ﾇ ﾞ036ﾒ2 ﾇ6ｾ ｦ ｸ7 ｨB06080ｸ ｧ , ap

Management of pain – humane endpoints –

euthanasia of laboratory animals

P. Ypsilantis,

DVM, PhD, MRCVS

Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace

∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ – ÂÎÙ›ÌËÛË ÙÂÏÈÎÔ‡ ÛËÌ›Ԣ –

ÂÈÏÔÁ¤˜ ¢ı·Ó·Û›·˜ ˙ÒˆÓ ÂÚÁ·ÛÙËÚ›Ô˘

¶. À„ËÏ¿ÓÙ˘,

∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶ÂÈÚ·Ì·ÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ¢¶£, DVM, PhD, MRCVS ∂ÚÁ·ÛÙ‹ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ Î·È ÃÂÈÚÔ˘ÚÁÈ΋˜ ŒÚ¢ӷ˜, ∆Ì‹Ì· π·ÙÚÈ΋˜ ¢¶£

Correspondence: Laboratory of Experimental Surgery and Surgical Research, School of Medicine,

Democritus University of Thrace, University General Hospital of Alexandroupolis, 681 00 Alexandroupolis ∆el./Fax: 25510-30404, e-mail: [email protected]

∞ÏÏËÏÔÁÚ·Ê›·: ¶. À„ËÏ¿ÓÙ˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ Î·È ÃÂÈÚÔ˘ÚÁÈ΋˜ ŒÚ¢ӷ˜, ∆Ì‹Ì· π·ÙÚÈ΋˜ ¢¶£, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘, 681 00 ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏË. ∆ËÏ/º·Í. 25510-30404, e-mail: [email protected] Submission date: 13.10.2009 Approval date: 19.10.2009 HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13.10.2009 HÌÂÚÔÌËÓ›· ÂÁÎÚ›Ûˆ˜: 19.10.2009

ABSTRACT. The minimization of pain and distress of laboratory animals before, during and after the experiment is one of the basic principles for the humane treatment of animals used in biomedical research. Pain and distress is assessed based on careful observation of laboratory animals and the evaluation of a series of parameters related to clinical signs, natural behaviour and provoked behaviour. Scoring of these parameters makes possible their quantitative assessment and the calculation of distress score. Based on this score we can define the humane endpoints according to which the experimenter decides to relieve the animal from pain and distress by administering analgesics, terminating the experiment or performing euthanasia. The reasons for implementing humane endpoints are ethical, legal, practical and scientific. Analgesic agents can be divided into three: narcotic analgesics, antipyretic analgesics and nociceptive blockers. The choice drug will be determined by the degree of analgesic effect, its required duration of action, the experimental protocol and the experience of the experimenter. Euthanasia methods can be divided into physical and chemical ones. Physical methods include shooting, concussion, electrical stunning, cervical dislocation, decapacitation and microwave irradiation. Chemical methods include the administration of inhalation agents (carbon dioxide, carbon monoxide, volatile inhalational anesthetics), agents absorbed through the skin and gills (benzocaine, tricaine methane sulphonate, etomidate, metomidate, quinaldine) and injectable agents (the barbiturates pentobarbitone and thiopental and the agent T-61). Euthanasia methods that can be applied to unconcious animals also incude pithing, rapid freezing, exsanguination, administration of nitrogen or argon, ethanol, chloral hydrate and potassium chloride and air embolism. Death should always be confirmed after performing an euthanasia method.

Keywords: laboratory animals, pain, humane endpoints, analgesia, euthanasia

¶∂ƒπ§∏æ∏. ∏ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ ÙˆÓ ˙ÒˆÓ ÂÚÁ·ÛÙËÚ›Ô˘ ηٿ ÙȘ ÂÚÈfi‰Ô˘˜ ÚÈÓ, ηٿ ÙË ‰È¿Ú-ÎÂÈ· Î·È ÌÂÙ¿ ·fi ÙÔ ›ڷ̷ ·ÔÙÂÏ› ıÂÌÂÏÂÈÒ‰Ë ·Ú¯‹ ÙÔ˘ ÎÒ‰Èη ËıÈ΋˜ ‰ÂÔÓÙÔÏÔÁ›·˜ Ù˘ ¯Ú‹Û˘ ˙ÒˆÓ ÁÈ· ÂÈÚ·Ì·ÙÈÎÔ‡˜ ÛÎÔÔ‡˜. ∏ ÂÎÙ›ÌËÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ Á›ÓÂÙ·È ÚˆÙ›ÛÙˆ˜ Ì ÙËÓ ÚÔÛÂÎÙÈ΋ ·Ú·Ù‹ÚËÛË ÙˆÓ ˙ÒˆÓ Î·È ÙËÓ ·ÍÈÔ-ÏfiÁËÛË Ì›·˜ ÛÂÈÚ¿˜ ·Ú·Ì¤ÙÚˆÓ Ô˘ ·ÊÔÚÔ‡Ó Û ÎÏÈÓÈο ÛËÌ›·, ·ÏÏ¿ Î·È Û ¯·Ú·ÎÙËÚÈÛÙÈο Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ·ÓÙ›‰Ú·Û˘. ∏ ‚·ıÌÔÓfiÌËÛË ·˘ÙÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÔÛÔÙÈ΋ ηٷÁÚ·Ê‹ ÙÔ˘˜ Î·È ÙËÓ ÂÍ·ÁˆÁ‹ ÙÔ˘ ‰Â›ÎÙË Ù·Ï·ÈˆÚ›·˜. ªÂ ‚¿ÛË ·˘Ùfi ÙÔ ÚˆÙfiÎÔÏÏÔ ÔÚ›˙ÔÓÙ·È Ù· ÙÂÏÈο ÛËÌ›· Ù· ÔÔ›· ÚÔÛ‰ÈÔÚ›˙Ô˘Ó ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ·ÔÊ·Û›˙ÂÙ·È

