急性高容量血液稀释对行妇科手术患者帕瑞昔布钠预防性镇痛作用的影响

Effect of acute hypervolemic hemodilution on parecoxib preemptive analgesia in patients undergoing gynecologic laparotomy

目的探讨急性高容量血液稀释(AHH)对帕瑞昔布钠预防性镇痛作用的影响。方法收集择期在全身麻醉下行妇科开腹手术、美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级患者60例,年龄29~55岁,随机分入帕瑞昔布钠组、帕瑞昔布钠+AHH组、乳酸钠林格组,每组20例。患者入手术室后,帕瑞昔布钠组患者静脉注射帕瑞昔布钠40mg并静脉输注复方乳酸钠林格注射液10mL/kg,帕瑞昔布钠+AHH组患者静脉注射帕瑞昔布钠40mg并静脉输注6%羟乙基淀粉130/0.4注射液15mL/kg,对照组患者静脉输注复方乳酸钠林格注射液10mL/kg,均于30min内完成注射。然后静脉靶控输注丙泊酚和瑞芬太尼,设定血浆浓度分别为3μg/mL和3ng/mL,静脉注射维库溴铵0.12mg/kg行麻醉诱导。患者在关腹前静脉注射芬太尼2μg/kg。拔除气管导管后行疼痛视觉模拟评分(VAS评分),>5分者追加静脉注射芬太尼0.5μg/kg,每隔20min评估1次,直至术毕2h。分别在患者入手术室(T0)、气管插管前(T1)、划皮后即刻(T2)、术毕即刻(T3)、术毕2h(T4)各时间点,记录其心率(HR)、平均动脉压(MAP)的变化。并在各时间点测定血浆白细胞介素(IL)-6、肿瘤坏死因子(TNF)-α水平,在T0、T2时间点测定血常规。结果帕瑞昔布钠+AHH组在T2时间点的红细胞计数、血红蛋白水平、红细胞比容均显著低于同组T0时间点(P值均<0.05),且显著低于帕瑞昔布钠组和乳酸钠林格组同时间点(P值均<0.05)。帕瑞昔布钠组、帕瑞昔布钠+AHH组在T4时间点的血浆IL-6水平均显著低于乳酸钠林格组同时间点(P值均<0.05),且帕瑞昔布钠组显著低于帕瑞昔布钠+AHH组同时间点(P<0.05)。乳酸钠林格组术毕拔除气管导管后10min的疼痛VAS评分和术毕2h内静脉注射芬太尼追加量均显著高于帕瑞昔布钠组和帕瑞昔布钠+AHH组(P值均<0.05),且帕瑞昔布钠+AHH组均显著高于帕瑞昔布钠组(P值均<0.05)。结论 AHH对帕瑞昔布钠的预防性镇痛有一定的削弱作用。

Objective To investigate the effect of acute hypervolemic hemodilution （AHH） on parecoxib preemptive analgesia. Methods Sixty patients, American Society of Anesthesiologists （ASA） grade Ⅰ or Ⅱ , aged from 29 to 55 years, undergoing elective gynecologic laparotomy under general anesthesia were randomly divided into 3 groups （n = 20）, parecoxib group, parecoxib＋ AHH group and Ringer group. The patients were given intravenous parecoxib 40 mg （in the parecoxib group and parecoxib＋ AHH group） or normal saline 5 mL （in the control group） when they entered operation room. Then lactated Ringer＇s solution 10 mL/kg （in the parecoxib group and Ringer group） or hydroxyethyl starch （6% HES 130/0.4） 15 mg/kg were given within 30 minutes （in parecoxib＋ AHH group）. Anesthesia was induced by target-controlled infusion （TCI） of propofol 3 μg/mL and remifentanil 3 ng/mL. Tracheal intubation was facilitated with vecuronium 0. 12 mg/kg. The patients were given fentanyl 2 μg/kg before closing the peritoneum. After extubation, we scored the patients with visual analogue scale （VAS）. If VAS score was more than 5, the patients were given additionally fentanyl 0.5 μg/kg every 20 minutesuntil 2 hours after operation. Heart rate （HR）, mean artery pressure （MAP）, and plasma levels of interleukin 6 （IL-6） and tumor necrosis factor a （TNF-α） were recorded before entering operating room （T0）, before intubation （T1）, immediately afte incision （T2）, immediately after operation （T3）, and 2 hours after operation （T4）. The routine blood tests were performed at To and ＂I＂2. Results The values of red blood cell （RBC）, hemoglobin （Hb） and hematocrit （HOT） in the parecoxib＋ AHH group were significantly decreased at T2 as compared with those at To （all P〈0.05）; the three values in the parecoxib ＋ AHH group at T2 were significantly lower than those in the other two groups （all P〈0.05）. The plasma levels of IL-6 in both parecoxib group and parecoxib＋ AHH group at T4 were significantly lower than that in the Ringer group （both P〈0.05） ; the plasma level of IL-6 in the parecoxib group at ＂1＂4 was significantly lower than that in the parecoxib ＋ AHH group （P^0.05）. VAS score at 10 minutes after extubation and total fentanyl consumption in 2 hours after operation were significantly higher in the Ringer group than those in the parecoxib group and parecoxib＋ AHH group （all P〈0.05） ; the two values in the parecoxib ＋AHH group were significantly higher than those in the parecoxib group （both P〈0.05）. Conclusion Acute hypervolemic hemodilution can attenuate parecoxib preemptive analgesia. （Shanghai Med J, 2014, 37= 1004- 1007）