胸段硬膜外注射新斯的明用于肝部分切除术后镇痛的效果

Efficacy of Thoracic Epidural Injection of Neostigmine in Postoperative Analgesia after Partial Hepatectomy

目的：研究胸段硬膜外单次注射新斯的明用于肝部分切除术后镇痛的有效性。方法：将75例18～65岁、ASAⅠ～Ⅱ级、限期于硬膜外阻滞复合全麻下行开腹肝部分切除术的患者随机分为3组，每组25例，诱导前分别通过硬膜外导管给予0．9％氯化钠液稀释的新斯的明100μg（终体积5mL，N组）、0．9％氯化钠液稀释的吗啡2mg（终体积5mL，M组）或0．9％氯化钠液5mL（S组）。手术结束后，3组患者均接受同种模式的患者自控硬膜外镇痛。记录术中芬太尼用量、术后第1次按压镇痛泵的时间、术后24h和48h的视觉模拟评分法（visual analogue scale，VAS）评分、术后镇痛用药总量、有效按压次数、总按压次数，恶心呕吐和皮肤瘙痒发生情况以及第1次肛门排气时间。结果：3组术中芬太尼的用量差异无统计学意义（P〉0．05）。S组第1次按压镇痛泵的时间显著短于N组和M组（P〈0．05），N组显著短于M组（P〈0．05）。术后24h和48h时3组的VAS评分差异无统计学意义（P〉0．05），但S组镇痛药的用量显著多于N组和M组（P〈0．05）；在术后24h，S组有效按压次数与总按压次数比值显著低于N组和M组（P〈0．05）。3组恶心呕吐和肛门第1次排气时间差异无统计学意义，而M组术后24h皮肤瘙痒发生率显著高于N组和s组（P〈0．05）。结论：胸段硬膜外单次给予新斯的明100μg能显著减少肝部分切除术后镇痛药物的用量，但不增加恶心呕吐的发生率，不影响术后第1次肛门排气时间。与硬膜外注射吗啡相比，硬膜外注射新斯的明后患者的皮肤瘙痒的发生率较低。

Objective：To evaluate the efficacy of single bolus of thoracic epidural neostigmine for postoperative analgesia after partial hepatectomy. Methods： A total of 75 patients, aged from 18 to 65 years, in American Society of Anesthesiologists （ASA） physical status classes Ⅰ and Ⅱ who were scheduled for elective partial hepatectomy under general anesthesia combined with epidural block have been enrolled. Patients were randomized into three groups（25 cases in each group） to receive a 5mL bolus of neostigmine 100μg （Group N）, a 5 mL bolus of morphine 2 mg （Group M）, or a 5 mL bolus of 0.9% sodium chloride solution （Group S） via the epidural catheter before the induction of general anesthesia. At the end of the surgery, standardized patient-controlled epidural analgesia （PCEA） was given. Fentanyl dosage, time to first bolus of PCEA requirement, visual analogue scale（VAS） at 24 h and 48 h after the operation, postoperative analgesia consumption, and delivered/required number of boluses were recorded. Possible side effects were noted. Results： The intraoperative fentanyl consumptions were similar among the three groups. Time to first bolus of PCEA requirement was significantly shorter in Group S than in the other two groups （P〈0.05）, while that in Group N was significantly shorter than in Group M （P〈0.05）. There were no significant difference in VAS at 24 h and 48 h post-operation in the three groups. However, postoperative analgesic consumptions at 24 h and 48 h in Group S were significantly higher than those in the other two groups. Ratio of boluses delivered/ required was significantly lower in Group S than in Group N and Group M （P〈0.05）. There was no difference with regard to postoperative nausea-vomiting and the time to first flatus. There was significant difference with regard to postoperative pruritus in Group M compared with those in the other two groups （P〈0.05）. Conclusions： Thoracic epidural administration of neostigmine 100 μg enables less postoperative analgesic consumption after partial hepatectomy, without influence on the incidence of nausea-vomiting and time to first flatus. In contrast with epidural administration of morphine 2 mg, less pruritus was found when neostigmine 100 μg is used.