氯胺酮和吗啡硬膜外超前镇痛效果的临床对比研究

A comparison of ketamine and morphine for Pre-emptive analgesia effects and stress response after hysterectomy

目的观察比较氯胺酮、吗啡超前镇痛对全子宫切除手术患者围术期应激反应及术后疼痛的影响。方法选择45例硬膜外麻醉下行全子宫切除术的患者,随机分为三组,C、K、M组硬膜外腔分别注入2%利多卡因5ml、2%利多卡因5ml+氯胺酮30mg、2%利多卡因5ml+吗啡1mg。术毕自控硬腺外镇痛(PCEA),药物为0.2%罗哌卡因5ml/h。分别于术前、术后第1、2天晨抽取静脉血,用高效液相色谱法测定血浆去甲肾上腺素(NE)、肾上腺素(E)。记录术后不同时间点的疼痛视觉模拟(VAS)评分、首次按压止泵的时间、按压次数以及术后恶心、呕吐和皮肤瘙痒的发生率。结果 K、M两组PCEA泵首次按压时间明显延长,按压次数、止痛剂总消耗量明显减少;M组的不良反应发生率明显高于C、K组。三组患者的NE、E、在术毕第1天显著高于术前(P<0.05),术后第1、2天时K、M组NE、E显著低于对照组(P<0.01),K、M两组间无差异。结论小剂量氯胺酮、吗啡硬膜外腔超前镇痛能减轻全子宫切除手术后儿茶酚胺的增高反应,提高患者自控镇痛效果,氯胺酮没有阿片类药物的不良反应,用于超前镇痛优于吗啡。

Objective This randomized double-blind study compared the efficacy and side-effect profile of ketamine and morphine for Pre-emptive analgesia in 45 patients undergoing hysterectomy. Methods Forty-five patients with hysteromyoma undergone hysteromyomectomy were randomly assigned to three groups（ n = 15,each group） ： group C ,control group without pre-emptive analgesia; group K ,30 mg ketamine was administrated into epidural analgesia before operation; group M,1 mg morphine was administrated into epidural analgesia before operation. Postoperative analgesia was achieved in three groups by patient-controlled epidural analgesia（ PCEA） with ropivacaine 0. 2% . The VAS and first PCEA trigger time （ min） ,analgetic consumption （ mg） and the number of PCEA successful triggers,analgesic-related adverse effects were observed. The changes of epinephrine （ E ） ,norepinephrine （ N E ） in plasma were detected. Results The VAS were not significantly different between group C ,K and M . The first PCEA trigger times of group K and M were longer than that of group C . The number of PCEA successful triggers and analgetic consumptions two days after operation in group K and M were significantly less than those in group C ; the levels of E and NE in plasma were increased in group K and M one day after operation and in groupC during 48 hours after operation（ P 0. 05） ,but the degree in group K and M was lower than that in group C two days after operation（ P 0. 01） . The levels of E and NE were not significantly different between group K and M. Conclusion The pre-emptive analgesia of ketamine or morphine can decrease analgetic consumption and stress response time. There were not any morphinerelated adverse effects in group K. And the efficacy of ketamine for Pre-emptive analgesia was better than morphine.