Spinal Anestezide Adjuvan İlaçlar
Özet
Adjuvan ilaçlar klinik uygulamada periferik ve nöroaksiyal bloklarda rağbet görse de intratekal kullanımda nörotoksisite acısından güvenlik ön plana cıkar. Spinal anestezi uygulamasında adjuvan ilaç olarak yaygın kullanılan ajanlar opioidlerdir. Morfin ve fentanil bu amaç ile kullanılan başta gelen opioid adjuvanlardır. Bu grupta sık kullanılan ajanlara ek, meperidin ve tramadol da kullanılır. Gunumuzde dexmedetomidin, deksametazon ile birlikte klinik pratikte opioidlerden sonra en cok tercih edilen adjuvanlardandır. Lokal anestezik ajanın düşük dozları ile yapılan spinal anestezi uygulamalarında blok kalitesine katkısı yanında daha uzun postoperatif analjezi sağlarlar. Steroidler de duyusal blok ve analjezik etki suresini uzatmaktadır. Deksametazon algologlarca da partikulsuz farmakolojik yapısı nedenli akut ve kronik ağrı tedavilerinde kullanılmaktadır. Alfa-2 agonist dexmedetomidin intratekal uygulamada giderek daha çok kullanılmaktadır. Ketaminin, S(+) ketamin olarak, midazolam, neostigminin intratekal kullanımına dair pek çok klinik çalışma yapılmış olsa da, günümüzde hala yan etkileri ve kanıtlanmayan ama olası nörolojik toksisite kullanımlarına dair kafa karışıklığının sürmesine neden olmaktadır.Opioidlere dair solunum depresyonu ve kaşıntı, alfa-2 adrenerjik agonistlere dair kardiyovasküler yan etkiler sebebi ile anestezi pratiğinde bu ajanlar intratekal kullanılırken, dikkat edilmesi gerektiğini unutmamak gerekir.
Although adjuvant drugs are widely preferred in peripheral and neuraxial blocks in clinical practice, safety regarding neurotoxicity comes to the forefront in intrathecal administration. Opioids are the most commonly used adjuvants in spinal anesthesia applications. Morphine and fentanyl are the leading opioid adjuvants. In addition to the frequently used agents in this group, meperidine and tramadol are also commonly utilized in clinical settings. Currently, dexmedetomidine, along with dexamethasone, is among the most preferred adjuvants after opioids in clinical practice. When used alongside low doses of local anesthetics in spinal anesthesia, they enhance block quality and provide longer postoperative analgesia. Steroids also prolong the duration of sensory block and analgesic effect. Dexamethasone is also utilized by pain specialists in the management of acute and chronic pain due to its non-particulate pharmacological formulation. The alpha-2 agonist dexmedetomidine is increasingly being used for intrathecal applications. Although numerous clinical studies have been conducted on the intrathecal use of ketamine [as S(+) ketamine], midazolam, and neostigmine, lingering concerns remain today due to their side effects and unproven yet potential neurotoxicity. It is essential to remember that caution should be exercised when administering these agents intrathecally in anesthesia practice, particularly due to respiratory depression and pruritus associated with opioids, and cardiovascular side effects related to alpha-2 adrenergic agonists.
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