氢吗啡酮替代吗啡改善术后镇痛的效能

Efficacy of Morphine Rotation to Hydromorphone in Postoperative Analgesia

【目的】调研氢吗啡酮应用于术后镇痛的效能。【方法】择期ASAⅠ-Ⅱ级肝胆或胃肠开腹手术120例,手术后随机双盲等分为4组,每组30例,根据术后镇痛方法分为静脉氢吗啡酮组（VH）、静脉吗啡组（VM）、硬膜外氢吗啡酮组（EH）、硬膜外吗啡组（EM）。VH组首剂量生理盐水5 mL＋氢吗啡酮0.4 mg,维持为生理盐水100 mL＋氢吗啡酮3.6 mg;VM组首剂量生理盐水5 mL＋吗啡2 mg,维持为生理盐水100 mL＋吗啡18 mg;EH组首剂量0.25%罗派卡因5 mL＋氢吗啡酮0.4mg,维持为0.125%罗派卡因100 mL＋氢吗啡酮1.6 mg;EM组首剂量0.25%罗派卡因5 mL＋吗啡2 mg,维持为0.125%罗派卡因100 mL＋吗啡8 mg,所有镇痛泵速度2 mL/h,镇痛48 h。围术期监测呼吸、循环、镇静、镇痛效果及不良反应。【结果】所有患者均顺利完成手术安返病房,术后镇痛满意度达98%,Ramsey镇静评分均为2～3分,属于满意镇静。VH组镇痛后12 h、24 h、48 h时与镇痛前SPO2比较下降,P〈0.05;VM组镇痛后2 h Sp O2较镇痛前下降,P〈0.05;VH组镇痛后48 h R-VAS评分较镇痛后6 h下降,P〈0.05;VH组镇痛后24 h、48 h M-VAS评分较镇痛后2 h、6 h下降,P〈0.05;VM组镇痛后6 h MVAS评分较镇痛后2 h下降,P〈0.05。EH组镇痛后2、6、12、24、48 h较镇痛前SBP下降,P〈0.05;EH组镇痛后12、24、48 h较镇痛前HR增快,P〈0.05;EH组镇痛后6、12、24、48 h较镇痛前SPO2下降,P〈0.05;EH组镇痛后48 h M-VAS评分较镇痛后2 h下降,P〈0.05。EH组镇痛后24 h、48 h时DBP较VH组下降,P〈0.05;VH组镇痛后12～48 h Sp O2较镇痛前下降,P〈0.05。四组术后恶心、呕吐的发生率无明显差异（P〈0.05）,硬膜外用药组瘙痒发生率均高于静脉用药组,P〈0.05;EM组和VH组嗜睡发生率均多于EH组,P〈0.05;EM组和VM组头晕发生率分别多于EH组和VH组,P〈0.05。【结论 】氢吗啡酮可以代替吗啡,无论静脉与硬膜外应用都能取得良好的术后镇痛效果,氢吗啡酮的副作用相对少于吗啡,值得临床推广应用。

[ Objective] To investigate the efficacy of hydromorphone in postoperative analgesia. [Methods] Selected 120 patients undergoing hepatobiliary or gastrointestinal surgery of ASA I-II levels , were randomly and double-blindly divided into four groups （n = 30 each）：VH group patients were treated by a bolus dose of normol saline 5 mL and hydromorphone 0.4 rag, continuously intravenous infusion with normal saline 100 mL and hydromorphone 3.6 nag; VM group were treated by a bolus dose normol saline 5 mL and morphine 2 rag, continuously intravenous infusion with normal saline 100 mL and morphine 18 mg; EH group were treated by a bolus dose of 0.25 % ropivacaine 5 mL and hydromorphone 0.4 nag, continuously epidural pumping with O. 125% ropivacaine 100 mL and hydromorphone 1.6 rag; EM group were treated by a bolus does 0.25% ropivacaine 5 mL and morphine 2 rag, continuously epidural pumping with 0.125% ropivacaine 100 mL and morphine 8mg. All the analgesia pump speed 2 mL/h during 48 h. Then the respiration, circulation, sedation, pain scores and side effects were perioperatively monitored in all groups. [Result] Postoperative analgesia satisfaction reached 98%. Ramsey＇s Sedation Scales are 2-3 scores belong to satisfied with sedation. SpO2 was significantly lower at 12, 24, 48 h after analgesia than that before analgesia in VH group （P 〈 0.05） ; SpO2 was significantly lower at 2 h after analgesia than that before analgesia in VM group （P 〈 0.05） ; R-VAS was significantly lower at 48 h than that at 6h after analgesia in VH group （P〈 0.05） ; M-VAS was significantly lower at 24 h, 48 h than that at 2 h, 6 h after analgesia in VH group （P〈 0.05） ; M- VAS was significantly lower at 6h than that at 2h after analgesia in VM group （P 〈 0.05） ; Compared with SBP before analgesia, there was significantly decrement at 2, 6, 12, 24, 48 h after analgesia in EH group （P 〈 0.05） ; HR was significantly higher at 12, 24, 48 h after analgesia than that before analgesia in EH group （P 〈 0.05） ; SpO2 was significantly lower at 6, 12, 24, 48 h after analgesia than that before analgesia in EH group （P 〈 0.05） ; M-VAS was significantly lower at 48 h than that at 2 h after analgesia in EH group （P 〈 0.05） ; Compared with DBP of VH group, there was significantly decrement at 24 h,48 h after analgesia in EH group （P 〈 0.05）. There was no signify difference in the rate of nausea and vomiting among four group （P 〉 0.05）. The incidence of pruritus in epidural group was higher than that in patients with intravenous administration （P 〈 0.05）. The rate of drowsiness in EM group and VH group was higher than that of EH group （P 〈 0.05）. The rate of dizzy in EM group and VM group was respectively higher than that of EH group and VH group （P 〈 0.05）. [Conclusion] This study found hydromorphone to be at least as effective as morphine when delivered by continuous intravenous or epidural infusion in postoperative analgesia, and side effects may be less.