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ÎÒ‰Èη˜ ËıÈ΋˜ Î·È ‰ÂÔÓÙÔÏÔÁ›·˜ Ô˘ ·ÊÔÚ¿ ÛÙ˯ڋÛË ˙ÒˆÓ ÁÈ· ÂÈÚ·Ì·ÙÈÎÔ‡˜ ÛÎÔÔ‡˜, Ô˘ Â-ÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Russell Î·È Burch ÙÔ 1959 (Russel and Burch, 1959), Û˘ÓÔ„›˙ÂÙ·È ÛÙËÓ ·Ú¯‹ ÙˆÓ 3 R: Replacement (·ÓÙÈηٿÛÙ·ÛË) – Reduction (Ì›ˆÛË) – Refinement (ÏÂÙfiÙËÙ·, ¢Á¤-ÓÂÈ·). ™ÙÔÓ ÙÂÏÂ˘Ù·›Ô fiÚÔ ‰È·Ù˘ÒÓÂÙ·È Ë ·Ó¿ÁÎË ÁÈ· ̤ÚÈÌÓ· ÁÈ· Ì›ˆÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ Ô˘ ˘Ê›ÛÙ·ÓÙ·È Ù· ÂÈÚ·Ì·Ùfi˙ˆ· ÚÈÓ, ηٿ ÙË ‰È¿Ú-ÎÂÈ· Î·È ÌÂÙ¿ ·fi Ì›· ÂÈÚ·Ì·ÙÈ΋ ‰È·‰Èηۛ·. ™ÙË ‚¿ÛË ·˘Ù‹ Ô ÂÚ¢ÓËÙ‹˜ ÔÊ›ÏÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Î·È Ó· ÂÎÙÈÌ¿ Ù· ÛËÌ›· fiÓÔ˘ Î·È Ù·Ï·ÈˆÚ›·˜, Ó· Ù· ÚÔ-Ï·Ì‚¿ÓÂÈ fiÔ˘ Â›Ó·È ‰˘Ó·ÙfiÓ ‹ Ó· ÊÚÔÓÙ›˙ÂÈ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ŸÙ·Ó ·˘Ù¿ ‰ÂÓ Â›Ó·È ·ÓÙÈÌÂÙˆ›-ÛÈÌ·, ı· Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È ÙÔ ›ڷ̷ Î·È Ó· Ô-‰ËÁÂ›Ù·È ÙÔ ÂÈÚ·Ì·Ùfi˙ˆÔ Û ¢ı·Ó·Û›·. OÚÈÛÌfi˜ ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ ø˜ «fiÓÔ˜» ÔÚ›˙ÂÙ·È Ì›· ‰˘Û¿ÚÂÛÙË ÂÌÂÈÚ›· ·È-Ûı‹ÛÂˆÓ Î·È Û˘Ó·ÈÛıËÌ¿ÙˆÓ, Ë ÔÔ›· ÌÔÚ› Ó· Û¯Â-Ù›˙ÂÙ·È Ì ‚Ï¿‚Ë ÈÛÙÒÓ Î·È Ô‰ËÁ› ÛÂ Û˘ÓÂȉËÙ¤˜ ‹ ·-ÓÙ·Ó·ÎÏ·ÛÙÈΤ˜ ÎÈÓ‹ÛÂȘ ¿Ì˘Ó·˜ ‹ / Î·È ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜. √ fiÚÔ˜ «Ù·Ï·ÈˆÚ›·» ·ÊÔÚ¿ ÙËÓ ·ÓÔ¯‹ Ì›·˜ ηٿÛÙ·Û˘, Ë ÔÔ›· Â›Ó·È ÂÒ‰˘ÓË, ÛÙÚÂ-ÛÔÁfiÓÔ˜ ‹ ÙÚ·˘Ì·ÙÈ΋. º˘ÛÈÔÏÔÁ›· ÙÔ˘ fiÓÔ˘ ™ÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ ÛÒÌ·ÙÔ˜ (.¯. ÙÔ ‰¤ÚÌ·) ¿Ú¯Ô˘Ó ˘ԉԯ›˜ fiÓÔ˘, ÔÈ ÔÔ›ÔÈ ·ÓÙȉÚÔ‡Ó Û ˘-ÂÚ‚ÔÏÈ΋ ›ÂÛË, ıÂÚÌÔÎÚ·Û›· ‹ ¯ËÌÈο ÂÚÂı›ÛÌ·Ù·. ¡Â˘ÚÈΤ˜ ÒÛÂȘ ÌÂÙ·‚È‚¿˙ÔÓÙ·È ·fi ÙÔ˘˜ ˘ԉԯ›˜ ̤ۈ ÎÂÓÙÚÔÌfiÏˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ ÚÔ˜ ÙÔ Ú·¯È·›Ô Τڷ˜ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡. √È ÂÈÛÂÚ¯fiÌÂÓ˜ ÒÛÂȘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ӈÙÈ·›Ô ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi, fi-ˆ˜ .¯. ÙËÓ ·fiÛ˘ÚÛË ÂÓfi˜ ¿ÎÚÔ˘, ˆ˜ ·Ì˘ÓÙÈÎfi ÌË-¯·ÓÈÛÌfi. ª›· ‰Â‡ÙÂÚË Ó¢ÚÈ΋ Ô‰fi˜ ÌÂٷʤÚÂÈ ÙȘ Ò-ÛÂȘ ÛÙÔÓ ÂÁΤʷÏÔ (ÓˆÙÈ·ÈÔı·Ï·ÌÈ΋ Ô‰fi˜) fiÔ˘ ÌÈ· ¿ÏÏË Û‡Ó·„Ë Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÛÙÔ ı¿Ï·ÌÔ. ∏ ÙÚ›ÙË Î·È ÙÂÏÂ˘Ù·›· Ó¢ÚÈ΋ Ô‰fi˜ ÍÂÎÈÓ¿ ·fi ÙÔ ı¿Ï·ÌÔ Î·È Î·-Ù·Ï‹ÁÂÈ ÛÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ÊÏÔÈfi, fiÔ˘ ÔÈ Ó¢ÚÈΤ˜ Ò-ÛÂȘ ÌÂÙ·ÊÚ¿˙ÔÓÙ·È Û ·›ÛıËÛË fiÓÔ˘. À¿Ú¯Ô˘Ó, ˆ-ÛÙfiÛÔ, Î·È Ê˘ÁfiÎÂÓÙÚ˜ Ó¢ÚÈΤ˜ Ô‰Ô› ÔÈ Ôԛ˜ ÌÔ-Ú› Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙË ‰›Ô‰Ô ÙˆÓ ÒÛÂˆÓ ·fi ÙÔ Óˆ-ÙÈ·›Ô Ì˘ÂÏfi Î·È Ó· ·˘Í‹ÛÔ˘Ó ‹ Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ·ÓÔ¯‹ Î·È ÙÔÓ Ô˘‰fi ÙÔ˘ fiÓÔ˘ (Smith 1994). ∂ÎÙ›ÌËÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ √È ÙÚfiÔÈ ·ÓÙ›‰Ú·Û˘ ÛÙÔÓ fiÓÔ ÌÔÚ› Ó· ·ÊÔ-ÚÔ‡Ó ÛÂ: ·) Û˘ÓÂȉËÙ‹ ÌÂÙ·‚ÔÏ‹ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÚÔ˜ ·ÔÊ˘Á‹Ó ÙÔ˘ ÂÒ‰˘ÓÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜, ‚) ·˘Ùfi-Ì·ÙË ·ÓÙ›‰Ú·ÛË ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ˙ÒÔ˘ (.¯. ·-ÓÙ·Ó·ÎÏ·ÛÙÈ΋ ·fiÛ˘ÚÛË ÙÔ˘ ¿ÎÚÔ˘, ·ÎÈÓËÙÔÔ›ËÛË Î.Ï.) Î·È Á) ·ÓÙ›‰Ú·ÛË ÁÈ· ÌÂÙ·‚›‚·ÛË ÙÔ˘ ÂÚÂı›-ÛÌ·ÙÔ˜ ÛÙ· ˘fiÏÔÈ· ˙Ò· (.¯. Ì ÎÚ·˘Á¤˜, ÂÎÎÚÈÛË ÊÂÚÔÌÔÓÒÓ Î.Ï.). ∏ ÂÎÙ›ÌËÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ ‚·Û›-˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ Ù·ÎÙÈ΋ ·Ú·Ù‹ÚËÛË ·fi ÙÔ ÚÔ-ÛˆÈÎfi Ô˘ ¯ÂÈÚ›˙ÂÙ·È Ù· ÂÈÚ·Ì·Ùfi˙ˆ·. ™ÙÔȯ›· Ô˘ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ Î·Ù¿ ÙËÓ ÂÎÙ›ÌË-ÛË ÙÔ˘ fiÓÔ˘ ›ӷÈ: Ù· ÛÙÔȯ›· ÙÔ˘ ˙ÒÔ˘ (›‰Ô˜, ËÏÈ-‚·ÛË ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ˙ÒÔ˘ Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ, ÙË ‰È·ÎÔ‹ Ù˘ ÂÈÚ·Ì·ÙÈ΋˜ ‰È·‰Èηۛ·˜ ‹ Î·È ÙË ‰ÈÂÓ¤ÚÁÂÈ· ¢ı·Ó·Û›·˜. OÈ ÏfiÁÔÈ ÂÊ·ÚÌÔÁ‹˜ ÙÂÏÈÎÒÓ ÛËÌ›ˆÓ Â›Ó·È ËıÈÎÔ›, ÓÔÌÈÎÔ›, Ú·ÎÙÈÎÔ› Î·È ÂÈÛÙËÌÔÓÈÎÔ›. √È Ô˘Û›Â˜ Ô˘ ¯ÚËÛÈÌÔ-ÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó·ÏÁËÛ›· ¯ˆÚ›˙ÔÓÙ·È Û ÙÚÂȘ ‚·ÛÈΤ˜ ηÙËÁÔڛ˜: Ù· Ó·ÚΈÙÈο ·Ó·ÏÁËÙÈο, Ù· ·ÓÙÈ˘ÚÂÙÈο ·Ó·ÏÁËÙÈο Î·È ÙÔ˘˜ ·ÔÎÏÂÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ fiÓÔ˘. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ ‚·ıÌfi ·Ó·ÏÁËÛ›·˜ Ô˘ ÂÈı˘Ì›ٷÈ, ÙË ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ ÙÔ˘, ÙÔ ÂÈÚ·Ì·ÙÈÎfi ÚˆÙfiÎÔÏÏÔ Î·È ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ ÂÚ¢ÓËÙ‹. √È Ì¤ıÔ‰ÔÈ Â˘ı·Ó·Û›·˜ ¯ˆÚ›˙ÔÓÙ·È ÛÙȘ Ê˘ÛÈΤ˜ Î·È ÙȘ ¯ËÌÈΤ˜. ™ÙȘ Ê˘ÛÈΤ˜ ÌÂıfi‰Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ˘ÚÔ‚ÔÏÈÛÌfi˜, Ë ·ÔÏËÍ›·, Ë ËÏÂÎÙÚÔÏË-Í›·, Ë ·ÂÍ¿ÚıÚˆÛË ÙÔ˘ ÙÚ·¯‹ÏÔ˘, Ô ·ÔÎÂÊ·ÏÈÛÌfi˜ Î·È Ù· ÌÈÎÚÔ·̷ٷ. ™ÙȘ ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ¯ÔÚ‹ÁË-ÛË ÂÈÛÓ¢ÛÙÈÎÒÓ Ô˘ÛÈÒÓ (‰ÈÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη, ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη, ÂÈÛÓ¢ÛÙÈο ·Ó·ÈÛıËÙÈο), Ô˘ÛÈÒÓ Ô˘ ·ÔÚÚÔ-ÊÒÓÙ·È ·fi ÙÔ ‰¤ÚÌ· Î·È Ù· ‚Ú¿Á¯È· (‚ÂÓ˙Ôη˝ÓË, ıÂÈÔ‡¯Ô˜ ÙÚÈη˝ÓË, ÂÙÔÌȉ¿ÙË, ÌÂÙÔÌȉ¿ÙË, ÎÔ˘˚ӷω›ÓË) Î·È ÂÓ¤ÛÈÌˆÓ Ô˘-ÛÈÒÓ (Ù· ‚·Ú‚ÈÙÔ˘ÚÈο ÂÓÙÔ‚·Ú‚ÈÙfiÓË Î·È ıÂÈÔÂÓÙ¿ÏË Î·È Ë Ô˘Û›· ∆-61). ™Ù· ˙Ò· ÛÙ· ÔÔ›· ¤¯ÂÈ ÚÔËÁËı› ·ÒÏÂÈ· Û˘Ó›-‰ËÛ˘ ÌÔÚÔ‡Ó ·ÎfiÌË Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ë Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ‚ÂÏfiÓ·, Ë Ù·¯Â›· ηٿ„˘ÍË, Ë ·Ê·›Ì·ÍË, Ë ÂÈÛÓÔ‹ ·˙ÒÙÔ˘ ‹ ·ÚÁÔ‡, Ë ¯ÔÚ‹ÁËÛË ·Èı·ÓfiÏ˘, ¤Ó˘‰Ú˘ ¯ÏˆÚ¿Ï˘ Î·È ¯ÏˆÚÈÔ‡¯Ô˘ Î·Ï›Ô˘ Î·È Ô ÂÌ‚ÔÏÈÛÌfi˜ ·¤Ú·. ªÂÙ¿ ·fi ÙË ‰ÈÂ-Ó¤ÚÁÂÈ· ¢ı·Ó·Û›·˜ ı· Ú¤ÂÈ Ó· ÂȂ‚·ÈÒÓÂÙ·È Ô ı¿Ó·ÙÔ˜. §¤ÍÂȘ ¢ÚÂÙËÚ›·Û˘: ˙Ò· ÂÚÁ·ÛÙËÚ›Ô˘, fiÓÔ˜, ÙÂÏÈο ÛËÌ›·, ·Ó·ÏÁËÛ›·, ¢ı·Ó·Û›· ∏ ÂÚÁ·Û›· ·˘Ù‹ ·ÚÔ˘ÛÈ¿ÛÙËΠÛÙÔ 2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™ÂÌÈÓ¿ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ µÈÔ˚·ÙÚÈ΋˜ ŒÚ¢ӷ˜, ¡ÔÛÔÎÔÌÂ›Ô ∫∞∆, 20-22 ¡ÔÂÌ‚Ú›Ô˘ 2008.

