术后不同镇痛方式对老年患者应激反应和凝血功能的影响

Effect of epidural or intravenous patient-controlled analgesia on stress response and blood coagulation in the elderly after orthopedic surgery of lower limb

目的观察两种镇痛方式：硬膜外自控镇痛（PCEA）与静脉自控镇痛（PCIA）对老年患者下肢手术后应激反应及凝血功能的影响。方法择期行下肢骨科矫形手术的老年患者40例，ASAⅡ～Ⅲ级，随机分为硬膜外自控镇痛组（PCEA组）与静脉自控镇痛组（PCIA组），每组20例。所有患者均施行腰麻硬膜外联合麻醉。术后PCEA组自硬膜外腔导管给予硬膜外自控镇痛，PCEA药物配制：罗哌卡因225mg＋吗啡8mg＋氟哌利多5mg加生理盐水配成100ml混合液，首次负荷量吗啡2mg，背景量2．0ml／h，PCA量1．5ml／次，间隔时间15min；PCIA组给予静脉自控镇痛，PCIA药物配制：芬太尼0．2mg＋曲马多1g＋氟哌利多5mg加生理盐水配成100ml混合液，首次负荷量为上述混合液10ml静注，背景量2．0ml／h，PCA量1．5ml／次，间隔时间15min。分别于麻醉前（T0）、术毕（T1）、术后24h（12）、术后48h（T3）各时间点静脉采血检测血浆皮质醇（COR）、血糖（BS）和凝血功能：血浆凝血酶原时间（PT），活化部分凝血活酶时间（APTT），凝血酶时间（TT）及血浆纤维蛋白原（Fg）。于手术后12、24、48h对两组患者进行视觉模拟疼痛评分（VAS）。结果术后12h及24hPCEA组VAS低于PCIA组（P均〈0．05）。两组患者术毕到术后48h（T1到T3）COR及Bs与术前（TO）时比较降低（P〈0．05或0．01）；而组间比较，他和，r3时PCEA组COR及BS均低于PCIA组（P均〈0．05）。凝血功能指标PT、APTY、TT自T1到T3与哟比较，两组均延长（P〈0．05或0．01），而组间比较，T1和T3时两组间差异无统计学意义，而他时上述三项指标PCEA组较PCIA组延长（P〈0．05）。PCEA组纤维蛋白原（Fg）T1至T3较T0时降低（P〈0．05或0．01），而PCIA组T1到T3Fg较T0时虽然有所降低，但差异无统计学意义（P〉0．05）；两组间比较，T1和T3时组间差异无统计学意义，仅他时PCEA组低于PCIA组（P〈0．05）。结论PCEA和PCIA均能提供有效的术后镇痛，并减轻手术后应激反应和改善凝血功能，但PCEA优于PCIA。

Objective To explore the effect of epidural or intravenous patient-controlled analgesia on stress response and blood coagulation after orthopedic surgery of lower limb in the elderly. Methods Forty ASA Ⅱ-Ⅲ patients （15 males,25 females） aged 65-85 years undergoing elective orthopedic proce- dures of lower limb were randomized to one of two groups ： epidural patient-controlled analgesia （EPCA） group （n =20） and intravenous patient-controlled analgesia （PCIA） （n = 20）. All the patients received combined spinal and epidural anesthesia. After surgery, the patients in PCEA group received PECA with a mixture of 100 ml,including 225 mg ropivaeaine,8 mg morphine and 5 mg droperidol, and those in PCIA group received PCIA with a mixture of 100 ml, including 0.2 mg fentanyl, 1 g tramadol and 5 mg droperidol. The parameters, including blood eortisol concentration （COR）, blood glucose concentration （BS）, and the parameters of blood coagulation, including prothrombin time （ PT）, activated partial thromboplastin time （APYF）, thrombin time （TF）, and the concentration of blood fibrinogen （Fg）, were determined at following time points ：before anesthesia induction （TO）, at the end of surgery （T1） ,24 h （T2） and 48 h （T3） after the operation. Pain intensity was tested using a visual analog scale （VAS） at 12,24 and 48 h after surgery. Results The demographic data, duration of operation, intraoperative transfusion volume and blood loss were comparable between the two groups. Pain relief was better at 12 and 24 h after surgery in PCEA group than in PCIA group （ P 〈 0.05 ）. The concentrations of COR and BS from T1 to T3 were decreased as compared with those before anesthesia induction （T0） in two groups （P 〈 0.05 or 0.01 ）. The concentrations of COR and BS were lower at T2 and T3 in PECA group than those in PCIA group （ P 〈 0.05）. PT,AFI^F and 33＇ were prolonged from T1 to T3 as compared with those at TO in two groups （P 〈 0.05 or 0.01 ）. PT,AFFF and TI＂ at T2 were longer in PCEA group than in PCIA group （P 〈0.05）. The concentrations of Fg from TI to T3 were decreased as compared with those at TO in PCEA group （ P 〈 0.05 or 0.01 ）. In PCIA group, the concentrations of Fg were lower from T1 to T3 than those at TO, but the difference was not significant （ P 〉 0.05 ）. The concentrations of Fg were lower only at T2 in PCEA group than those in PCIA group （P 〈 0.05 ）. Conclusion After the surgery of lower limb in the elderly patient, patient-controlled analgesia, regardless of the route （ epidnral or intravenous）, is effective, and decreases the stress response to surgery and improves the blood coagulation. The epidural route provides better pain relief,decreases the stress response to surgery, and improves the blood coagulation more preferably.