曲马多复合芬太尼在小儿术后持续静脉镇痛中的应用

Postoperative intravenous analgesia with a combination of tramadol and fentanyl continuously infused in children

目的：比较曲马多与不同剂量芬太尼复合用于小儿术后持续静脉自控镇痛（PCIA）效果和副作用。方法：选择行全麻择期手术患儿120例（ASAⅠ～Ⅱ级）进行术后PCIA，随机分成四组：T组：1％曲马多；TF1组：1％曲马多＋芬太尼2μg·ml^-1；FT2组：1％曲马多＋芬太尼4μg·ml^-1；TF3组：1％曲马多＋芬太尼6μg·ml^-1。手术缝皮时开启镇痛泵，负荷量0．1ml·kg^-1 ＋持续量0．5^-1ml·h^-1，＋PCA量0．5^-1 ml^-1次。（由患儿双亲或护士控制，NPCIA／PPCIA），锁定时间10min。均静脉注射格拉司琼40μg·k^-1。记录术后24h内的血压、心率、脉氧饱和度（SPO2）、呼吸频率（RR）、CHEOPS（Children＇s Hospital of Estem Ontario Pain Score）镇痛评分〈4分：无痛，〉6分：中度疼痛，〉13分：重度疼痛）、表情疼痛评分（FRS）、TSS镇静评分、24h用药量以及不良反应。结果：四组术后24h的BP、HR、呼吸频率（RR）无明显变化，均可达到满意的镇痛效果，FRS各组间的差异无显著性（P〉0．05），T组和TF1组HEOPS在术后30min时明显降低（P〈0．05）；24h曲马多用量T组〉TF1组〉TF2组（P〈0．05），TR组〉TF3组，但差异无统计学意义（P〉0．05）；按压次数（PCAe）、术后恶心呕吐（PONV）发生率四组间的差异无显著性，TF3组术后苏醒时间较另三组明显延长，各组内均有一例患儿出现眩晕。结论：小剂量芬太尼与曲马多复合用于小儿PCIA镇痛效果良好，可明显减少曲马多的用量，最佳方案是镇痛用药为1％曲马多＋芬太尼4μg·ml^-1，负荷量0．1ml·kg^-1 ＋持续量0．5^-1ml·h^-1 ＋PCA0．5～1ml；格拉司琼在小儿中的应用尚需进一步的研究。

Objective： To compare the efficacy of patient - controlled intravenous analgesia （PICA） with a eo - application of different dosage of tramadol and fentanyl in postoperative analgesia in children. Methods： By an observer -blinded design, 120 ASA Ⅰ-Ⅱ pediatrle patients （1 ～ 12 years old） underwent general anesthesia were randomly given a postoperative intravenous infusion of 1% tramadol （ Group T）, 1% tramadol plus fentanyl 2 μg/ml （ Group TF1 ） , 1% tramadol plus fentanyl 4 μg/ml （ Group TF2 ） , or 1% tramadol plus fentanyl 6μg/ml （ Group TF3 ） . Exclusion erlteria included children with mental disorders, hypothyroidism pilepsy, and long - term analgesic users. All the patients received Granisentran Hydrochloride 40 μg/kg via intravenous injection at the end of surgery. PCIA was commenced and continued for 24 h. The analgesic effect was assessed by Wong- Baker Faces Pain Rating Scale （FRS） and the Children＇s Hospital of Ontario Pain Scale （CHEOPS）, less than 4 （no pain）, more than 6 （moderate pain）, more than 13 （severe pain）, eousumption of analgosies and the ineideneos of side - effects were recorded. Results： （ 1 ） There were no significant differences in the demographic data ineluding sex, age, body weight, types of surgery and duration of operation among the four groups （ P 〉 0. 05 ） ; （ 2 ） No significant differenees were found in BP, HR, RR （respiratory rate） and SpO2 among the four groups （P 〉0. 05） ; （3） The FRS did not significantly change among the four groups, and the CHEOPS at the point of 30 min were significantly decreased in both group T and group TF1 ; （4） With the dosages of fentanyl increased, the 24 h consumptions of tramadol were significantly reduced in Group T , Group TF1 and Group TF2 （P 〈0. 05）, but the tendency was disturbed in Group TF3; （5） The incidences of vertigo, nausea and vomiting had no significant differenees among the four groups, while the recovery time of Group TF3 was significantly longer than that of the other three groups. Conclusion： A eo - applleation of small dose of fentanyl and tramadol may produce more effective and safe PCIA in children. Meanwhile, demand of tramadol was reduced. Optimal combination may be 1% tramadol adding fentanyl 4 μg/ml, administering plan was loading dose of 0. 1 ml/kg, continuous infusion of 0. 5 ～ 1 ml/h, PCA dose of 0. 5 ～1 ml. By the way, the safety of Granisetron in using of children is remain to be investigated.