严重烧伤病人休克期镇痛的临床研究

Analgesia for the patients with severe burn during shock stage

目的探讨严重烧伤休克期静脉注射小剂量氯胺酮、芬太尼病人自控镇痛(PCA)的安全性、有效性及对血糖和应激激素的影响。方法60例严重烧伤病人于伤后24 h内入院,随机分为传统镇痛组(CAT组)、静脉注射氯胺酮组(PCIKA组)、芬太尼组(PCIFA组)和氯胺酮、芬太尼联合镇痛组(PCIKFA组),每组15例。CAT组根据病人需要肌注哌替啶50 mg和异丙嗪25 mg,其余三组静脉自控镇痛(PCIA)药物配制为:PCIKA组氯胺酮20 mg/ml+氟哌利多50μg/ml,PCIFA组芬太尼10μg/ml+氟哌利多50μg/ml,PCIKFA组氯胺酮10 mg/ml+芬太尼5μg/ml+氟哌利多50μg/ml,负荷量均为1.5 ml,PCA量1 ml,锁定时间30 min,持续输注量1.5 ml/h。观察并记录镇痛开始前及开始后1、4、8、24、48 h时的HR、MAP、SpO2、视觉模拟评分(VAS)和镇静状态及有无恶心、呕吐、幻觉、呼吸抑制等不良反应。检测镇痛开始前及开始后1、8、24、48 h的血糖和血浆应激激素的水平。结果另外三组病人静脉镇痛效果明显优于CAT组(P<0.01),并且有良好的镇静作用;HR、MAP和SpO2各组间差异无显著意义,各组病人无恶心、呕吐、幻觉及呼吸抑制等不良反应;三组PCIA病人镇痛开始后血糖和血浆应激激素明显降低(P<0.01),各组之间胰岛素水平差异无显著意义。结论严重烧伤病人休克期静脉注射小剂量氯胺酮、芬太尼,病人PCA安全、有效,并降低此类病人的高血糖反应和应激反应。

Objective To observe the efficacy of patient-controlled intravenous analgesia （PCIA） with small dose of ketamine solely or combined with fentanyl for severely burned patients during shock stage. Methods Sixty patients administred within 24 h after severe burn were enrolled in this study. The patients were randomly divided into four groups with 15 cases each. In group CAT, the patients received intramuscular injection of dolantin 50 mg and phenergan 25 mg when patients complained of pain. In group PCIKA, the patients were given intravenous infusion with a mixture of ketamine 20 mg/ml＋droperidol 50μg/ml. In group PCIFA, with a mixture of fentamyl 10μg/ml＋droperidol 50μg/ml,and in group PCIKFA, with a mixture of ketamine 10 mg/ml＋fentanyl 5μg/ml droperidol 50μg/ml. In three groups of PCIA, patients received loading dose of 1.5 ml, back ground infusion of 1.5 ml/h, respectively. Pain scores, HR, MAP, SpO2 and side effects were recorded before analgesia,at 1,4,8,24 and 48 h during analgesia, and blood sugar, plasma levels of stress hormones such as insulin, ACTH, cortisol,epinephrine and noreprinephrine were measured at the same time points. Results Pain scores in PCIFA, PCIKA and PCIKFA groups were significantly lower than those in group CAT （P〈0. 01）. There were no significant differences in HR, MAP, and SpO2 among the four groups. No significant difference of side effects was found among four groups. Hyperglycemia was inhibited more efficiently in three PCIA groups than that in group CAT. The serum level of stress hormones was significantly lower in three PCIA groups than that in group CAT CAT（P〈0.01）. Conclusion PCIA with ketamine solely or combined with fentanyl for severe burned patients during shock is efficient and safe.