration and by the heterogeneity of primary endpoints. Sodium bicarbonate has been shown to speed the onset of mepivacaine nerve blocks but delay the onset of others. Epinephrine has been shown to prolong sensory nerve blockade and delay systemic uptake of local anesthetics, thus reducing the risk of anesthetic toxicity. Tramadol, buprenorphine, dexamethasone, and clonidine appear to be effective additives in some situations. Midazolam, magnesium, dexmedetomidine, and ketamine cannot be routinely recommended as nerve block additives due to a dearth of supportive data, modest efficacy, and (in the case of ketamine) significant adverse effects. Recent studies suggest that administering additives intravenously or intramuscularly can provide many of the benefits of perineural administration while reducing the potential for neurotoxicity, contamination, and other hazards.
Some additives to local anesthetics can hasten the onset of nerve block, prolong block duration, or reduce toxicity. On the other hand, poorly selected or unnecessary additives may not have the desired effect and may even expose patients to unnecessary risks.
综述了联合局麻药用于外周神经阻滞治疗的药物的治疗原理、临床疗效和潜在不良反应。
为了在手部或手臂手术、颈部或脊柱手术及其他手术期间或之后进行区域麻醉，广泛测试了各种药物作为外周神经阻滞的辅助药物。为确定神经阻滞辅助药物的相对优势而进行的研究受到了多种联合使用的局部麻醉剂和给药部位以及主要终点异质性的复杂性的限制。碳酸氢钠已被证明可以加速甲哌卡因神经阻滞的起效，但会延迟其他药物的起效。肾上腺素已被证明可以延长感觉神经阻滞并延迟局部麻醉剂的全身吸收，从而降低麻醉毒性的风险。在某些情况下，曲马多、丁丙诺啡、地塞米松和可乐定似乎是有效的添加剂。咪达唑仑、镁、右美托咪定和氯胺酮由于缺乏支持性数据、疗效有限（氯胺酮）以及（氯胺酮）显著的不良反应，不能常规推荐作为神经阻滞添加剂。最近的研究表明，静脉内或肌内给予添加剂可以提供许多神经周围给药的益处，同时降低神经毒性、污染和其他危害的可能性。
一些局部麻醉剂的添加剂可以加速神经阻滞的起效、延长阻滞持续时间或降低毒性。另一方面，选择不当或不必要的添加剂可能不会产生预期的效果，甚至可能使患者面临不必要的风险。