Λ·, ÚԤϢÛË), ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ˙ÒÔ˘, ÎÏÈÓÈο ¢ڋ-Ì·Ù· (ηډȷÎfi˜ Ú˘ıÌfi˜, ·Ó·Ó¢ÛÙÈÎfi˜ Ú˘ıÌfi˜, ıÂÚÌÔÎÚ·Û›·, Ì˘˚Îfi˜ ÙfiÓÔ˜), ‚ÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· (fi-ˆ˜ ACTH, ÂÓ‰ÔÚʛӘ), ÚfiÛÏË„Ë ÙÚÔÊ‹˜ (ÔÛfi-ÙËÙ·, ÙÚfiÔ˜), ÓÔËÙÈ΋ ηٿÛÙ·ÛË (ηًÊÂÈ·, ηٷ-ÛÙÔÏ‹, ÂÈıÂÙÈÎfiÙËÙ·, ˘ÂډȤÁÂÚÛË), ‰Ú·ÛÙËÚÈfiÙË-Ù· (·fiÏ˘ÙË ·‰Ú¿ÓÂÈ· ¤ˆ˜ Ì·ÓÈ҉˘ ˘ÂÚÎÈÓËÙÈÎfi-ÙËÙ·), ÎÚ·˘Á¤˜ (ÌÔÚ› Ó· Â›Ó·È ÂÎÙfi˜ Ê¿ÛÌ·ÙÔ˜ ·Ó-ıÚÒÈÓ˘ ·ÎÔ‹˜) Î·È ·ÓÙ›‰Ú·ÛË ÛÙË ¯ÔÚ‹ÁËÛË ·Ó·Ï-ÁËÙÈÎÒÓ (Morton and Townsend 1995).

™ËÌ›· ÔͤԘ fiÓÔ˘ À¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ÂȉÒÓ, ·ÏÏ¿ Î·È ÌÂٷ͇ ÙˆÓ ˙ÒˆÓ ÙÔ˘ ›‰ÈÔ˘ ›‰Ô˘˜, ˆ˜ ÚÔ˜ ÙȘ ÂΉË-ÏÒÛÂȘ ÙÔ˘ fiÓÔ˘. √È ·Ú·ÙËÚ‹ÛÂȘ ı· Ú¤ÂÈ Ó· Á›-ÓÔÓÙ·È ¯ˆÚ›˜ ÙÔ ˙ÒÔ Ó· ·ÓÙÈÏ·Ì‚¿ÓÂÙ·È ÙËÓ ·ÚÔ˘Û›· Ì·˜. ∆· ÛËÌ›· ÙÔ˘ fiÓÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ˘ÂÚÎÈÓË-ÙÈÎfiÙËÙ· ‹ ·‰Ú¿ÓÂÈ·, ηٿÎÏÈÛË, ·ÔÌfiÓˆÛË, Ì›ˆÛË ‹ ·‡ÍËÛË ÙˆÓ ÎÚ·˘ÁÒÓ, ÌÂÙ·‚ÔϤ˜ ÛÙËÓ ÔÛfiÙËÙ· Î·È ÙÔÓ ÙÚfiÔ ÚfiÛÏ˄˘ ÓÂÚÔ‡ Î·È ÙÚÔÊ‹˜, ÂÈıÂÙÈ΋ ‹ ·Ì˘ÓÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÚÔ˜ ¿ÏÏ· ˙Ò·, ÓÂÔÁÓ¿ (η-ÓÈ‚·ÏÈÛÌfi˜) ‹ ÙÔÓ Â·˘Ùfi ÙÔ˘˜ (·˘ÙÔÙÚ·˘Ì·ÙÈÛÌfi˜), ÌÂ-Ù·‚ÔϤ˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ Ô˘ ·ÊÔÚ¿ ÛÙË Û˘ÏÏÔÁ‹ Ù˘ ÙÚÔÊ‹˜, ÙËÓ ·˘ÙÔÂÚÈÔ›ËÛË, ÙËÓ ¿ÛÎËÛË, ÙË ÛÂ-ÍÔ˘·ÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È ÙÔÓ ‡ÓÔ Î·È ÌÂÙ·‚ÔϤ˜ ÛÙË ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ÛÒÌ·ÙÔ˜ (Smith 1994). ™ËÌ›· ¯ÚfiÓÈÔ˘ fiÓÔ˘ Î·È Ù·Ï·ÈˆÚ›·˜ √È ÌÂÙ·‚ÔϤ˜ Â›Ó·È Û˘Ó‹ıˆ˜ ÌÈÎÚ¤˜ Î·È ··ÈÙ›-Ù·È ÚÔÛÂÎÙÈ΋ ·Ú·Ù‹ÚËÛË Î·È Î·Ï‹ ÁÓÒÛË Ù˘ Û˘-ÌÂÚÈÊÔÚ¿˜ ÙˆÓ ˙ÒˆÓ. ∂ÎÙfi˜ ·fi ÙÔ ÛˆÌ·ÙÈÎfi fiÓÔ, Ù·Ï·ÈˆÚ›· ÌÔÚ› Ó· Â¤ÏıÂÈ ·fi ÌÂÙ·‚ÔϤ˜ ÛÙÔ Â-ÚÈ‚¿ÏÏÔÓ ÙˆÓ ˙ÒˆÓ, fiˆ˜ ·ÏÏ·Á‹ ÙÔ˘ Ù‡Ô˘ Îψ‚Ô‡, ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ˙ÒˆÓ ·Ó¿ ÎÏÔ˘‚›, ÁÂÈÙÓ›·ÛË Ì ·-ÓÙ·ÁˆÓÈÛÙÈο ›‰Ë ˙ÒˆÓ, Î.Ï. (Smith 1994). ∂ÎÙ›ÌËÛË ÙÂÏÈÎÔ‡ ÛËÌ›Ԣ ∆· ·ÓıÚˆÈÛÙÈο-˙ˆÔÊÈÏÈο ÙÂÏÈο ÛËÌ›· ·ÊÔ-ÚÔ‡Ó ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÎÚÈÙËÚ›ˆÓ Ì ‚¿ÛË Ù· ÔÔ›· ·-ÔÊ·Û›˙ÂÙ·È Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ·fi ÙÔÓ fiÓÔ Î·È ÙËÓ Ù·Ï·ÈˆÚ›·, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·fi ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ ¤ˆ˜ ÙË ‰È·ÎÔ‹ ÙÔ˘ ÂÈÚ·Ì·-ÙÈÛÌÔ‡ Î·È ÙËÓ Â˘ı·Ó·Û›· ÙÔ˘ ÂÈÚ·Ì·Ùfi˙ˆÔ˘. √È Ïfi-ÁÔÈ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘˜ Â›Ó·È ËıÈÎÔ›, ÓÔÌÈÎÔ›, Ú·ÎÙÈÎÔ› Î·È ÂÈÛÙËÌÔÓÈÎÔ›. ∆· ÙÂÏÈο ÛËÌ›· ‚Ú›ÛÎÔ˘Ó ÂÊ·Ú-ÌÔÁ‹: ·) fiÙ·Ó ¤Ó· ˙ÒÔ ‰ÂÓ ÌÔÚ› Ó· ·Ú¤¯ÂÈ ·ÍÈfiÈ-ÛÙË Î·È ¯Ú‹ÛÈÌË ÂÈ·ÍÈfiÈ-ÛÙËÌÔÓÈ΋ ÏËÚÔÊÔÚ›· ÏfiÁˆ ÛË-Ì·ÓÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙËÓ ˘Á›· ÙÔ˘, ‚) fiÙ·Ó ¤Ó· ˙ÒÔ ‰ÂÓ ÌÔÚ› Ó· ·Ú¤¯ÂÈ ·ÍÈfiÈÛÙË Î·È ¯Ú‹ÛÈÌË Â-ÈÛÙËÌÔÓÈ΋ ÏËÚÔÊÔÚ›· ÏfiÁˆ ÛËÌ·ÓÙÈÎÒÓ ‰È·Ù·Ú·-¯ÒÓ ÛÙËÓ „˘¯ÔÏÔÁ›· ÙÔ˘, ÔÈ Ôԛ˜ ÌÔÚ› Ó· ‰È·Ù·-Ú¿ÍÔ˘Ó ÙË Ê˘ÛÈÔÏÔÁ›· ÙÔ˘, Á) fiÙ·Ó Ë Ù·Ï·ÈˆÚ›· Ô˘ ˘Ê›ÛÙ·Ù·È ÙÔ ÂÈÚ·Ì·Ùfi˙ˆÔ ‰ÂÓ ·ÓÙÈÛÙ·ıÌ›˙ÂÈ ÙÔ fi-ÊÂÏÔ˜ Ù˘ ÌÂϤÙ˘, ‰) fiÙ·Ó Ë Ù·Ï·ÈˆÚ›· Ô˘ ˘Ê›ÛÙ·-Ù·È ÙÔ ÂÈÚ·Ì·Ùfi˙ˆÔ Â›Ó·È ÙfiÛÔ ÌÂÁ¿ÏË ÒÛÙ ӷ ÂÌ›-ÙÂÈ ÛÙËÓ Î·ÙËÁÔÚ›· Ù˘ «‚¿Ó·˘Û˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÚÔ˜ Ù· ˙Ò·» Ô˘ ÔÚ›˙ÂÈ Ë Û¯ÂÙÈ΋ ÓÔÌÔıÂÛ›· ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙˆÓ ˙ÒˆÓ Î·È Â) fiÙ·Ó, ÂÓÒ Ô ˘„ËÏfi˜ ‚·ı-Ìfi˜ Ù·Ï·ÈˆÚ›·˜ ÌÔÚ› Ó· ‰ÈηÈÔÏÔÁËı›, ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË Ë Û˘Ó¤¯ÈÛË ÙÔ˘ ÂÈÚ·Ì·ÙÈÛÌÔ‡, ·ÊÔ‡ ‰Â-‰Ô̤ӷ ·fi ÚÔËÁÔ‡ÌÂÓ· ÛÙ¿‰È¿ ÙÔ˘ Â›Ó·È ·ÚÎÂÙ¿ Ò-ÛÙ ӷ ÚÔ‚ÏÂÊı› Ë ¤Î‚·ÛË Ù˘ ÌÂϤÙ˘ (Morton 2008). °È· ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ÔÛÔÙÈÎÔÔ›ËÛË ÙÔ˘ ‚·ı-ÌÔ‡ Ù·Ï·ÈˆÚ›·˜ ÂÓfi˜ ˙ÒÔ˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈË-ı› Ë ‚·ıÌÔÓfiÌËÛË ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Ô˘ ·ÊÔÚÔ‡Ó Û ‚·ÛÈο ÎÏÈÓÈο ÛËÌ›·, ηıÒ˜ Î·È ¯·Ú·ÎÙËÚÈÛÙÈο Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ·ÓÙ›‰Ú·Û˘. ∞˘Ù¤˜ ÔÈ ·Ú¿ÌÂÙÚÔÈ ı· Ú¤ÂÈ Ó· ÔÚ›˙ÔÓÙ·È ÁÈ· οı ÂÈÚ·Ì·ÙÈÎfi ÚˆÙfi-ÎÔÏÏÔ ¯ˆÚÈÛÙ¿. ∞fi ÙÔ ¿ıÚÔÈÛÌ· ÙˆÓ ÂÈ̤ÚÔ˘˜ ‚·ı-ÌÔÏÔÁÈÒÓ ÂÍ¿ÁÔ˘Ì ÙÔ ‰Â›ÎÙË Ù·Ï·ÈˆÚ›·˜ Ì ‚¿ÛË ÙÔÓ ÔÔ›Ô Ï·Ì‚¿ÓÔÓÙ·È ·ÔÊ¿ÛÂȘ Û¯ÂÙÈο Ì ÙË ¯Ô-Ú‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ, ÙË Û˘Ó¤¯ÈÛË ‹ fi¯È ÙÔ˘ ÂÈÚ¿Ì·-ÙÔ˜ ‹, Ù¤ÏÔ˜, ÙË ‰ÈÂÓ¤ÚÁÂÈ· ¢ı·Ó·Û›·˜ (¶›Ó·Î·˜ 1). ∞ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÚfiÎÏËÛ˘ fiÓÔ˘ Î·È Ù·-Ï·ÈˆÚ›·˜ ¶ÂÚ›Ô‰Ô˜ ÚÈÓ ·fi ÙÔ ›ڷ̷ ¶ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÈÚ·Ì·ÙÈ΋˜ ‰È·‰Èηۛ·˜, ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó ÛÙËÓ Ù·-Ï·ÈˆÚ›· ÙˆÓ ÂÈÚ·Ì·Ùfi˙ˆˆÓ, fiˆ˜ Ë ÌÂÙ·ÊÔÚ¿ Û Ӥ˜ ÂÁηٷÛÙ¿ÛÂȘ ÂÎÙÚÔÊ‹˜ ‹ ÂÈÚ·Ì·ÙÈÛÌÔ‡, ÔÈ ÌÂ-Ù·‚ÔϤ˜ ÛÙËÓ ˘ÎÓfiÙËÙ· ÙˆÓ ˙ÒˆÓ ·Ó¿ Îψ‚fi, Ë ‰È·-Ù·Ú·¯‹ Ù˘ ÈÂÚ·Ú¯›·˜, ÙÔ ÛÙÚ˜ Ù˘ ·ÔÌfiÓˆÛ˘, Ó¤-˜ Â·Ê¤˜ Ì ÙÔÓ ¿ÓıÚˆÔ, ÌÂÙ·‚ÔϤ˜ ÛÙË ıÂÚÌÔÎÚ·-Û›·, ÙË Û¯ÂÙÈ΋ ˘ÁÚ·Û›· Î·È ÙË ÊˆÙÔÂÚ›Ô‰Ô ‹ ÌÂÙ·-‚ÔϤ˜ ÛÙȘ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ. ∆Ô ÛÙÚ˜ Ô˘ ‰Ë-ÌÈÔ˘ÚÁÂ›Ù·È Û ¤Ó· ˙ÒÔ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› Ì ¢ÎÔ-Ï›· ÛÙ· ˘fiÏÔÈ· ̤ۈ ¤ÎÎÚÈÛ˘ ÊÂÚÔÌÔÓÒÓ Î·È ÌÂ-Ù·‚ÔÏÒÓ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ (ÎÚ·˘Á¤˜, ÎÈÓËÙÈÎfiÙËÙ·). ª›· ÂÚ›Ô‰Ô˜ ÂÁÎÏÈÌ·ÙÈÛÌÔ‡ 7-10 ËÌÂÚÒÓ Â›Ó·È ··-Ú·›ÙËÙË ÁÈ· ÙËÓ ÂÍÔÈΛˆÛË ÙˆÓ ÓÂÔÂÈÛÂÚ¯fiÌÂÓˆÓ ÂÈ-Ú·Ì·Ùfi˙ˆˆÓ Û ̛· ÂÁηٿÛÙ·ÛË ÂÈÚ·Ì·ÙÈÛÌÔ‡ fi-Ô˘ ÂÈÎÚ·ÙÔ‡Ó Ó¤Â˜ Û˘Óı‹Î˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶ÂÚ›Ô‰Ô˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÂÈÚ¿Ì·ÙÔ˜ ¢È·‰Èηۛ˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ¯ÒÚ· ηٿ ÙË ‰È¿Ú-ÎÂÈ· ÙÔ˘ ÂÈÚ·Ì·ÙÈÛÌÔ‡, fiˆ˜ ¯ÂÈÚÈÛÌÔ› ÙˆÓ

