艾司洛尔对瑞芬太尼诱发的术后痛觉过敏的影响

The effects of esmolol on postoperative remifentanil-induced hyperalgesia

目的 研究腹腔镜宫颈癌根治术患者围术期静脉输注艾司洛尔对瑞芬太尼诱发的术后痛觉过敏的影响. 方法 将50例美国麻醉医师协会（ASA）分级Ⅰ～Ⅱ级择期行腹腔镜宫颈癌根治术的患者按随机数字表法分为两组（每组25例）：艾司洛尔组（Ⅰ组）于麻醉诱导前静脉注射艾司洛尔0.5 mg/kg,10 μg·kg-1·min-1维持输注至拔除气管导管即刻,对照组（Ⅱ组）给予等量生理盐水.术毕立即实施芬太尼静脉自控镇痛（patient controlled intravenous analgesia,PCIA）.测量术前疼痛阈值作为基础值,术后24 h和48 h重复测量,疼痛阈值为3个不同的围切口区疼痛阈值的平均值.记录麻醉诱导前（T0）、气管插管即刻（T1）、气管插管后5 min （T2）、拔除气管导管即刻（T3）、拔除气管导管后5 min （T4）患者的平均动脉压（mean arterial pressure,MAP）和心率（heart rate,HR）.记录患者术后30 min、6、24 h视觉模拟评分（visual analogue scale,VAS）,并记录术后24 h和48 h芬太尼的总用量. 结果 Ⅰ组疼痛阈值在术后24h[（3.21±0.23） kg/cm2]和术后48 h[（3.18±0.19） kg/cm2]均明显高于Ⅱ组相应时点的疼痛阈值[（2.69±0.21）、（2,62±0.20） kg/cm2]（P＜0.05）;Ⅰ组疼痛阈值在术后24h[（3.21 ±0.23） kg/cm2]和术后48 h[（3.18±0.19） kg/cm2]比术前基础值[（2.93±0.17） kg,/cm2]明显升高（P＜0.05）;Ⅱ组疼痛阈值在术后24 h[（2.69±0.21） kg/cm2]和术后48 h[（2.62±0.20） kg/cm2]比术前基础值[（2.91±0.18） kg/cm2]显著降低（P＜0.05）;Ⅰ组VAS评分在术后30 min[（4.56±1.36）分]、术后6 h[（3.64±1.32）分]和术后24 h[（2.52±1.08）分]明显低于Ⅱ组[（5.84±1.70）、（4.68±1.41）、（3.20±1.12）分]（P＜0.05）;Ⅰ组芬太尼的总用量在术后24 h[（0.53±0.03） mg]和术后48 h[（1.09±0.09） mg]低于Ⅱ组[（0.55±0.04）、（1.15±0.08）mg]（P＜0.05）. 结论 腹腔镜宫颈癌根治术患者围术期静脉输注艾司洛尔可能降低瑞芬太尼诱发的术后痛觉过敏,减少术后芬太尼的用量.

Objective To investigate the effects of peri-operative esmolol for patients undergoing laparoscopic radical hysterectomy of cervical cancer on remifentanil-induced hyperalgesia.Methods Fifty patients American Society of Anesthesiology （ASA） Ⅰ-Ⅱ undergoing laparoscopic radical hysterectomy of cervical cancer were randomly assigncd by a table of random numbers to two groups （n=25）.Before the induction of anesthesia,the group esmolol （group Ⅰ）,patients were administered 0.5 mg/kg esmolol,10 μg·kg-1·min-1 maintained to extubation,and the group control （group Ⅱ） patients received normal saline of the same volume.Anesthesia was induced with remifentanil 2 μg/kg,midazolam 0.05 mg/kg,etomidate 0.2 mg/kg,rocuronium 0.6 mg/kg,maintained with propofol 3 mg· kg-1· h-1-6 mg· kg-1· h-1 and remifentanil 0.15 μg· kg-1· min-1-0.5 μg· kg1· min-1,cisatracurium besilate for injection 0.1 mg·kg-1 ·h-1 in both groups.Thirty minutes before the expected end of surgery,1 μg/kg Fentanyl was administered intravenously.At the end of surgery,patients received fentanyl patient controlled intravenous analgesia （PCIA）.Peri-incisional pain thresholds were measured for baseline values before operation,at 24 h and 48 h repeated postoperatively.Pain thresholds were established by an detecting meter for pain threshold.The visual analogue scale （VAS） was assessed at 30 min,6,24 h after surgery.Total fentanyl consumption was recorded for 24 h and 48 h after surgery.Results peri-incision region pressure pain thresholds were obviously higher at 24 h [（3.21±0.23） kg/cm2] and 48 h [（3.18±0.19） kg/cm2] postoperatively in group Ⅰ than group Ⅱ [（2.69±0.21）,（2.62±0.20） kg/cm2] （P〈0.05）.In group Ⅰ,pain thresholds were higher at 24 h [（3.21±0.23） kg/cm2] and 48 h [（3.18±0.19） kg/cm2] postoperatively compared with preoperative baseline values [（2.93±0.17） kg/cm2] （P〈0.05）.Pain thresholds in group Ⅱ at 24 h [（2.69±0.21） kg/cm2] and 48 h [（2.62±0.20） kg/cm2] postoperatively were lower compared with preoperative baseline values [（2.91±0.18） kg/cm2].In group Ⅰ,the VAS scores at 30 min [（4.56±1.36） score],6 h [（3.64±1.32） score] and 24 h [（2.52± 1.08） score] postoperatively were significantly lower compared with group Ⅱ [（5.84± 1.70）,（4.68±1.41）,（3.20± 1.12） score] at all evaluation times （P〈0.05）.The fentanyl consumption was lower at 24 h [（0.53±0.03） mg] and 48 h [（1.09±0.09） mg] postoperatively compared with group Ⅱ [（0.55±0.04）,（1.15±0.08） mg] （P〈0.05）.Conclusions Peri-operative esmolol for patients undergoing laparoscopic radical hysterectomy of cervical cancer may attenuate remifentanil-induced hyperalgesia and reduce the required dosage of the postoperative fentanyl.