老年患者腹腔镜直肠癌术后硬膜外麻醉与静脉自控镇痛的效果及对血气的影响

Effects of patient controlled epidural analgesia and patient controlled intravenous analgesia on analgesic result and blood gas in aged patients undergoing laparoscopic rectectomy

目的:观察老年患者腹腔镜直肠癌术后甲磺酸罗哌卡因、芬太尼硬膜外自控镇痛(patient controlled epidural analgesia,PCEA)与芬太尼、氟哌利多静脉自控镇痛(patient controlled intravenous analgesia,PCIA)的临床效果及对血气的影响。方法:随机将52例65岁以上ASAⅠ或Ⅱ级择期直肠癌根治术患者分成两组,每组26例,PCEA选用0.238%甲磺酸罗哌卡因加0.0002%芬太尼硬膜外镇痛,PCIA组选用0.001%芬太尼加0.005%氟哌利多静脉镇痛。观察镇痛效果、镇静程度、舒适评分、不良反应,持续监测平均动脉压(MAP)、心率(HR)、脉搏氧饱和度(SpO2)和呼气末二氧化碳分压(PETCO2),分别于麻醉前,术后4、12、24h在患者不吸氧或停吸氧0.5h的情况下抽取动脉血,监测pH、PaCO2,并计算动脉血与呼气末CO2梯度(Pa-PETCO2)的变化。结果:两组患者视觉模拟评分(visual analogue scale,VAS)均较低,PCIA组高于PCEA组,但无明显差异(P>0.05),PCIA组Ramesay法(RSS)镇静评分显著高于PCEA(P<0.05)布氏评分法(BCS),舒适评分明显低于PCEA组(P<0.05),恶心、呕吐、皮肤搔痒等的发生率显著高于PCEA组(P<0.05),评估两组患者术后镇痛总体满意度,优秀者PCEA组明显多于PCIA组(P<0.05);术后较术前pH降低,PaCO2、PETCO2、Pa-PETCO2升高(P<0.05),术后各时点上述指标无显著差异(P>0.05)。结论:腹腔镜直肠癌手术后的老年患者,甲磺酸罗哌卡因硬膜外自控镇痛与芬太尼静脉自控镇痛均安全可行,镇痛效果满意,术后PaCO2、PETCO2、上升,pH下降,但不呈进行性的变化。综合总体镇痛质量,PCEA组优于PCIA组,但PCEA组镇痛需加强硬膜外导管的管理。

Objective：To observe the effects of patient controlled epidural analgesia（PCEA） with ropivacaine mesilate and fentanyl and patient controlled intravenous analgesia（PCIA） with fentanyl and droperidol on clinical result and blood gas urdergoing laparoscopic rectectomy in aged patients. Methods：Fifty-two patients （ASA Ⅰ -Ⅱ） with retal carcinoma undergoing laparoscopic redical operation were randomly divided into two groups named group PCEA and group PCIA. Group PCEA cases received epidural analgesia with 0.238% ropivacaine mesilate and 0. 0002% fentanyl ,and group PCIA cases received intravenous analgesia with 0. 001% fentanyl and 0. 005% droperidol. Analgesia result, sedation scale, comfort score and side effect were studied. Mean arteriol pressure （MAP）, heart rate （HR） ,pulse blood oxygen saturation （SpO2 ） and partial pressure of end tital carbon dioxide（ PETCO2 ） were monitored continuously pH,PaCO2 and changes between arteriol partial pressure of carbon dioxide and end-expired carbon dioxide tension（Pa-PEyCO2 ） were monitored by blood gas before anesthesia and 4,12,24hour after operation on the condition that the patients could not take in oxygen or stop taking in it for 0.5 hour. Results：The visual analogue scale （VAS） was low in two groups. The VAS was higher in group PCIA than that in group PCEA ,but there was no significant defference（P 〉 0.05 ）. The sedation score by Ramesay（RSS） was significantly higher and the comfort score by BCS was significantly lower in group PCIA than that in group PCEA（P 〈 0.05 ）. The rate of nausea, vomiting and itch was significantly higher in group PCIA than in the other group（ P 〈 0.05 ）. The cases with satisfaction of group PCEA were significantly more than the other cases on postoperative analgesia （P 〈 0.05 ）. After operation pH was reduced, PaCO2, PETCO2, and PaPETCO2 were increased（ P 〈 0.05 ）. There was no significant difference at different time after operation（ P 〉 0.05 ）. Conclusions ： Both methods of PCEA with ropivaeaine mesilate and PCIA with fentanyl are safe,feasible and satisfying. After operation PaCO2 and PETCO2 are increased and PH is reduced. But the change is not progressive. In genenal, PCEA is better than PCIA in quality, but the epiduraltubes need strengthen the management.