曲马多或左旋布比卡因切口浸润对全身麻醉剖宫产术后疼痛的影响

Postoperative Analgesic Effects of Wound Infiltration with Tramadol or Levobupivacaine in Cesarean Delivery Patients

目的观察曲马多或左旋布比卡因切口浸润对全身麻醉剖宫产患者术后疼痛的影响。方法将美国麻醉医师学会(ASA)分组Ⅰ～Ⅱ级全身麻醉下急诊或择期剖宫产产妇90例,随机分为左旋布比卡因组(L组)、曲马多组(T组)及0.9%氯化钠注射液组(N组),每组30例。缝合腹直肌筋膜后,L组、T组、N组分别由手术医生沿切口皮下注射0.25%左旋布比卡因20 mL、曲马多1.5 mg/kg(以0.9%氯化钠注射液稀释至20 mL)、0.9%氯化钠注射液20 mL。产妇完全苏醒且能正确对答后即行患者自控静脉镇痛(PCIA)。每隔3 min分次静脉注射曲马多20 mg/kg作为负荷剂量,直至疼痛VAS不超过3 cm;PCIA参数设定为1%曲马多单次剂量2 mL(20 mg)、锁定时间15 min、背景剂量0.5 mL/h。静脉注射帕瑞昔布钠20～40 mg作为曲马多镇痛效果欠佳的补救措施。比较3组产妇苏醒后即刻、术后2,4,8,12,24 h 5个时间点产妇静息或运动状态疼痛VAS、24 h内曲马多用量、帕瑞昔布用量、术后瘙痒、呕吐、发热、切口感染等不良反应。结果 L组、T组产妇苏醒后即刻疼痛VAS分别为(4.6±1.3)cm,(4.5±1.3)cm,均低于N组的(7.7±1.8)cm(P<0.05),术后2,4,8,12,24 h疼痛VAS 3组相似(P>0.05);与N组相比,L组、T组24 h内曲马多用量明显减少(P=0.000 1),与L组相比,T组曲马多用量明显减少(P=0.007);3组产妇术后24 h内帕瑞昔布用量,以及瘙痒、呕吐、发热、切口感染等不良反应相似(P>0.05)。结论 0.25%左旋布比卡因及1.5 mg/kg曲马多切口浸润能有效降低全射麻醉剖宫产产妇苏醒期疼痛VAS、减少术后24 h内静脉曲马多用量,且不增加术后不良反应;与0.25%左旋布比卡因相比,曲马多切口浸润产妇术后曲马多用量更少。

Objective To assess the efficacy of wound infiltration with tramadol or levobupivacaine on postoperative analgesic in cesarean delivery patients. Methods ASA I - II 90 patients scheduled for emergency or elective cesarean section under general anesthesia were randomly allocated into one of the 3 groups. The levobupivacaine group（group L）received 20 mL local would infiltration with 0. 25% levobupivacaine,the tramadol group（group T）received 20 mL local would infiltration with 1.5 mg/kg tramadol within 0.9% saline solution,and the normal saline group（group N）received 20 mL local would infiltration with 0.9% saline solution. After closure of the uterine incision and the rectus fascia,20 mL solution was infiltrated subcutaneously along the skin wound edges. All patients received 1% tramadol PCIA for postoperative analgesia,and 20-40 mg intravenous parecoxib was used as an additional analgesic. The VAS at awake,and 2, 4, 8, 12, 24 h postoperative were recorded. The 24h tramadol consumption,parecoxib requirement,itching,vomiting,fever,wound infection were also recorded. Results At time of awake,VAS were lower in group T and group L than that in group N（ P〈0. 05）. Compared with group N,the 24 h tramadol consumption were lower in group T and group L （P=0. 0001）,Compared with groupL,the tramadol consumption was lower in group T（P=0.007）.There was no difference among groups regarding the rescue parecoxib doses and side effects such as itching,vomiting,fever, wound infection. Conclusion Wound infiltration with 1. 5 mg/kg tramadol and 0. 25% levobupivaeaine in patients having cesarean section under general anesthesia could decrease the VAS at awake time,and 24 h tramadol consumption postoperative. Furthermore, tramadol may be a better choice than levobupivacaine.