氯胺酮联合芬太尼静脉自控镇痛在重度烧伤患者休克期镇痛的临床价值

Analgesia for Patients with Severe Burn at Shock Stage

目的探讨重度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。方法将伤后24 h内入院的60例严重烧伤病人,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50mg和异丙嗪25mg,其余三组静脉自控镇痛(PCIA)药物配制为:PCIKA组氯胺酮10 g/L+氟哌利多50 mg/L,PCIFA组芬太尼5 g/L+氟哌利多50 mg/L,PCIKFA组氯胺酮5 g/L+芬太尼2.5 mg/L+氟哌利多50 mg/L,负荷量均为5 ml,PCA量1 ml,锁定时间30 min,持续输注量2 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统计意义。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） at small dose of ketamine used solely or combined with fentanyl for severely burned patients during shock stage. Methods Sixty patients admitted to the hospital within 24 h after being severely burned were enrolled in this study. The patients were divided into four groups （ 15 ones per group） at random. In Group CAT, the patients received intramuscular injection of dolantin （50 rag） and phenergan （25 mg） when they complained of pain. In Group PCIKA, the patients were given intravenous infusion with a mixture of ketamine （ 10 mg/ml） and droperidol （50 μg/ml） . In Group PCIFA, the patients were administered with a mixture of fcntanyl （5μg/ml） and droperidol （50 μg/ml） , and in Group PCIKFA, the patients with a mixture of ketamine （5mg/ml） , fentanyl （2.5μg/ml） and droperido150 μg/ ml）. Pain scores, HR, MAP, SpO2 , and side effects were recorded respectively before analgesia and 1, 4, 8, 24 and 48 h after the beginning of analgesia. Blood sugar level and the plasma levels of stress hormones were measured at the same time points. Resuits Pain scores in PCIFA, PCIKA and PCIKFA groups were significantly lower than that in Group CAT （ P 〈 0.01 ）. There were neither significant differences in HR, MAP, and SpO2 , nor significant difference in side effects among the four groups. Hyperglycemia was inhibited more efficiently in the three PCIA groups than in Group CAT. The plasma levels of stress hormones were significandy lower in the three PCIA groups than in Group CAT （ P 〈 0.01 ）. Conclusion PCIA with ketamine used solely or combined with fentanyl is efficient and safe for the severe burned patients at shock stage.