帕瑞昔布钠复合吗啡对瑞芬太尼致骨科手术患者术后痛觉过敏的影响

Effects of parecoxib and morphine on remifentanil-induced postoperative hyperalgesia in patients undergoing orthopedic operation

目的 探讨帕瑞昔布钠复合吗啡对瑞芬太尼致骨科手术患者术后痛觉过敏的影响.方法 择期拟行骨科手术患者60例,ASA分级Ⅰ或Ⅱ级,年龄20～62岁,体重45～100 kg,随机分为3组（n=20）.静脉注射咪达唑仑、异丙酚、瑞芬太尼和罗库溴铵麻醉诱导,气管插管后行机械通气.气管插管完成后,M组静脉注射吗啡0.15 mg/kg;MP1组静脉注射帕瑞昔布钠20 mg和吗啡0.075 mg/kg;MP2组静脉注射帕瑞昔布钠40 mg和吗啡0.075 mg/kg.术中静脉输注异丙酚和瑞芬太尼,间断静脉注射维库溴铵维持麻醉.记录苏醒时间、意识恢复时间和拔管时间;记录拔管期间躁动和寒战的发生情况,以及意识恢复后5 min时的口述痛觉评分（VRS评分）.分别于术后1 h（T1）、2 h（T2）、4 h（T3）、8 h（T4）、12 h（T5）和24 h（T6）时,采用VAS评分评价患者静态和动态的疼痛程度,同时记录MAP和HR.记录术后24 h内恶心呕吐的发生情况.分别于麻醉诱导前、术毕和术后24 h时,采集外周静脉血样2 ml,采用ELISA法测定血浆前列腺素E2（PGE2）和TNF-α的浓度.结果 三组苏醒时间、意识恢复时间、拔管时间、VRS评分、MAP、HR、躁动、寒战和恶心呕吐发生率比较差异无统计学意义（P＞0.05）.与M组比较,MP1组T1～2时静态VAS评分升高,T1-6时动态VAS评分升高,MP2组T1-5时静态和动态VAS评分降低（P＜0.05）;与MP1组比较,MP2组T1-6时静态VAS评分降低,T1-5时动态VAS评分降低（P＜0.05）.与M组比较,MP1组各时点血浆PGE2和TNF-α的浓度差异无统计学意义（P＞0.05）,MP2组术毕血浆PGE2和TNF-α的浓度降低（P＜0.05）;与Mpi组比较,MP2组术毕时血浆PGE2和TNF-α的浓度降低（P＜0.05）.结论 术前静脉注射帕瑞昔布钠40 mg复合吗啡0.075 mg/kg可减轻瑞芬太尼致骨科手术患者术后痛觉过敏,且效果优于单独应用吗啡.

Objective To investigate the effects of parecoxib and morphine on remifentanil-induced postoperative hyperalgesia in patients undergoing orthopedic operation. Methods Sixty ASA Ⅰ or Ⅱ patients,aged 20-62 yr, weighing 45-100 kg, undergoing orthopedic surgery, were randomly divided into 3 groups （ n = 20 each）. Anesthesia was induced with midazolam, propofol, remifentanil and rocuronium. The patients were mechanically ventilated after tracheal intubation. Group Ⅰ received iv injection of morphine 0.15 mg/kg, group Ⅱ received iv injection of parecoxib 20 mg and morphine 0.075 mg/kg and group Ⅲ received iv injection of parecoxib 40 mg and morphine 0.075 mg/kg. Anesthesia was maintained with infusion of propofol and remifentanil and intermittent iv boluses of vecuronium. The emergence time, consciousness recovery time, extubation time,incidence of agitation and shivering, and VRS score at 5 min after recovery of consciousness were recorded. Pain at rest and at movement was evaluated using VAS score at 1,2, 4, 8, 12 and 24 h （T1-6） after surgery and MAP andHR were recorded simultaneously. The incidence of nausea and vomiting during 24 h after surgery was also recorded. Blood samples were taken before induction of anesthesia, at the end of operation and 24 h after operation for determination of plasma concentrations of PGE2 and TNF-α. Results There was no significant difference in emergence time, consciousness recovery time, extubation time, VRS scores, MAP, HR, incidence of agitation,shivering, nausea and vomiting among the 3 groups. Compared with group Ⅰ , VAS scores at rest at T1-2 and at movement at T1-6 were significantly increased in group Ⅱ , while VAS scores at rest and at movement decreased at T1-5 in group Ⅲ （P〈0.05）. VAS scores at rest at T1-6 and at movement at T1-5 were significantly lower in group Ⅲ than in group Ⅱ （P〈 0.05）. There was no significant difference in the plasma concentrations of PGE2 and TNF-α at different time points between group Ⅰ and Ⅱ （P〉0.05）. The plasma concentrations of PGE2 and TNF-α were significantly lower at the end of surgery in group Ⅲ than in group Ⅰ and Ⅱ （P〈0.05）. Conclusion Preoperative iv parecoxib 40 mg and morphine 0.075 mg/kg can reduce remifentanil-induced postoperative hyperalgesia in patients undergoing orthopedic operation, and the efficacy is better than that of morphine alone.