ÂÈÚ·-Ì·Ùfi˙ˆˆÓ, ÂÁ¯‡ÛÂȘ Ô˘ÛÈÒÓ, ·ÈÌÔÏË„›·, ·Ó·ÈÛıËÛ›· Î·È Ë ›‰È· Ë ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, ·ÔÙÂÏÔ‡Ó ·Ú¿-ÁÔÓÙ˜ ÚfiÎÏËÛ˘ Ù·Ï·ÈˆÚ›·˜ Î·È fiÓÔ˘. ¶ÂÚ›Ô‰Ô˜ ÌÂÙ¿ ÙÔ ›ڷ̷ ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙË ‰È·ÛÊ¿ÏÈÛË ÙˆÓ Û˘ÓıËÎÒÓ Ô˘ ‰ÂÓ ı· Â·˘Í‹ÛÔ˘Ó ÙÔÓ fiÓÔ Î·È ÙËÓ Ù·Ï·ÈˆÚ›· Ô˘ ¤¯Ô˘Ó ‹‰Ë ˘ÔÛÙ› Ù· ÂÈÚ·Ì·Ùfi˙ˆ· ÛÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÂÚÈfi‰Ô˘˜. £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Û ıÂÚÌÔ-ÎÚ·Û›· ÛÒÌ·ÙÔ˜, ÙË ‰È·ÛÊ¿ÏÈÛË Ù˘ ÈÛÔÚÚÔ›·˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ, ηıÒ˜ Î·È ·Ó¿·˘ÛË Û ‹Û˘¯Ô Î·È ˙Â-ÛÙfi ÂÚÈ‚¿ÏÏÔÓ. ∏ ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÙÈÎÒÓ Table 1. Pain and distress score sheet.

¶›Ó·Î·˜ 1. ¢ÂÏÙ›Ô ‚·ıÌÔÏfiÁËÛ˘ ÛËÌ›ˆÓ fiÓÔ˘ Î·È Ù·Ï·ÈˆÚ›·˜. ¶·Ú¿ÌÂÙÚÔÈ ÂÎÙ›ÌËÛ˘ µ·ıÌÔÏÔÁ›· ∏ÌÂÚ/· ∏ÌÂÚ/· ∏ÌÂÚ/· - ÒÚ· - ÒÚ· - ÒÚ· ∂ÌÊ¿ÓÈÛË º˘ÛÈÔÏÔÁÈ΋ 0 ŒÏÏÂÈ„Ë ·˘ÙÔÂÚÈÔ›ËÛ˘ 1 £·Ìfi ÙÚ›¯ˆÌ·, ÔÊı·ÏÌÈΤ˜ Î·È ÚÈÓÈΤ˜ ÂÎÎÚ›ÛÂȘ 2 ∞ÓfiÚıˆÛË ÙÚȯÒÌ·ÙÔ˜, ·ÚÙˆÛË Ú¿¯Ë˜ 3 ¶ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ÓÂÚÔ‡ º˘ÛÈÔÏÔÁÈ΋ 0 ∞‚¤‚·ÈË: Ì›ˆÛË ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ <5% 1 ªÂȈ̤ÓË: Ì›ˆÛË ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ 10-15% 2 ∞Ô˘Û›· Ï‹„˘ ÙÚÔÊ‹˜ ‹ ÓÂÚÔ‡ 3 ∫ÏÈÓÈο ÛËÌ›· º˘ÛÈÔÏÔÁÈ΋ ıÂÚÌÔÎÚ·Û›·, ηډȷÎfi˜ Ú˘ıÌfi˜, ·Ó·Ó. Ú˘ıÌfi˜ 0 ªÈÎÚ¤˜ ÌÂÙ·‚ÔϤ˜ 1 £ÂÚÌÔÎÚ ± 1ÆC, ∫·Ú‰/·Ó·Ó Ú˘ıÌfi˜ ± ¤ˆ˜ 30% 2 £ÂÚÌÔÎÚ ± 2ÆC, ∫·Ú‰/·Ó·Ó Ú˘ıÌfi˜ ± ¤ˆ˜ 50% 3 ™˘ÌÂÚÈÊÔÚ¿ º˘ÛÈÔÏÔÁÈ΋ 0 ªÈÎÚ¤˜ ÌÂÙ·‚ÔϤ˜ 1 ªÂ›ˆÛË ÎÈÓËÙÈÎfiÙËÙ·˜ Î·È ÂÁÚ‹ÁÔÚÛ˘, ·ÔÌfiÓˆÛË 2 ∫Ú·˘Á¤˜, ·˘ÙÔ-·ÎÚˆÙËÚÈ·ÛÌfi˜, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ‹ ·ÎÈÓËÙÔÔ›ËÛË 3 ¶ÚÔηÏÔ‡ÌÂÓË Û˘ÌÂÚÈÊÔÚ¿ º˘ÛÈÔÏÔÁÈ΋ 0 ªÈÎÚ‹ ηٷÛÙÔÏ‹ ‹ ˘ÂÚ‚ÔÏÈ΋ ·ÓÙ›‰Ú·ÛË 1 ª¤ÙÚÈ· ÌÂÙ·‚ÔÏ‹ ÛÙËÓ ·Ó·ÌÂÓfiÌÂÓË Û˘ÌÂÚÈÊÔÚ¿ 2 ∞ÓÙ›‰Ú·ÛË ‚›·ÈË ‹ Ôχ ·ÛıÂÓ‹˜ 3 ¢ÈfiÚıˆÛË ‚·ıÌÔÏÔÁ›·˜ ∞Ó ¤¯ÂÙ ‚·ıÌÔÏÔÁ›· 3 Û ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ÂÚÈÙÒÛÂȘ, 2-5 ÚÔÛı¤ÛÙ 1 ÂÈϤÔÓ fiÓÙÔ ÁÈ· οı ‚·ıÌÔÏÔÁ›· 3 ™À¡√§√ ∂ÚÌËÓ›· ‚·ıÌÔÏÔÁ›·˜ 0-4: Ê˘ÛÈÔÏÔÁÈ΋ 5-9: ÚÔÛÂÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, Èı·ÓfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÙÈÎÒÓ 10-14: ∆·Ï·ÈˆÚ›·. §‹„Ë Ì¤ÙÚˆÓ ·Ó·ÎÔ‡ÊÈÛ˘, Ù·ÎÙÈ΋ ·Ú·Ù‹ÚËÛË, ·Ó·˙‹ÙËÛË ‰Â‡ÙÂÚ˘ ÁÓÒÌ˘ ·fi ÎÙËÓ›·ÙÚÔ, Èı·ÓfiÙËÙ· ‰È·-ÎÔ‹˜ ÂÈÚ¿Ì·ÙÔ˜ 15-20: ™Ô‚·Úfi˜ fiÓÔ˜. ∞Ó·ıÂÒÚËÛË ÙÔ˘ ÂÈÚ·Ì·ÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘

ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÚÈÓ ÙËÓ ·Ó¿ÓË„Ë ·fi ÙËÓ ·Ó·È-ÛıËÛ›·. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Ì ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ °È· ÙËÓ ÔÚı‹ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ·Ó·ÏÁËÙÈ-ÎÔ‡ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ, ÌÂٷ͇ ¿Ï-ψÓ, ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ ÛÙËÓ ·Ó·ÙÔÌ›·, ÙË Ê˘ÛÈÔÏÔÁ›·, ÙË Ê·ÚÌ·ÎÔÏÔÁ›·, ÙȘ ‰È·ÙÚÔÊÈΤ˜ ·Ó¿ÁΘ Î·È ÙËÓ È-‰ÈÔÛ˘ÁÎÚ·Û›· ÙÔ˘ ˙ÒÔ˘, Ô ‚ÈÔÏÔÁÈÎfi˜ Ú˘ıÌfi˜ ÙÔ˘ ˙Ò-Ô˘, ηıÒ˜ Î·È ÙÔ ÛÙ¿‰ÈÔ Ù˘ ˙ˆ‹˜ ÙÔ˘. £· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÁÓÒÛË ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡ÚÔ˘˜ ÙÈÌÒÓ ·-ڷ̤ÙÚˆÓ, fiˆ˜ Ë ıÂÚÌÔÎÚ·Û›· ÛÒÌ·ÙÔ˜, Ô ·Ó·-Ó¢ÛÙÈÎfi˜ Ú˘ıÌfi˜ Î·È Ô Î·Ú‰È·Îfi˜ Ú˘ıÌfi˜. ∞Ó Î·È ˘¿Ú¯ÂÈ Ë ·ÓËÛ˘¯›· ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ÂÚ¢ÓËÙÒÓ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ ÌÔÚ› Ó· ·ÏÏÔÈÒÛÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ÌÂϤÙ˘, ÚˆÙ·Ú¯ÈÎfi˜ ÛÎÔfi˜ Ì·˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ë ·ÚÔ¯‹ Â·ÚÎÔ‡˜ ·Ó·ÏÁËÛ›·˜ ÛÙÔ ÂÈÚ·Ì·Ùfi˙ˆÔ (Smith 1994). ∫·ÙËÁÔڛ˜ ·Ó·ÏÁËÙÈÎÒÓ ∆· ·Ó·ÏÁËÙÈο ÌÔÚÔ‡Ó Ó· ¯ˆÚÈÛÙÔ‡Ó ÛÙȘ ÂÍ‹˜ ÙÚÂȘ ηÙËÁÔڛ˜: Ó·ÚΈÙÈο ·Ó·ÏÁËÙÈο, ·ÓÙÈ˘ÚÂ-ÙÈο ·Ó·ÏÁË·ÓÙÈ˘ÚÂ-ÙÈο Î·È ·ÔÎÏÂÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ fi-ÓÔ˘. ™Ù· Ó·ÚΈÙÈο ·Ó·ÏÁËÙÈο ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ÔÈÔÂȉ‹ ÌÔÚÊ›ÓË, Âıȉ›ÓË, ÂÙÔÚÊ›ÓË, ÊÂÓÙ·Ó‡ÏË, ÚÂ-ÌÈÊÂÓÙ·Ó‡ÏË Î·È ÌÔ˘ÚÂÓÔÚÊ›ÓË, Ù· ÔÔ›· ÚÔη-ÏÔ‡Ó Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ∫¡™. ™Ù· ·ÓÙÈ˘ÚÂÙÈο ·Ó·ÏÁË-ÙÈο (ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë-NSAIDs) ÂÚÈ-Ï·Ì‚¿ÓÔÓÙ·È ÙÔ ·ÎÂÙ˘ÏÔÛ·ÏÈ΢ÏÈÎfi Ô͇ (·ÛÈÚ›ÓË), Ë ÊÏÔ˘ÓÈÍ›ÓË, Ë ·Ú·ÎÂÙ·ÌfiÏË Î·È Ë ÊÂÓ·ÎÂÙ›ÓË. ™ÙÔ˘˜ ·ÔÎÏÂÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ fiÓÔ˘ ÂÚÈ-Ï·Ì‚¿ÓÔÓÙ·È Ù· ÙÔÈο ·Ó·ÈÛıËÙÈο Î·È ÔÈ ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ·2 ·‰ÚÂÓÂÚÁÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ (Í˘Ï·˙›ÓË, ̉ÂÙÔ-Ìȉ›ÓË). ∞ÓÙÈÌÂÙÒÈÛË ÔͤԘ fiÓÔ˘ ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ı· Ú¤-ÂÈ Ó· Á›ÓÂÙ·È Ì ‚¿ÛË ÙÔ ‚·ıÌfi ·Ó·ÏÁËÛ›·˜ Ô˘ ÂÈ-ı˘Ì›ٷÈ, ÙË ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ ÙÔ˘, ÙÔ ÂÈÚ·Ì·ÙÈÎfi ÚˆÙfiÎÔÏÏÔ Î·È ÙËÓ ÚÔÛˆÈ΋ ÂÌÂÈÚ›· ÙÔ˘ ÂÚ¢-ÓËÙ‹. ™Â ÂÚÈÙÒÛÂȘ ÛÔ‚·ÚÔ‡ fiÓÔ˘ ÚÔÙÈÌÒÓÙ·È Ë Ì-·ÁˆÓÈÛÙ¤˜, fiˆ˜ Ë ÌÔÚÊ›ÓË. ∏ ÌÔ˘ÚÂÓÔÚÊ›ÓË ¤-¯ÂÈ ÈÛ¯˘Ú‹ Î·È ·Ú·ÙÂٷ̤ÓË ‰Ú¿ÛË. ∞fi Ù· NSAID, Ë ÊÏÔ˘ÓÈÍ›ÓË ¤¯ÂÈ ÈÛ¯˘Ú‹ Î·È ·Ú·ÙÂٷ̤ÓË ‰Ú¿ÛË. ∆· ÙÔÈο ·Ó·ÈÛıËÙÈο ÌÔÚÔ‡Ó Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó ÙÔ-Èο ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ™Â Ì·ÎÚÔ-¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ·-ÓÙϛ˜ ¤Á¯˘Û˘ ‹ Ë ¯ÔÚ‹ÁËÛË Ó· Á›ÓÂÙ·È ·fi ÙÔ ÛÙfiÌ·. ∞ÓÙÈÌÂÙÒÈÛË ¯ÚfiÓÈÔ˘ fiÓÔ˘ ™˘ÓÈÛÙ¿Ù·È Ë Â·Ó·Ï·Ì‚·ÓfiÌÂÓË ¯ÔÚ‹ÁËÛË NSAIDs Û ÌÈÎÚ¤˜ ‰fiÛÂȘ. ªÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó Î·È ÛÙÔ fiÛÈÌÔ ÓÂÚfi. ∏ ÌÔ˘ÚÂÓÔÚÊ›ÓË ÌÔÚ›, Â›-Û˘, Ó· ¯ÔÚËÁËı› ÛÙÔ ÓÂÚfi. ™ÙÔÓ ›Ó·Î· 2 ·Ú·Ù›ıÂÓÙ·È Û˘ÓÈÛÙÒÌÂÓ˜ ‰fiÛÂȘ ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙ· ˙Ò· ÂÚÁ·ÛÙËÚ›Ô˘. ∂˘ı·Ó·Û›· ø˜ ¢ı·Ó·Û›· ÔÚ›˙ÂÙ·È Ë ı·Ó¿ÙˆÛË Ì ÙËÓ Úfi-ÎÏËÛË ÂÏ¿¯ÈÛÙÔ˘ fiÓÔ˘, Êfi‚Ô˘ Î·È Ù·Ï·ÈˆÚ›·˜. ∂Ê·ÚÌfi˙ÂÙ·È ˆ˜ ÙÂÏÂ˘Ù·›· χÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈ-ÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ Ù·Ï·ÈˆÚ›·˜ ÂÓfi˜ ˙ÒÔ˘ ‹ ÛÙÔ Ù¤-ÏÔ˜ Ì›·˜ ÂÈÚ·Ì·ÙÈ΋˜ ‰È·‰Èηۛ·˜, fiÙ·Ó ÔÈ Û˘Óı‹Î˜ ‰ÂÓ Â›Ó·È ϤÔÓ Û˘Ì‚·Ù¤˜ Ì ÙË ˙ˆ‹. ª›· ̤ıÔ‰Ô˜ ¢-ı·Ó·Û›·˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂÍ·ÛÊ·Ï›˙ÂÈ ÁÚ‹ÁÔÚË Î·È ÌË ·Ó·ÛÙÚ¤„ÈÌË Î·Ù¿ÚÁËÛË Ù˘ Û˘Ó›‰ËÛ˘, ÂÓÒ Ô ¯ÚfiÓÔ˜ ̤¯ÚÈ ÙËÓ Â›Ù¢ÍË ı·Ó¿ÙÔ˘ ¤¯ÂÈ ÌÈÎÚfiÙÂÚË ÛËÌ·Û›·. ª›· ̤ıÔ‰Ô˜ ¢ı·Ó·Û›·˜ ÁÈ· Ó· Â›Ó·È ·Ô‰ÂÎÙ‹ ı· Ú¤ÂÈ Ó· ÏËÚÔ› Ù· ·ÎfiÏÔ˘ı· ÎÚÈÙ‹ÚÈ·: Ó· ÚÔ-ηÏ› ÂÏ¿¯ÈÛÙÔ fiÓÔ, Ó· ÚÔÚÔ-ηÏ› Ù·¯Â›· ·ÒÏÂÈ· Û˘-Ó›‰ËÛ˘ Î·È ı¿Ó·ÙÔ, Ó· ··ÈÙ› ÂÏ¿¯ÈÛÙË Û˘ÁÎÚ¿ÙË-ÛË, Ó· ÌËÓ ÚÔηÏ› ‰È¤ÁÂÚÛË ÙÔ˘ ˙ÒÔ˘, Ó· Â›Ó·È Î·-Ù¿ÏÏËÏË ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ Â›‰Ô˜ Î·È ÙËÓ Î·Ù¿ÛÙ·ÛË Ù˘ ˘Á›·˜ ÙÔ˘, Ó· ÂÏ·¯ÈÛÙÔÔÈ› ÙÔ Êfi‚Ô Î·È ÙÔ ÛÙÚ˜, Ó· Â›Ó·È ·ÍÈfiÈÛÙË, ·Ó··Ú·ÁÒÁÈÌË, ÌË ·Ó·ÛÙÚ¤„È-ÌË, Ó· Â›Ó·È ·Ï‹ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘, Ó· Â›Ó·È ·ÛÊÏ‹˜ ÁÈ’ ·˘ÙfiÓ Ô˘ ÙËÓ ÂÎÙÂÏ›, Ó· Â›Ó·È ·ÈÛıËÙÈο ·-Ô‰ÂÎÙ‹ ÁÈ· ÙÔÓ ÂÎÙÂÏÂÛÙ‹, Ó· Â›Ó·È Û˘Ì‚·Ù‹ Ì ÙÔ ÂÈÚ·Ì·ÙÈÎfi ÚˆÙfiÎÔÏÏÔ Â¿Ó ··ÈÙÂ›Ù·È Ë ‰ÂÈÁÌ·ÙÔ-ÏË„›· ÈÛÙÒÓ ‹ ۈ̷ÙÈÎÒÓ ˘ÁÚÒÓ ÌÂÙ¿ ·fi ÙËÓ ÂÎÙ¤-ÏÂÛ‹ Ù˘, Ó· Â›Ó·È ÔÈÎÔÓÔÌÈ΋ Î·È fi¯È ¯ÚÔÓÔ‚fiÚÔ˜ Î·È Ó· ··ÈÙ› ˘ÏÈο Ù· ÔÔ›· Ó· Â›Ó·È Â‡ÎÔÏ· ‰È·ı¤ÛÈÌ· (Wolfensohn and Lloyd 1994).

