小剂量氯胺酮对地佐辛在经腹全子宫切除患者术后静脉自控镇痛效应的影响

Effect of low- dose ketamine on patient- controlled intravenous analgesia with dezocine after transabdominal hysterectomy

目的观察小剂量氯胺酮对地佐辛在经腹全子宫切除患者术后静脉自控镇痛效应的影响。方法妇科择期经腹全宫切除患者80例（ASAⅠ~Ⅱ级）,年龄30~55岁,随机分为4组,每组20例。D1组：地佐辛1.2mg/kg,D2~D4组分别给予1.0、0.8、0.6 mg/kg地佐辛复合氯胺酮3 mg/kg,各组镇痛药用生理盐水稀释至100m L注入镇痛泵。所有患者采取LCP模式给药：负荷量（地佐辛5 mg）＋维持量2.0 m L/h＋单次按压剂量1 m L,锁定时间10 min,镇痛24 h。观察和记录术后第1、2、4、8、16及24小时的VAS评分,PCA泵的按压次数（P＇1）及实际有效次数（P＇2）,Ramesay镇静评分,改良Bromage分级,肛门排气时间,可能发生的不良反应及患者对其镇痛效果的综合满意度。结果 4组患者术后各时点镇痛效果中,D2组在8、16、24 h时VAS评分低于D1组、D3组、D4组（P〈0.05）;4~24 h时段D2组P＇_1最少,P＇1/P＇_2比值D2组较小（P〈0.05）;恶心呕吐的发生率D2组高于D1组、D3组、D4组（P〈0.05）;D1组、D3组、D4组各时点均镇痛良好,VAS评分、P＇1/P＇2比值组间比较差异无统计学意义;4组患者24 h地佐辛的用量分别为D1组〉D2组〉D3组〉D4组（P〈0.05）,术后肛门恢复排气时间D4组快于D1组、D2组、D3组（P〈0.05）;而D1组、D3组、D4组综合满意度高于D2组（P〈0.05）。结论小剂量氯胺酮复合地佐辛术后静脉镇痛效果良好,能有效地减少地佐辛的用量,推荐氯胺酮3 mg/kg复合地佐辛0.6 mg/kg用生理盐水稀释至100 m L用于经腹全子宫切除患者术后静脉镇痛为首选方案。

Objective To investigate the effect of low- dose ketamine on patient- controlled intravenous analgesia with dezocine after transabdominal hysterectomy.Methods Eighty patients（ASA I- Ⅱ）,aged 35- 55 years and scheduled for elective transabdominal hysterectomy,were randomly assigned to four groups of 20 cases each.All patients received patient- controlled intravenous analgesia（PCIA） for 24 h after operation.The PCIA solution（100 mL NS） contained dezocine 1.2 mg/kg in Group D1.The PCIA solution（100 mL NS） contained combination of ketamine（3 mg/kg）with dezocine at 1.0,0.8 and 0.6 mg/kg in Groups D2,D3,D4,respectively.The intravenous PCA device was set to deliver 1 mL bolus dose with lockout intervals of 10 minutes and background infusion at 2 mL/h after a loading dose of 5mg of dezocine.VAS score,Ramsay sedation score,Bromage score,ratio of total number of attempts（P1＇） to times of effective delivery（P2＇） were recorded at 1 h,2 h,4 h,8 h,16 h and 24 h after operation.Side effects,time of first flatus,overall satisfaction of PCA were also recorded.Results The VAS score in Group D2 was lower than that in Groups D1,D3 and D4 at 8,16,24 h after initiation of PCIA（P〈0.05）.P1＇ and the ratio of P1＇/P2＇ in Group D2 were lower than Groups D1,D3 and D4 at 4- 24 h（P〈0.05）;The incidence of postoperative nausea and vomiting in Group D2 was significantly higher than that in Groups D1,D3 and D4（P〈0.05）.VAS score and P1＇/P2＇ were similar among Groups D1,D3 and D4（P〉0.05）.Comparing the total amount of dezocine administered via PCIA device during the 24 h after operation,Group D1 〉Group D2 〉Group D3 〉Group D4（P〈0.05）.Time of first flatus in Group D4 was significantly shorter than that in Groups D1,D2 and D3（P〈0.05）.The overall satisfaction of PCIA was significantly higher in Groups D1,D3 and D4 than that in Group D2（P〈0.05）.Conclusion The postoperative analgesia effect of combination of low-dose ketamine with dezocine is satisfactory,which significantly reduces the total dosage of dezocine.Ketamine at 3 mg/kg with dezocine at 0.6 mg/kg in 100 mL NS on PCIA is the preferred solution after transabdominal hysterectomy.