静脉与硬膜外病人自控镇痛对剖胸术后应激反应影响的比较

Comparison of the impacts of PCIA vs PCEA on stress response after thoracotomy

目的比较剖胸术后静脉自控镇痛（PCIA）与硬膜外自控镇痛（PCEA）的镇痛效果、副作用及对患者应激反应的影响。方法33例（ASAⅠ～Ⅱ）食道癌择期手术患者随机分为两组：PCIA组（n=17）镇痛用药为吗啡（1mg／m1）＋氟哌利多（0．1mg／ml）；PCEA组（n=16）镇痛用药为吗啡（0．1mg／ml）＋布比卡因（0．125％）。分别于术前、术终及术后检测血清皮质醇（Cortisol）、血管紧张素Ⅱ（AngⅡ）、内皮素（ET）及血糖（Glu）浓度；记录术后患者疼痛评分（VAS）及副作用。结果PCEA组VAS评分明显低于PCIA组，尤其是在患者咳嗽和深呼吸时（P〈0．01）。两组Glu、Cortisol水平在术终均显著升高，但组间无显著差异，而在术后PCEA组明显低于PCIA组（P〈0．05）；各观察点两组AngⅡ、ET水平相似，组间及组内差异均无显著性。结论剖胸术后PCEA镇痛效果明显优于PCIA；PCEA能有效抑制部分应激素如Cortisol及Glu的增高，但对An4E及ET的影响不明显。

Objective To compare the analgesic effect, adverse effects of patient-comrolled epiduml analgesia （PCEA） vs patient-controlled intravenous analgesia （PCIA） and their influences on stress response in thoracotomy patiems. Methods 33 ASA Ⅰ--Ⅱ patiems undergoing elective esophagectomy were randomly assigned to receive either morphine plus droperidol （Group PCIA, n= 17） or morphine plus bupivacaine （Group PCEA, n= 16） for 3 days postoperatively. Serum concentrations of cortisol, angiotensin Ⅱ （AngⅡ）, endothelin （ET） and blood glucose were measured before operation, at the end of the operation and on the next morning after operation. Pain scores with visual analogue scale （VAS） at rest, deep breathing and with cough, and adverse effects were also recorded. Results Blood glucose and cortisol were increased to similar levels in both groups at the end of the operation, but were much lower in Group PCEA postoperatively （P 〈0.05）. No obvious change in Ang Ⅱ or ET level was found at each endpoim within or between groups （P〉0. 05）. Pain scores with VAS were much lower in Group PCEA, especially when the patient was at deep breathing or during coughing （P〈0. 001）. Conclusions PCEA is superior to PCIA in pain relief, but it has limited comribution in depressing the increase of stress hormone. It can subdue an increase in cortisol and blood glucose, but has no impact on blood Ang Ⅱ and ET levels in post-thoracotomy patients.