硬膜外不同用药超前镇痛临床观察及对儿茶酚胺的影响

EFFECTS OF PREEMPTIVE ANALGESIA WITH DIFFERENT ANAESTHETICS EPIDURAL ON POSTOPERATIVE PAIN AND CA RESPONSE

目的 :观察硬膜外吗啡、氯胺酮加吗啡行超前镇痛的临床效果及对儿茶酚胺的影响。方法 :4 5例患者随机分为 3组 ,硬膜外穿刺成功后经硬膜外导管注入吗啡 2mg(BM组 ) ,氯胺酮 10mg加吗啡 2mg(KT +M )组 ,对照组于术毕注入吗啡 2mg(AM组 )。术后患者需镇痛时肌注哌替啶 75mg/次。观察镇痛效果 ,检测血浆NE、E、DA及CA变化。结果 :BM组与AM组相比 ,除运动时VAS评分降低外 (P <0 .0 5) ,其余观察指标差异无显著性 ,KT +M组与AM、BM组相比 ,首次要求镇痛时间延长 (P <0 0 5) ,肌注派替啶次数减少 (P <0 .0 5) ,休息时VAS评分降低 (P <0 .0 5) ,运动时VAS评分与BM组相似。 3组患者儿茶酚胺含量术后第 1天均高于术前值 (P <0 .0 1) ,术后第 3天下降 ,KT +M组下降最明显 ,与术后第 1天差异有高度显著性 (P <0 .0 1) ,接近术前值 ;BM组和AM组儿茶酚胺变化相似 ,术后第 3天低于术后第 1天 (P <0 .0 5) ,但仍明显高于术前值 (P <0 .0 5)。结论 :硬膜外吗啡超前镇痛与吗啡术后镇痛临床效果差异无显著性 ,联合应用氯胺酮和吗啡行超前镇痛效果较好 ,氯胺酮能增强吗啡的超前镇痛作用 。

Objective:To investigate the effect of preemptive analgesia with epidural morphine and ketamine plus morphine, and to find out the influence of preemptive epidural analgesia on CA. Methods:45 patients for elective pelvic surgery with epidural lidocaine anesthesia were divided randomly into 3 groups.In one group, patients recieved 2mg of morphine (BMgroup). In another group 10mg of ketamine plus 2mg of morphine were given (KT+Mgroup) epidurally before operation. In the controll group,2mg of morphine were given epidurally at the end of surgery (AM group). After operation 75mg of pethedine was injected intramuscularly when needed. Pain scores at rest and at movement, additional analgesia requirement, and side effects were recored. Vence blood was tested for NE, E, DA before opereation and on the first and third day afrer operation. Results:Pereemptive analgesia with epidural morphine had no significant different compared with postoperative analgesia with morphine except for pain scores at movement (P< 0.05 ). The effect of preemptive analgesia in KT+M Group was better than in AM Group and BM Group. The first requirment after operation for analgesia was postponed (P<0.05), and the additional analgesitic requirement was less (P<0.05),Pain scores at rest was lower(P<0.05). but pain scores at movement were similar to those in BM Group. The first day afrter operation ,total of serum CA elevated in all three groups.(P<0.01). On the third day ,it remained higher than before operation in AM Group and BM Groups(P<0.05), but there was no sigeificant difference in KT+M Group(P<0.05). Conclusion:The effect of preemptive analgesia with epidural morphine alone was of no significant difference from that with epidural morphine given at the end of peration. Preemptive analgesia with epidural ketamine plus morphine could relieve pain better because Ketamine could potentiate the analgsic effect of morphine ,and ketamine plus morphine could effectively inhibit the stress response to postoperative pain.