√ ı¿Ó·ÙÔ˜ ÌÔÚ› Ó· Â¤ÏıÂÈ Ì¤Ûˆ ÙÚÈÒÓ Ì˯·ÓÈ-ÛÌÒÓ: 1) ˘ÔÍ›·, ¿ÌÂÛË ‹ ¤ÌÌÂÛË, 2) ¿ÌÂÛË Î·Ù·ÛÙÔÏ‹ ÙˆÓ Ó¢ÚÒÓˆÓ Ô˘ Â›Ó·È ··Ú·›ÙËÙÔÈ ÁÈ· ÙË ˙ˆ‹ Î·È 3) Ê˘ÛÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ Ó¢ÚÒÓˆÓ Ô˘ Â›Ó·È ··Ú·›ÙËÙÔÈ ÁÈ· ÙË ˙ˆ‹ (Andrews et al 1993). √È Ì¤ıÔ‰ÔÈ Â˘ı·Ó·Û›·˜ ÌÔÚÔ‡Ó Ó· ¯ˆÚÈÛÙÔ‡Ó ÛÂ Ê˘ÛÈΤ˜ Î·È ¯ËÌÈΤ˜. ™ÙȘ Ê˘ÛÈΤ˜ ÌÂıfi‰Ô˘˜ ¢ı·Ó·-Û›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ˘ÚÔ‚ÔÏÈÛÌfi˜, Ë ·ÔÏËÍ›·, Ë ËÏÂÎÙÚÔÏËÍ›·, Ë ·ÂÍ¿ÚıÚˆÛË ÙÔ˘ ÙÚ·¯‹ÏÔ˘, Ô ·-ÔÎÂÊ·ÏÈÛÌfi˜ Î·È Ù· ÌÈÎÚÔ·̷ٷ (Close et al, 1996). 1. ¶˘ÚÔ‚ÔÏÈÛÌfi˜. O ˘ÚÔ‚ÔÏÈÛÌfi˜ Ù˘ ÎÂÊ·Ï‹˜

·ÔÛÎÔ› ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. µÚ›ÛÎÂÈ ÂÊ·ÚÌÔÁ‹ Û ÌÂÁ¿Ï· ÂÚÂÙ¿ Î·È ıËÏ·ÛÙÈο. À¿Ú-¯Ô˘Ó ‰‡Ô Ù¯ÓÈΤ˜: Ù˘ ÂχıÂÚ˘ ÛÊ·›Ú·˜ Î·È ÙÔ˘ Â-ÎÙÈÓ·ÛÛfiÌÂÓÔ˘ ÂÌ‚fiÏÔ˘. 2. ∞ÔÏËÍ›·. ∂Ê·ÚÌfi˙ÂÙ·È ÛÙ· ÌÈÎÚfiۈ̷ ÂÈ-Ú·Ì·Ùfi˙ˆ·, fiˆ˜ ÌÈÎÚ¿ ÎÔ˘Ó¤ÏÈ·, Â›Ì˘Â˜, ̇˜, ÓÂ-ÔÁ¤ÓÓËÙ˜ Á¿Ù˜, ÓÂÔÁ¤ÓÓËÙ· ÎÔ˘Ù¿‚È·, Ó·ڿ ÈÓ‰Èο ¯ÔÈÚ›‰È·, ¯¿ÌÛÙÂÚ, ÙËÓ¿, ÌÈÎÚ¿ ÂÚÂÙ¿, ·ÌÊ›‚È· Î·È Table 2. Suggested doses of analgesic agents used in laboratory animals (Smith 1994).

¶›Ó·Î·˜ 2. ™˘ÓÈÛÙÒÌÂÓ˜ ‰fiÛÂȘ ·Ó·ÏÁËÙÈÎÒÓ Ô˘ÛÈÒÓ ÁÈ· ¯Ú‹ÛË Û ˙Ò· ÂÚÁ·ÛÙËÚ›Ô˘ (Smith 1994).

ª˘˜ ∂›Ì˘˜ πÓ‰ÈÎfi ¯ÔÈÚ›‰ÈÔ ∫Ô˘Ó¤ÏÈ

∞ÛÈÚ›ÓË 120 mg/kg/4h, p.o. 100 mg/kg,4h, p.o. 85 mg/kg/4h, p.o. 100 mg/kg/4h, p.o. ªÔ˘ÚÂÓÔÚÊ›ÓË 0,05-0,1 mg/kg/8-12h, 0,01-0,05 mg/kg/8-12h, 0,05 mg/kg/8-12h, 0,01-0,05 mg/kg/8-12h,

s.c. s.c. s.c. s.c., i.v.

µÔ˘ÙÔÚÊ·ÓfiÏË 1-5 mg/kg/4h, s.c. 2 mg/kg/4h, s.c. 0,1-0,5 mg/kg/4h, i.v.

∫ˆ‰Â˝ÓË 60-90 mg/kg, p.o.

20 mg/kg/4h, s.c. 60 mg/kg/4h

¢ÈÎÏÔÊÂÓ¿ÎË 8 mg/kg, p.o. 10 mg/kg, p.o. 2,1 mg/kg, p.o.

ºÏÔ˘ÊÂÓ·ÌÈÎfi Ô͇ 5 mg/kg, p.o. 30 mg/kg, p.o.

ºÏÔ˘ÓÈÍ›ÓË 2,5 mg/kg/12h, s.c. 2,5 mg/kg/12h, s.c. 1,1 mg/kg/12h, s.c.

πÌÔ˘ÚÔʤÓË 30 mg/kg/4h, p.o. 15 mg/kg/4h, p.o. 10 mg/kg/4h, i.m. 10 mg/kg/4h, i.v. πÓ‰ÔÌÂı·Î›ÓË 1 mg/kg, p.o. 2 mg/kg, p.o. 2,5-8,8 mg/kg, p.o. 12,5 mg/kg, p.o.

ªÂÊ·Ó·ÌÈÎfi Ô͇ 224 mg/kg, p.o. ªÔÚÊ›ÓË 2-5 mg/kg/2-4h, s.c. 2-5 mg/kg/2-4h, s.c. 2-5 mg/kg/4h, s.c. 2-5 mg/kg/2-4h, s.c. ¡·ÏÌÔ˘Ê›ÓË 4-8 mg/kg/4h, s.c. 1-2 mg/kg/3h, s.c. 1-2 mg/kg/4-5h, i.v. ¡·ÚÔͤÓË 14,9 mg/kg, p.o. ¶·Ú·ÎÂÙ·ÌfiÏË 200 mg/kg/4h, p.o. 200 mg/kg/4h, p.o. ¶ÂÓÙ·˙ÔΛÓË 10 mg/kg,/3-4h, s.c. 10 mg/kg/3-4h, s.c. 5 mg/kg/2-4h, i.v. ¶Âıȉ›ÓË 10-20 mg/kg/2-3h, s.c. 10-20 mg/kg/2-3h, s.c. 10-20 mg/kg/2-3h, s.c. 10-20 mg/kg/2-3h, s.c. ºÂÓ˘ÏÔ‚Ô˘Ù·˙fiÓË 30 mg/kg, p.o. 20 mg/kg, p.o. 40 mg/kg, p.o.

¶ÈÚÔÍÈοÌË 3 mg/kg, p.o. 3 mg/kg, p.o. 5,7 mg/kg, p.o. ™Ô˘ÚÔʤÓË 25 mg/kg, p.o.

∆ÂÓÔÍÈοÌË 10 mg/kg, p.o. 7,2 mg/kg, p.o.

