不同多模式镇痛策略对腹腔镜手术后疼痛的影响

Effect of different multimodal analgesia methods on postoperative pain after laparoscopic surgery

目的评估切口局部罗哌卡因浸润配合帕瑞昔布钠或肺复张手法对术后切口疼痛和肩痛的影响。方法 90例全麻下行妇科腹腔镜手术的患者随机均分为三组:A组诱导前静脉注射帕瑞昔布钠40mg,建立气腹前切口局部0.5%罗哌卡因浸润(20ml),术毕按传统手法放气腹;B组静脉注射等量生理盐水,切口局部0.5%罗哌卡因浸润(20ml),术毕放气腹前实施肺复张手法;C组静脉注射等量生理盐水,切口局部0.5%罗哌卡因浸润(20ml),术毕按传统手法放气腹。记录患者在恢复室内(术后0h)和术后2、4、8、12、24和48h的切口疼痛和肩痛的评分以及相关不良反应。结果A和B组患者术后0h的切口静态和动态NRS评分明显低于C组,术后12hA组切口动态和静态明显低于C组(P<0.05或P<0.01);术后4、24hB组患者的切口动态和静态NRS评分明显低于C组(P<0.05或P<0.01)。术后12hA组患者的双侧肩NRS评分明显低于C组,术后24h A和B组患者的左侧肩NRS评分低于C组(P<0.05或P<0.01)。结论与单独应用切口局部罗哌卡因浸润相比,联合应用帕瑞昔布钠或放气腹时应用肺复张手法这两种多模式镇痛策略均可显著降低腹腔镜术后的腹部切口疼痛和肩痛程度。

Objective To evaluate the combined effect of local infiltration of ropinvocaine and parecoxib sodium application,or with pulmonary recruitment manoeuvre （RM）,on postoperative incisional pain and shoulder pain in patients undergoing gynecological laparoscopy.Methods Ninety patients undergoing elective gynecological laparoscopy were randomly allocated into three groups.Patients in group A were premedicated with 40 mg parecoxib sodium （diluted with 2 ml normal saline）,and 0.5％ ropivacaine （20 ml） were infiltrated around the incision site before establishment of CO2 pneumoperitoneum.Abdominal CO2 was evacuated through trocars at the end of surgery.Patients in group B received 2 ml normal saline intraveniously before anesthesia induction,and infiltration of 0.5％ ropivacaine （20 ml） were also applied as group A.The evacuation of CO2 was achieved by pulmonary RM.Patients in group C were treated the same way as in group B,but the abdominal CO2 evacuation was performed in the usual fashion as in group A.The intensity of postoperative incisional pain and shoulder pain were recorded and evaluated at 0,2,4,8,12,24 and 48 h after surgery.Other related adverse effects were also noted.Results Compared with group C,the static pain and dynamic pain at 0 h after operation were alleviated in groups A and B （P＜0.05 or P＜0.01）.Compared with group C,the numerical rating scales（NRS）of incisional static and dynamic pain in group A were lower at 12 h postoperatively.The NRS of incisional static and dynamic pain of group B were decreased in group C 4 and 24 h after operation.The shoulder pain of group A were lessened than in group C at 12 h after operation.The NRS of left shoulder pain of group A at 24 h after operation was lower than that in group C （P＜0.05 or P＜0.01）.Conclusion Compared with incisional infiltration of ropinvocaine alone,combined application of parecoxib sodium or pulmonary RM could significantly reduce the incidence of postoperative shoulder pain and incisional pain in patients undergoing gynecological laparoscopy.