不同镇痛方法用于开胸手术后镇痛效果的评价

Evaluation on analgesia methods in patients undergoing thoracic surgery

目的:比较肌肉注射镇痛、硬膜外镇痛、静脉镇痛、皮下镇痛4种镇痛方法对开胸术后患者镇痛和镇静效果。方法:①选择2004-01/2006-01石河子大学医学院第一附属医院120例行择期胸科手术的患者,男78例,女42例;年龄32～67岁。均符合美国麻醉医师协会标准Ⅰ～Ⅱ级,且对镇痛方法知情同意。按随机数字表法将患者分为4组:肌肉注射镇痛组、硬膜外镇痛组、静脉镇痛组、皮下镇痛组,每组30例。硬膜外镇痛组:于末次硬膜外麻醉后追加负荷量内含吗啡1mg+2.5g/L布比卡因+生理盐水10mL后接镇痛泵行硬膜外镇痛,镇痛药物配方为每100mL中含吗啡6mg+布比卡因125mg+生理盐水至100mL。静脉镇痛组:静脉内推注吗啡负荷量5mg后在静脉穿刺套管针处联接镇痛装置,配方为吗啡50mg+生理盐水至100mL。皮下镇痛组:皮下注射吗啡负荷量5mg后在患者前臂置入静脉穿刺针置于皮下,连接镇痛泵,镇痛药配方为吗啡25mg+生理盐水至100mL。肌肉注射镇痛组:不用镇痛输泵,按0.1mg/kg剂量肌注哌替啶。②于术后4,8,12,24,48h采用Kecle口述描绘评分法评估术后镇痛效果,将疼痛程度(0～9分)分为:0分为无痛,7～9分为重度痛。③于术后48h用Ramsay评分法评估镇静效果(0～6分):1分为不安静烦躁,6分为深睡状态呼唤不醒。④记录术后4,8,12,24及48h患者因镇痛泵持续给药后仍然感觉疼痛而按自控按键单次给镇痛药的次数。⑤观察术后心肺系统主要并发症及不良反应。结果:行胸外科手术患者120例均进入结果分析。①镇痛效果:肌肉注射镇痛组术后4,8,12,24及48hKecle口述描绘评分法评分明显高于其他3组(P<0.01);皮下镇痛组术后12和48h明显高于硬膜外镇痛组(P<0.05),静脉镇痛组术后48h明显高于硬膜外镇痛组(P<0.05)。②镇静效果:肌肉注射镇痛组术后Ramsay评分为1分的比例为27%(8/30),明显高于其他3组(均为0,P<0.01),术后Ramsay评分为2分的比例为67%(20/30),明显低于硬膜外镇痛组[100%(30/30),P<0.01]。静脉镇痛组术后48hRamsay评分为4分的比例明显高于其他3组(均为0,P<0.01)。③患者自己按压给药次数的比较:硬膜外镇痛组患者术后48h内自己按压给药的次数明显少于静脉镇痛组和皮下镇痛组(P<0.01),皮下镇痛组患者术后4,8,24,48h自己按压给药的次数明显多于静脉镇痛组(P<0.05～0.01)。④不良事件和副反应发生情况:静脉镇痛组不良事件和副反应总发生率为40%(12/30),明显高于肌肉注射镇痛组、硬膜外镇痛组、皮下镇痛组[3%(1/30),20%(6/30),13%(4/30),P<0.01]。结论:①静脉镇痛、硬膜外镇痛、皮下镇痛均能达到良好的镇痛效果,镇痛效果优于肌肉注射镇痛。②静脉自控镇痛不良反应最多,镇静作用也最强。

AJM： To compare the efficacy of patients-controlled intravenous analgesia （PCIA）, epidural PCA （PCEA）, subcutaneous PCA （PCSA） with morphine and intramuscular （IM） injection on the analgesia and sedation of patients undergoing thoracic surgery. METHODS： ①A total of 120 patients aging 32-67 years and undergoing thoracic surgery （ Ⅰ - Ⅱ grade by American Society of Anesthesiologists） in the First Affiliated Hospital, Medial College of Shihezi University From January 2004 to January 2006, including 78 males and 42 females, ware divided randomly into four groups： IM group, PCEA group, PCIA group and PCSA group, each containing 30 patients. They ware informed of analgesia methods and consented. PCEA group： After additional loading of 1 mg morphine ＋ 2.5 g/L bupivacaine ＋ 10 mL saline, every 100 mL analgesic containing 6 mg morphine, 125 mg bupivacaine and saline ware administrated via analgesia pump. PCIA group： After loading of 5 mg morphine, 100 mL analgesic containing 50 mg morphine and saline ware administrated via venipuncture trochar. PCSA group： After injection of 5 mg morphine, 100 mL analgesic containing 25 mg morphine and saline ware administrated via venipuncture needle and analgesia pump. IM group： 0.1 mg/kg pethidine of IM injection.②The following indexes ware recorded respectively at 4, 8, 12, 24 and 48 hours after the PCA pumps ware used： Verbal Rating Scale （VRS） scores of pain （0 point as painlessness and 7-9 points as severe pain, totally 9 points）; Ramsay scores of sedation effect （0 point as unease and fidget and 6 points as deep sleep and unawake, totally 6 points） at 48 hours postoperation; times of pressing PCA after continuous delivery via analgesia pump; complication and adverse effect of cardiopulmonary system. RESULTS： All 120 patients undergoing thoracic surgery were involved in the result analysis. ①Analgesia effect： The VRS values ware significantly higher in IM group than those inother groups at 4, 8, 12, 24 and 48 hours post-operation （P 〈 0.01）, significantly higher in PCSA group than that in PCEA group at 12 and 48 hours post-operation （P 〈 0.05）, and also significantly higher in PCIA group than in PCEA group at 48 hours post-operation （P 〈 0.05）. ②Sedation effect： Ramsay scale of I point in IM group （27%, 8/30） was obviously higher than those in other groups （0, P 〈 0.01）, but Ramsay scale of 2 points was obviously lower in IM group than that in PCEA group [67% （20/30）, 100% （30/30）, P〈 0.01]. In addition, Ramsay scale of 4 points, was markedly higher in PCIA group than in other groups at 48 hours after operation （0, P 〈 0.01）. ③The times of temporarily pressing PCA ware significantly lower in PCEA group than those in PCIA group and PCSA group within 48 hours post-operation （P 〈 0.01）, but significantly higher in PCSA group than in PCIA group at 4, 8, 24 and 48 hours post-operation （P 〈 0.05-0.01）.④lncidences of adverse effect and side effect ware markedly higher in PCIA group than that in IM group, PCEA group and PCSA group [40% （12/30）, 3% （1/30）, 20% （6/30）, 13% （4/30）, P 〈 0.01]. CONCLUSION： ①The postoperative analgesia through epidural, venous or subcutaneous pathway may alleviate the post-operation analgesia efficiently better than IM injection with pethidine. ②However, the incidents of side effect and sedation effect in PCIA group are higher than that in other groups.