硬膜外和皮下病人自控镇痛对胸部手术后呼吸功能的影响

The effects of patient-controlled epidural and subcutaneous analgesia on pulmonary function after chest operation

目的 探讨硬膜外和皮下病人自控镇痛两种方法对胸部手术后病人呼吸功能的影响。方法 3 6例ASAⅠ～Ⅲ级胸部手术全麻病人根据术后镇痛方法不同 ,随机分为 3组 :Ⅰ组 :对照组 (12例 ) ;Ⅱ组 :硬膜外病人自控镇痛组 (12例 ) ;Ⅲ组 :皮下病人自控镇痛组 (12例 ) ,分别于术前 (T1 )、术后 4h(T2 )、2 4h(T3)、48h(T4 )及 72h(T5)监测呼吸频率 (RR)、潮气量 (VT)、分钟通气量 (MV)、脉搏氧饱和度 (SpO2 ) ,抽动脉血测动脉氧分压PaO2 、动脉二氧化碳分压PaCO2 ,并于术后 3d内观察病人的咳嗽、咯痰反射及疼痛评分。结果 Ⅱ组病人的VT、SpO2 、PaO2 在术后明显低于Ⅲ组病人 (P <0 .0 5或 0 .0 1)。而RR、PaO2 在术后明显高于Ⅲ组病人 (P <0 .0 5或 0 .0 1)。而Ⅱ、Ⅲ组病人的咳嗽、咯痰反射和疼痛评分差异无显著性 (P >0 .0 5 ) ,并明显优于Ⅰ组病人 (P <0 .0 1)。结论 皮下病人自控镇痛不仅能达到硬膜外病人自控镇痛的镇痛效果 ,而且对全麻下胸部手术后病人的呼吸功能的抑制明显低于硬膜外术后镇痛。

Objective To compare the analgesic effects between the patient controlled epidural analgesia and patient controlled subcutaneous analgesia on pulmonary function of chest postoperative patients.Methods Thirty six ASA Ⅰ～Ⅲ patients undergoing general anesthesia and chest operation,according to different postoperative pain relief, were randomly divided into three groups:control group (group 1,12 cases);patient controlled epidural analgesia (PCEA) group(group 2,12 cases);patient controlled subcutaneous analgesia (PCSA) group (group 3,12 cases).All the patients in three groups were premeditated with intramuscular atropine 0.5 mg,phenobarbital 0.1 g and pethidine 50 mg.Anesthesia was induced with midazolam 0.1 mg/kg,propofol 1 mg/kg and fentanyl 5～10 μg/kg,maintained with inhalation of enflurane(or isoflurane),combined with intravenous pancuronium and fentanyl.The patients in group 1 didn't use postoperative analgesia;patients in group 2 used patient controlled epidural analgesia;patients in group 3 used patient controlled subcutaneous fentanyl analgesia.The respiratory rate (RR),tidal volume (V T),minute ventilation(MV),pulse oxygen saturation (SpO 2),and blood gas (including PaO 2 and PaCO 2) were measured before operation (T 1) and 4 h,24 h,48 h,72 h after operation(T 2,T 3,T 4,T 5).The cough and expectorant reflexes and pain scores were observed in 3 days after operation.Results V T,SpO 2 and PaO 2 of patients in group 2 decreased significantly,as compared with that in group 3 after operation (P<0.05 or 0.01),and RR,PaCO 2 in group 2 increased significantly,as compared with that in group 3 patients after operation(P<0.05 or 0.01).There were no significant differences in patients'cough,expectoration reflexes and pain scores between group 2 and group 3 (P>0.05),but the indexes in the two groups were superior to that in group 1(P<0.01).Conclusion The analgesia effects are similar between patient controlled subcutaneous fentanyl analgesia and patient controlled epidural analgesia.The inhibition effect of patient controlled subcutaneous fentanyl analgesia on pulmonary function after chest operation is lower than that of patient controlled epidural analgesia.