右美托咪定混合地佐辛和左布比卡因用于剖宫产术后病人自控硬膜外镇痛的效果

Efficacy of dexmedetomidine mixed with dezocine and levobupivacaine for patient-controlled epidural analgesia after cesarean section

目的评价右美托咪定混合地佐辛和左布比卡因用于剖宫产术后病人自控硬膜外镇痛（PCEA）的效果。方法择期硬膜外麻醉下行剖宫产术病人300例，年龄23—35岁，BMI24～28kg／m2，ASA分级I或Ⅱ级。采用随机数字表法，将其分为3组（n=100），术后行PCEA，吗啡和左布比卡因组（ML组）：负荷剂量为吗啡2mg＋左布比卡因10mg＋生理盐水共5ml，PCEA泵配方为吗啡5mg＋左布比卡因150mg＋生理盐水共100ml；地佐辛和左布比卡因组（DL组）：负荷剂量为地佐辛3mg＋左布比卡因10mg＋生理盐水共5ml，PCEA泵配方为地佐辛15mg＋左布比卡因150mg＋生理盐水共100ml；右美托咪定、地佐辛和左布比卡因组（DDL组）：负荷剂量为地佐辛2mg＋左布比卡因10mg＋右美托咪定0．5txg／kg＋生理盐水共5ml，PCEA泵配方为地佐辛7．5mg＋左布比卡因150mg＋右美托咪定1．5μg／kg＋生理盐水共100ml。手术结束前10min经硬膜外导管给予负荷剂量后连接PCEA泵，背景输注速率2ml／h，PCA剂量2ml，锁定时间15min，镇痛至术后42h，维持VAS评分≤3分和（或）视觉模拟疲劳评分≤2分，当PCEA失败时，硬膜外注射吗啡2mg进行补救镇痛。分别于术后4、8、24、42h时记录改良Bromage评分和Ramsay评分，并评估病人镇痛满意度。记录硬膜外镇痛有关不良反应发生情况。结果与DL组比较，ML组和DDL组PCEA药液消耗量与补救镇痛率降低，DDL组镇痛满意度升高，头晕和尿潴留的发生率降低（P〈O．05）。与ML组比较，DL组和DDL组术后4、8h时Ramsay评分降低，镇痛满意度升高，恶心、呕吐、头晕和皮肤瘙痒的发生率降低，DDL组尿潴留发生率降低（P〈0．05）。3组未见硬膜外镇痛有关低血压、心动过缓和呼吸抑制。结论右美托咪定混合地佐辛和左布比卡因用于剖宫产术后PCEA的效果好，不良反应少。

Objective To evaluation the efficacy of dexmedetomidine mixed with dezocine and levobupivacaine for patient-controlled epidural analgesia （PCEA） after cesarean section. Methods A total of 300 patients, aged 23-35 yr, with body mass index of 24-28 kg/m2 , of American Society of Anes- thesiologists physical status I or 11 , undergoing elective cesarean section under epidural anesthesia, were randomly divided into 3 groups （n = 100 each） according to the random number table： morphine and levobupivacaine group （ML group）, dezocine and levobupivacaine group （DL group） , and dexmedetomi- dine, dezocine and levobupivacaine group （DDL group）. In group ML, the loading dose included morphine 2 mg ＋ levobupivacaine 10 mg ＋ 5 ml normal saline, and PCEA solution contained morphine 5 mg＋ levobupivacaine 150 mg ＋ normal saline 100 ml. In group DL, the loading dose included dezocine 3 mg ＋ levobupivacaine 10 mg ＋ normal saline 5 ml, and PCEA solution contained dezocine 15 mg ＋ levobupivacaine 150 mg ＋ normal saline 100 ml. In group DDL, the loading dose included dezocine 2 mg ＋ levobupivacaine 10 mg ＋ dexmedetomidine 0.5 μg/kg ＋ normal saline 5 ml, and PCEA solution contained dezocine 7.5 mg ＋ levobupivacaine 150 mg ＋ dexmedetomidine 1.5 μg/kg ＋ normal saline 100 ml. At 10 min before the end of operation, the loading dose was given via the epidural catheter, and the PCEA pump was connected and set up to deliver a 2 ml bolus dose with a 15-min lockout interval and background infu- sion at 2 ml/h. Analgesia was maintained until 42 h after operation. Visual analog scale score was main- tained ≤ 3, and （or） visual analog scale for fatigue score ≤ 2. When PCEA failed, morphine 2 mg was injected epidurally as rescue analgesic. At 4, 8, 24 and 42 h after operation, the modified Bromage score and Ramsay sedation score were recorded, and patients＇ satisfaction with analgesia was evaluated. The occurrence of epidural analgesia-related adverse reactions was recorded. Results The consumption of PCEA solution and requirement for rescue analgesics were significantly lower in group ML than in group DL. Compared with group ML, Ramsay sedation score was significantly decreased at 4 and 8 h after operation, the degree of patients＇ satisfaction with analgesia was increased, and the incidence of nausea, vomiting, dizziness and pruritus was decreased in DL and DDL groups, and the incidence of urinary retention was de- creased in group DDL. The degree of patients＇ satisfaction with analgesia was significantly higher, and the incidence of dizziness and urinary retention was lower in DDL group than in group DL. No patients devel- oped epidural analgesia-related hypotension, bradycardia, or respiratory depression in the three groups. Conclusion The efficacy of dexmedetomidine mixed with dezocine and levobupivacaine is good when used for PCEA after cesarean section, and the adverse reactions are fewer.