°¿Ù· ™Î‡ÏÔ˜ ÃÔ›ÚÔ˜ ¶Úfi‚·ÙÔ ¶ÚˆÙ‡ÔÓÙ·

∞ÛÈÚ›ÓË ∆ÔÍÈ΋ 10 mg/kg/6h, p.o. 20 mg/kg/6h,po

ªÔ˘ÚÂÓÔÚÊ›ÓË 0,005-0,01 mg/kg/ 0,01-0,02 mg/kg/ 0,005-0,01/ 0,005-0,01 mg/kg/ 0,01 mg/kg/8-12h, 8-12h, s.c., i.v. 8-12h, s.c, i.v. 8-12h, i.m. 4-6h,i.m. i.m., i.v.

µÔ˘ÙÔÚÊ·ÓfiÏË 0,4 mg/kg/3-4h, s.c. 0,4 mg/kg/3-4h, s.c. ∫ˆ‰Â˝ÓË 0,25-0,5 mg/kg/6h, po (Ì ·Ú·ÎÂÙ·ÌfiÏË) ºÏÔ˘ÓÈÍ›ÓË 1 mg/kg/d x 5 d, sc 1 mg/kg/d, p.o. 1 mg/kg/d, s.c. 1 mg/kg/d, s.c. 2,5-10,0 mg/kg/d, i.m. πÌÔ˘ÚÔʤÓË 5-10 mg/kg/24-48h,po ªÔÚÊ›ÓË 0,1 mg/kg/4h, s.c. 0,5-5,0 mg/kg/4h, s.c. ¤ˆ˜ 20 mg/4h, i.m. 10 mg/4h, s.c. 1-2 mg/kg/4h, s.c. ¡·ÏÌÔ˘Ê›ÓË 1,5-3,0mg/kg/3h, i.v. 0,5-2,0 mg/kg/3-8h, sc ¶·Ú·ÎÂÙ·ÌfiÏË ∆ÔÍÈ΋ 10-20 mg/kg/6h, p.o. (Ì Έ‰Â˚ÓË)

¶ÂÓÙ·˙ÔΛÓË 8 mg/kg/4-6h, i.p. 2 mg/kg/4h, i.m. 2 mgkg/4h, i.m. 2-5 mg/kg/4h, i.m. ¶Âıȉ›ÓË 10 mg/kg/2-3h, s.c. 10 mg/kg/2-3h, i.m. 2 mg/kg/4h, i.m. 200 mg/4h, im. 2-4 mg/kg/3-4h, i.m.

„¿ÚÈ·. ∂ÎÙÂÏÂ›Ù·È ¤Ó· ÎÙ‡ËÌ· ÛÙËÓ ÎÂÊ·Ï‹ Ô˘ Ô-‰ËÁ› Û ·ÒÏÂÈ· ÙˆÓ ·ÈÛı‹ÛˆÓ. ™Â ÌÂÁ·Ï‡ÙÂÚ· ˙Ò· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÂȉÈÎfi˜ ÂÍÔÏÈÛÌfi˜, fiˆ˜ fiÏÔ Ì ÌË ‰È·ÙÈÙÚ·›ÓÔÓ ¤Ì‚ÔÏÔ. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ı· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·Ê·›Ì·ÍË, ÂÎÙÔÌ‹ Ù˘ ηډȿ˜ ‹ ηٷÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÒÛÙ ӷ ÂȂ‚·ÈÒÓÂÙ·È Ë ı·Ó¿ÙˆÛË. 3. ∏ÏÂÎÙÚÔÏËÍ›·. ∂Ê·ÚÌfi˙ÂÙ·È Û „¿ÚÈ·, ·ÌÊ›-‚È·, ÙËÓ¿, Û·ÏÔ˘˜ Î·È ¿ÏÏ· Û·ÚÎÔÊ¿Á·, fiÚÓÈı˜, ¯Ô›ÚÔ˘˜, Úfi‚·Ù·, ÌÔÛ¯¿ÚÈ·, ·›Á˜ Î·È ÎÔ˘Ó¤ÏÈ·. ÃÚËÛÈÌÔÔÈÂ›Ù·È ÂÓ·ÏÏ·ÛfiÌÂÓÔ Ú‡̷ ‰È¿ÊÔÚ˘ Ù¿-Û˘ ÌÂÙ¿ ·fi ÙÔÔı¤ÙËÛË ‰‡Ô ËÏÂÎÙÚÔ‰›ˆÓ, ¤Ó· Û οı ‚Ú·¯›ÔÓ· ÙÔ˘ ˙ÒÔ˘. ∏ ̤ıÔ‰Ô˜ Ô‰ËÁ› Û ·Ò-ÏÂÈ· ÙˆÓ ·ÈÛı‹ÛÂˆÓ Î·È ı· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ¿ÏÏË ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂȂ‚·ÈÒÓÂÙ·È Ë ı·Ó¿Ùˆ-ÛË. ∂Ó·ÏÏ·ÎÙÈο, ÌÔÚ› Ó· ÚÔÎÏËı› ηډȷ΋ ·-Ó·ÎÔ‹ fiÙ·Ó ÙÔ ¤Ó· ËÏÂÎÙÚfi‰ÈÔ ÙÔÔıÂÙËı› ÛÙËÓ ÎÂ-Ê·Ï‹ Î·È ÙÔ ¿ÏÏÔ ÛÙË Ú¿¯Ë ÙÔ˘ ˙ÒÔ˘. 4. ∞ÂÍ¿ÚıÚˆÛË ÙÔ˘ ÙÚ·¯‹ÏÔ˘. ∂Ê·ÚÌfi˙ÂÙ·È ÁÈ· ÙËÓ Â˘ı·Ó·Û›· „·ÚÈÒÓ, ÔÚÓ›ıˆÓ, Ì˘ÒÓ, Ó·ÚÒÓ ÈÓ‰È-ÎÒÓ ¯ÔÈÚȉ›ˆÓ, Ó·ÚÒÓ ÂÈ̇ˆÓ, ÓÂÔÁ¤ÓÓËÙˆÓ ÎÔ˘ÓÂ-ÏÈÒÓ, ÓÂÔÁ¤ÓÓËÙˆÓ Á·ÙÒÓ Î·È ÓÂÔÁ¤ÓÓËÙˆÓ ÎÔ˘Ù·-‚ÈÒÓ. ªÔÚ›, Â›Û˘, Ó· ÂÊ·ÚÌÔÛÙ› Î·È Û ÂÓ‹ÏÈ-ÎÔ˘˜ Â›Ì˘Â˜ Î·È ÎÔ˘Ó¤ÏÈ· ¤ˆ˜ 1 kg ·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ÚÔÎÏËı› ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘. ¶ÚÔηÏÂ›Ù·È Â-ÎÙÂٷ̤ÓË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ Î·È ¿ÌÂÛË ·ÒÏÂÈ· ÙˆÓ ·ÈÛı‹ÛˆÓ. £· Ú¤ÂÈ, ˆ-ÛÙfiÛÔ, Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·Ê·›Ì·ÍË ‹ ηٷÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÁÈ· Ó· ÂȂ‚·ÈÒÓÂÙ·È Ë ı·Ó¿ÙˆÛË. 5. ∞ÔÎÂÊ·ÏÈÛÌfi˜. ∂Ê·ÚÌfi˙ÂÙ·È ÁÈ· ÙËÓ Â˘ı·Ó·-Û›· „·ÚÈÒÓ, ·ÌÊ›‚ȈÓ, ÙËÓÒÓ, ÙÚˆÎÙÈÎÒÓ Î·È ÌÈÎÚÒÓ ÎÔ˘ÓÂÏÈÒÓ. ™˘Ó‹ıˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÎÈÏÔÙ›Ó˜ ÂÈ-‰Èο ۯ‰ȷṲ̂Ó˜ ÁÈ’ ·˘ÙfiÓ ÙÔ ÛÎÔfi. ™Ù· „˘¯Úfi·ÈÌ· ÛÔÓ‰˘ÏˆÙ¿ ı· Ú¤ÂÈ ÚÔËÁÔ˘Ì¤Óˆ˜ Ó· ÚÔηÏ›-Ù·È ·ÒÏÂÈ· ·ÈÛı‹ÛÂˆÓ ‰Â‰Ô̤ÓÔ˘ fiÙÈ Â›Ó·È ·ÓıÂÎÙÈ-ο ÛÙËÓ ·ÓÔÍ›·. 6. ªÈÎÚÔ·̷ٷ. ∂Ê·ÚÌfi˙ÂÙ·È ·fi ÙÔ˘˜ Ó¢ÚÔ-‚ÈÔÏfiÁÔ˘˜ ˆ˜ ̤ıÔ‰Ô˜ ÌÔÓÈÌÔÔ›ËÛ˘ ÙˆÓ ÌÂÙ·‚ÔÏÈ-ÙÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¯ˆÚ›˜ ·ÒÏÂÈ· Ù˘ ·Ó·ÙÔÌÈ΋˜ ‰Ô-Ì‹˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂȉÈο ۯ‰ȷ-Ṳ̂Ó˜ Û˘Û΢¤˜ Ì ÙȘ Ôԛ˜ ηÙ¢ı‡ÓÂÙ·È Ë ·ÎÙ›Ó· ÌÈÎÚÔÎ˘Ì¿ÙˆÓ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÈÔ¯‹ ÙÔ˘ ÂÁÎÂÊ¿-ÏÔ˘. ∂Ê·ÚÌfi˙ÂÙ·È ÌfiÓÔ Û ÌÈÎÚfiۈ̷ ˙Ò·, fiˆ˜ ·Ì-Ê›‚È·, ÙËÓ¿, ̇˜, Â›Ì˘Â˜ Î·È ÌÈÎÚ¿ ÎÔ˘Ó¤ÏÈ·. ™ÙȘ ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜ ¢ı·Ó·Û›·˜ ÂÚÈÏ·Ì‚¿ÓÂ-Ù·È Ë ¯ÔÚ‹ÁËÛË ÂÈÛÓ¢ÛÙÈÎÒÓ Ô˘ÛÈÒÓ, Ô˘ÛÈÒÓ Ô˘ ·-ÔÚÚÔÊÒÓÙ·È ·fi ÙÔ ‰¤ÚÌ· Î·È ÂÓ¤ÛÈÌˆÓ Ô˘ÛÈÒÓ (Close et al 1996). 1. ∂ÈÛÓ¢ÛÙÈΤ˜ Ô˘Û›Â˜. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ù ÙËÙÈΤ˜ Ô˘Û›Â˜ Ô˘ ÂÍ·ÂÚÒÓÔÓÙ·È Â›Ù ·¤ÚÈ·. ∏ ¯Ô-Ú‹ÁËÛË Á›ÓÂÙ·È Â›Ù Ì ‰ÈÔ¯¤ÙÂ˘Û‹ ÙÔ˘˜ Û ÂȉÈÎÔ‡˜ ı·Ï¿ÌÔ˘˜ fiÔ˘ ÙÔÔıÂÙÂ›Ù·È ÙÔ ÂÈÚ·Ì·Ùfi˙ˆÔ ›Ù ‰È·Ì¤ÛÔ˘ ΢ÎÏˆÌ¿ÙˆÓ ·Ó·ÈÛıËÛ›·˜. ∂Ê·ÚÌfi˙ÂÙ·È Û ÌÈÎÚfiۈ̷ ˙Ò·, fiˆ˜ ÙËÓ¿, ÙÚˆÎÙÈο, Á¿Ù˜ Î·È ÌÈ-ÎÚÔ‡˜ Û·ÏÔ˘˜. √È Ô˘Û›Â˜ Ô˘ ÂÈϤÁÔÓÙ·È ‰ÂÓ ı· Ú¤ÂÈ Ó· Â›Ó·È ÂÚÂıÈÛÙÈΤ˜ ÁÈ· ÙȘ ·ÂÚÔÊfiÚ˜ Ô‰Ô‡˜ Ô‡Ù ӷ ÚÔηÏÔ‡Ó Û·ÛÌÔ‡˜ ÚÈÓ ÙËÓ ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÔ ‰ÈÔÍ›‰ÈÔ ÙÔ˘ ¿Ó-ıڷη (ÛÂ Û˘ÁΤÓÙÚˆÛË >70%), ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη Î·È Ù· ÙËÙÈο ÂÈÛÓ¢ÛÙÈο ·Ó·ÈÛıËÙÈο Û ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË (·ÏÔı¿ÓÈÔ, ÂÓÊÏÔ˘Ú¿ÓÈÔ, ÈÛÔ-ÊÏÔ˘Ú¿ÓÈÔ). 2. √˘Û›Â˜ Ô˘ ·ÔÚÚÔÊÒÓÙ·È ·fi ÙÔ ‰¤ÚÌ· Î·È Ù· ‚Ú¿Á¯È· ˘‰Úfi‚ÈˆÓ ˙ÒˆÓ. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ Â˘ı·Ó·Û›· „·ÚÈÒÓ Î·È ·ÌÊ›‚ȈÓ. ™Â ·˘Ù¤˜ ÂÚÈÏ·Ì-‚¿ÓÔÓÙ·È Ë ‚ÂÓ˙Ôη˝ÓË, Ë ıÂÈÔ‡¯Ô˜ ÙÚÈη˝ÓË, Ë ÂÙÔÌÈ-‰¿ÙË, Ë ÌÂÙÔÌȉ¿ÙË Î·È Ë ÎÔ˘˚ӷω›ÓË. ¶ÚÔÛÙ›ıÂÓÙ·È ÌÂÙ¿ ·fi ‰È·Ï‡Û‹ ÙÔ˘˜ ÛÙÔ ÓÂÚfi Ù˘ ‰ÂÍ·ÌÂÓ‹˜. ¢ÚÔ˘Ó Î·Ù·ÛÙ¤ÏÏÔÓÙ·˜ ÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· (∫¡™). 3. ∂Ó¤ÛÈ̘ Ô˘Û›Â˜. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ù ÂÓ¤ÛÈ-Ì· ÁÂÓÈο ·Ó·ÈÛıËÙÈο ›Ù Û΢¿ÛÂÓ¤ÛÈ-Ì·Ù· ÌÂ Û˘Ó‰˘·-ÛÌfi Ô˘ÛÈÒÓ Ì ·Ó·ÈÛıËÙÈ΋ Î·È Ì˘Ô¯·Ï·ÚˆÙÈ΋ ‰Ú¿-ÛË. ∏ ‰fiÛË ¯ÔÚ‹ÁËÛ˘ Â›Ó·È ·fi ‰ÈÏ¿ÛÈ· ¤ˆ˜ ÙÂÙÚ·-Ï¿ÛÈ· Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘ ÁÈ· ·Ó·ÈÛıËÛ›·. ñ µ·Ú‚ÈÙÔ˘ÚÈο (ÂÓÙÔ‚·Ú‚ÈÙfiÓË, ıÂÈÔÂÓÙ¿ÏË, Î.¿.). ¶ÚÔηÏÔ‡Ó Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ∫¡™, ηıÒ˜ Î·È Î·Ú‰È·Î‹ Î·È ·Ó·Ó¢ÛÙÈ΋ ·Ó·ÎÔ‹. ÃÔÚËÁÔ‡ÓÙ·È Ì ÙËÓ ÂÓ‰ÔÊϤ‚È· ‹ ÂÓ‰ÔÂÚÈÙÔÓ·˚΋ Ô‰fi. ñ ∆-61. ∆Ô Û··ÛÌ· ·˘Ùfi ÂÚȤ¯ÂÈ Û˘Ó‰˘·ÛÌfi ÙÔÈÎÔ‡ ·Ó·ÈÛıËÙÈÎÔ‡, ˘ÓˆÙÈ΋˜ Ô˘ÛÈ¿˜ Î·È Ì˘Ô¯·-Ï·ÚˆÙÈÎÔ‡. ÃÔÚËÁÂ›Ù·È Ì ·ÚÁ‹ ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ·ÊÔ‡ ÚÔËÁËı› ËÚ¤ÌÈÛË ÙÔ˘ ˙ÒÔ˘. ∞Ô‰ÂÎÙ¤˜ ̤ıÔ‰ÔÈ ÁÈ· ¢ı·Ó·Û›· Û ˙Ò· ÛÙ· Ô-Ô›· ¤¯ÂÈ ÚÔËÁËı› ·ÒÏÂÈ· Û˘Ó›‰ËÛ˘ ›ӷÈ, Â›-Û˘, Ë Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ‚ÂÏfiÓ·, Ë Ù·-¯Â›· ηٿ„˘ÍË, Ë ·Ê·›Ì·ÍË, Ë ÂÈÛÓÔ‹ ·˙ÒÙÔ˘/·ÚÁÔ‡, Ë ¯ÔÚ‹ÁËÛË ·Èı·ÓfiÏ˘, ¤Ó˘‰Ú˘ ¯ÏˆÚ¿Ï˘, ¯ÏˆÚÈÔ‡-¯Ô˘ Î·Ï›Ô˘ Î·È Ô ÂÌ‚ÔÏÈÛÌfi˜ ·¤Ú· (Close et al 1996). 1. ∫·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ‚ÂÏfiÓ·. ∂Ê·Ú-Ìfi˙ÂÙ·È ÛÙ· „¿ÚÈ·, Ù· ·ÌÊ›‚È· Î·È Ù· ÂÚÂÙ¿. 2. ∆·¯Â›· ηٿ„˘ÍË. ∂Ê·ÚÌfi˙ÂÙ·È ÛÙȘ ÂÚÈÙÒ-ÛÂȘ fiÔ˘ ÂÈ˙ËÙÂ›Ù·È Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ÂÓ˙˘ÌÈ΋˜

