胃癌根治术静脉小剂量氯胺酮复合硬膜外吗啡超前镇痛的效果观察

Preemptive Analgesia by Intravenous Low-dose Ketamine and Epidural Morpine in Gastrectomy

目的观察胃癌根治术中静脉小剂量氯胺酮复合硬膜外吗啡超前镇痛与对照组术后镇痛效果及吗啡用量.方法选择胃癌择期手术患者60例,ASAⅠ～Ⅱ级,随机分为三组,每组各20例,三组均采用硬膜外复合全麻.A组(试验组)静脉小剂量氯胺酮复合硬膜外吗啡超前镇痛,B组仅硬膜外吗啡超前镇痛,C组(对照组)未用超前镇痛.三组术后均采用术后镇痛.分别记录术后6、12、24、48小时的BP、RR、HR、SPO2、VAS(疼痛评分)、吗啡用量.结果A组在4个时间点VAS均为最低,与B组、C组相比差异有显著性(P＜O.05).6h、12hB组与C组VAS比较差异有显著性(P＜O.05),24h、48h差异无显著性(P＞O.05).A组PCEA(病人自控硬膜外镇痛)吗啡累积消耗量在4个时间点均为最低,与B组、C组比较差异有显著性(P＜O.05);B组与C组的吗啡累积消耗量在4个点比较差异均有显著性(P＜O.05).结论为胃癌根治术患者达到满意的超前镇痛,并且尽量减少术后吗啡及其它阿片类药物的使用,可使用静脉小剂量氯胺酮复合硬膜外吗啡超前镇痛的方法,这种方法可以同时发挥外周及中枢的镇痛作用.

Objective To examine the difference among preemptive analgesia by intravenous low-dose ketamine and epidural morphine,singly using epidural morphine and control group. Methods Sixty ASA classⅠ～Ⅱpatients undergoing elective gastrectomy, were randomly assigned to be preemptive analgesia by intravenous low-dose ketamine and epidural morphine(group A,n=20),singly using epidural morphine(group B,n=20)and control group which has not preemptive analgesia(group C,n=20). All patients were accepted epidural anesthesia combined intravenous and inhalational anesthesia. Epidural morphine was administered as a bolus dose of 0.06mg.kg -1 30min prior to skin incision.Intravenous ketamine was administered as a bolus dose of 1.0 mg.kg -1 ,10min prior to skin incision,and maintained continuously until skin closure at a dosage of 0.5 mg.kg -1.h -1.Postsurgical pain intensity was rated by visual analog scale(VAS) and cumulative morphine consumption in 6h,12h,24h,48h. Results VAS:Group A was significantly effective in 4 periods, the VAS of groupA is lowest.Group B was significantly effective compared with group C in 6h,12h, not significantly effective in 24h,48h.Cumulative morphine consumption: group A was significantly the lowest in 6h,12h,24h,48h compared with group B,C. GroupB was significantly lower than group C in 6h,12h,24h,48h. Conclusions The results suggest that for definitive preemptive analgesia,blockade of opioid and N-methyl-D-aspartate receptors be necessary for upper abdominal surgery such as gastrectomy. Epidural morphine may affect the spinal cord segmentally, whereas intravenous ketamine may block brain stem sensitization via the vagus nerve during upper abdominal surgery.