经尿道前列腺电切术后老年患者自控-靶控舒芬太尼镇痛的安全性和有效性

Safety and efficacy of patient controlled analgesia effect-site target controlled infusion of sufentanll in elderly patients after transurethral resection of the prostate

目的 研究经尿道前列腺电切（TURP）术后老年患者应用自控-靶控舒芬太尼镇痛的安全性和有效性。方法 选择择期行TURP老年患者60例，随机分成4组。Ⅰ组：自控-靶控镇痛（PCATCI）模式，设置舒芬太尼初始血浆靶浓度（Cp） 0.06μg/L，最低有效Cp 0.04μg/L。Ⅱ组：PCA-TCI模式，设置舒芬太尼初始Cp 0.08 μg/L，最低有效Cp 0.05μg/L。Ⅲ组：PCA-TCI模式，设置舒芬太尼初始Cp 0.10 μg/L，最低有效Cp 0.05μg/L。Ⅰ、Ⅱ、Ⅲ组药液配置相同：舒芬太尼（sufentanil）Ⅰ mg/L。Ⅳ组（对照）：吗啡硬膜外自控镇痛（PCEA），药液0.06％吗啡＋0.2％罗哌卡因，用负荷剂量＋持续输注＋PCA（LCp）模式。4组患者术后均待腰麻感觉阻滞平面下降至T10后开启镇痛装置，监测其启动前及启动后各时点的视觉模拟评分（VAS）、Ramsay镇静评分、术后运动恢复时间（改良Bromage评分）、舒芬太尼Cp、收缩压（SBP）、舒张压（DBP）、心率（HR）、脉搏血氧饱和度（SpO2）、呼吸频率（RR）和患者对该镇痛装置的综合满意度；记录按压次数（D1）与实际进入次数（D2）、肛门排气时间、不良反应及24h用药总量。结果4组患者均获得满意的镇痛效果。在相同时间点的Ramsay镇静评分4组间比较差异无统计学意义（P＞0.05）；在相同时间点的VAS评分和D1，D2值在Ⅱ、Ⅲ、Ⅳ组组间比较差异无统计学意义（P＞0.05）,Ⅰ组1、2、4h时点VAS评分较高（P＜0.05）。所有患者24h内均有肛门排气，Ⅰ组为（16.5±3.9）h,Ⅱ组为（ 16.2±3.8）h,Ⅲ组为（16.8±4.1）h，均较IV组的（19.1±2.5）h时间缩短（P＜0.05）。Ⅰ、Ⅱ组用药量相似[（36.7±5.1）μg和（37.8±4.7）μg,P＞0.05]，Ⅲ组用药量[（42.3±5.6） μg]比Ⅰ、Ⅱ组高（P＜0.05）。各组不良反应发生率相似（P＞0.05）。结论 舒芬太尼PCA-TCI用于老年患者TURP术后镇痛安全有效。其设置舒芬太尼初始Cp为0.08μg/L，最低有效Cp为0.05 μg,/L时，VAS评分较低，用药量较少，且有利于患者循环功能的稳定。

Objective To evaluate the safety and efficacy of patient controlled analgesia effect-site target controlled infusion （PCA-TCI） of sufentanil in elderly patients after transurethral resection of benign prostatic hyperplasia （TURP）. Methods Sixty elderly patients （ASA Ⅰ - Ⅱ ） scheduled for TURP were randomized into four groups （n=15 each）. PCA-TCI was used in the first three groups with the same analgesic dosage （1 mg/L sufentanil） but different initial target plasma concentrations （Cp） （0.06 μg/L in group Ⅰ ,0.08 μg/L in group Ⅱ and 0.10 μg/L in group Ⅲ ） and minimum effective Cp （0.04 μg/L in group Ⅰ , 0.05μg/L in groups Ⅱ and Ⅲ ）. The group Ⅳ was set as control group, using patient controlled epidural analgesia （PECA） with 0.06 mg/L morphine ＋ 0.2% ropivacaine＋0.9% normal saline under losding＋continous＋PCA （LCP） mode. After the operation, the analgesia device was switched on when the level of sensory blockade receded to T10. Before and at different time points after the start of analgesia, visual analogue score （VAS）,Ramsay sedation score, modified Bromage score, plasma target concentration （Cp） of sufentanil, systolic blood pressure （SBP）, diastolic blood pressure （DBP）, heart rate （HR）, blood oxygen saturation （SpO2）,respiratory rate （RR） and patient satisfaction with analgesia were assessed. Moreover, number of patient-pressed bolus （D1） and of bolus delivered （D2） , the time to pass gas and adverse reactions were recorded.Results All the patients in the four groups were satisfied with the PCA device. At any given time points,there were no significant differences in Ramsay score among the 4 groups （P〉0.05）, VAS and D1/D2 among groups Ⅱ, Ⅲ and Ⅳ （P〉0.05）, whereas the VAS score in group Ⅰ was higher at 1, 2 and 4 hours （P〈0.05）compared to groups Ⅱ and Ⅲ. All the patients passed gas within 24 h, but the time to gas-passing was longer in group Ⅳ （19.1±2.5）h compared with group Ⅰ （16.5±3.9）h, group Ⅱ （16.2±3.8）h and groupⅢ （16.8±4.1 ）h （P〈0.05）. The total sufentanil use was similar in groups Ⅰ and Ⅱ[（36.7±5.1）μg vs （37.8±4.7）μg,P〉0.05], and was the highest in group Ⅲ （42.3±5.6） μg （P〈0.05）. There was no significant difference in adverse reactions among the four groups. Conclusions PCA- TCI of sufentanil in elderly patients for postoperative analgesia after TURP is effective and safe. Configurations of sufentanil analgesia with initial target plasma concentration being 0.08 μg/L and minimum effective concentration being 0.05 μg/L may result in lowest VAS and reduced dosage, which is favorable for stable blood circulation among the patients.