‰Ú·ÛÙËÚÈfiÙËÙ·˜, fiˆ˜ .¯. fiÙ·Ó ·ÎÔÏÔ˘ı› ‚ÈÔ¯ËÌÈ-΋ ·Ó¿Ï˘ÛË ÈÛÙÒÓ. ÃÚËÛÈÌÔÔÈÂ›Ù·È Ë ÂÌ‚‡ıÈÛË ÙÔ˘ ˙ÒÔ˘ Û ˘ÁÚfi ¿˙ˆÙÔ, Ô ·ÔÎÂÊ·ÏÈÛÌfi˜ Î·È Ë ÂÌ‚‡ıÈÛË Ù˘ ÎÂÊ·Ï‹˜ Û ˘ÁÚfi ¿˙ˆÙÔ, Ë Î·Ù¿„˘ÍË in situ Î·È Ë ÚÔ‹ „˘¯ÚÔ‡ ·¤Ú·. 3. ∏ ·Ê·›Ì·ÍË. 4. ∏ ÂÈÛÓÔ‹ ·˙ÒÙÔ˘ ‹ ·ÚÁÔ‡. 5. ∏ ¯ÔÚ‹ÁËÛË ·Èı·ÓfiÏ˘. ÃÔÚËÁÂ›Ù·È ÂÓ‰ÔÂÚÈ-ÙÔÓ·˚ο Î·È ÚÔηÏ› ηٷÛÙÔÏ‹ ÙÔ˘ ∫¡™. 6. ∏ ¯ÔÚ‹ÁËÛË ¤Ó˘‰Ú˘ ¯ÏˆÚ¿Ï˘. ÃÔÚËÁÂ›Ù·È Û ÌÂÁ·Ïfiۈ̷ ˙Ò· ÂÓ‰ÔÂÚÈÙÔÓ·˚ο, ÌfiÓË Ù˘ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ıÂÈÈÎfi Ì·ÁÓ‹ÛÈÔ ‹ ıÂÈÔ‡¯Ô ÂÓÙÔ‚·Ú-‚ÈÙfiÓË. 7. ∏ ¯ÔÚ‹ÁËÛË ¯ÏˆÚÈÔ‡¯Ô˘ Î·Ï›Ô˘. Œ¯ÂÈ Î·Ú‰ÈÔ-ÙÔÍÈ΋ ‰Ú¿ÛË. 8. ∂Ì‚ÔÏÈÛÌfi˜ ·¤Ú·. °›ÓÂÙ·È ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁË-ÛË ·¤Ú· Û ‰fi¯ÔÚ‹ÁË-ÛË 5-10 ml/kg ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜. ∂Ȃ‚·›ˆÛË ÙÔ˘ ı·Ó¿ÙÔ˘ ªÂÙ¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ¢ı·Ó·Û›·˜ ı· Ú¤ÂÈ Ó· Â-Ȃ‚·ÈÒÓÂÙ·È Ô ı¿Ó·ÙÔ˜ Ì ‚¿ÛË ÙËÓ ·Ô˘Û›· ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ú˘ıÌÔ‡ Î·È ÙˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ. ™Ù· ÌÈÎÚfiۈ̷ ÂÈÚ·Ì·Ùfi-˙ˆ·, Ë ıÂÚÌÔÎÚ·Û›· ÛÒÌ·ÙÔ˜ ÌÂÈÒÓÂÙ·È Î¿Ùˆ ·fi 25ÆC (Close et al 1996). REFERENCES - BIµ§π√°ƒ∞ºπ∞

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