帕瑞昔布钠复合吗啡多模式镇痛对老年患者术后谵妄的影响

Influence of Parecoxib combined with Morphine on delirium incidence in elderly patients

目的观察帕瑞昔布钠复合吗啡多模式镇痛对老年患者术后谵妄发生率的影响。方法成组设计的前瞻性研究。择期全身麻醉下行胸科、普外科或骨科手术的患者560例，年龄60～85岁，采用分层区组随机方法，以手术类型（胸科、普外科或骨科手术）作为分层因素，随机分为帕瑞昔布钠复合吗啡多模式镇痛组（多模式镇痛组）或单纯吗啡镇痛组（吗啡镇痛组）。两组患者术后均连接吗啡静脉患者自控镇痛泵，多模式镇痛组患者于手术结束前静脉注射帕瑞昔布钠40mg，之后72h内给予帕瑞昔布钠40mg每12h静脉注射，吗啡镇痛组患者同时点给予等剂量生理盐水静脉注射。观察术后5d内谵妄发生率，采用监护病房意识模糊评估量表（CAM—Icu）、术后第1、2、3天疼痛视觉模拟评分（VAS）、吗啡用量及不良反应发生情况。结果术后5d内257例多模式镇痛组患者谵妄发生率4．3％（11例），250例吗啡镇痛组为6．8％（17例），两组差异无统计学意义（P〉0．05）。与吗啡镇痛组患者比较，多模式镇痛组患者术后第1～3dVAs评分降低（P〈0．01），吗啡用量、恶心呕吐发生率降低（P〈O．05）。结论老年患者术后行帕瑞昔布钠复合吗啡多模式镇痛可有效降低术后疼痛程度及吗啡用量，降低术后恶心呕吐发生率，但对老年患者术后谵妄发生率无明显影响。

Objectives To investigate the influence of multimodel analgesia of Pareeoxib combined with Morphine on delirium in elderly patients. Methods Patients aged 60-85 years scheduled for thoracic surgery,general surgery or orthopedic surgery were randomized into Parecoxib combined with Morphine group （PM group）or Morphine alone group （M group）. All patients in two groups received the same regimen of Morphine for patient controlled intravenous analgesia（PCIA）after operation. Patients in PM group received the first dose of Pareeoxib 40 mg at the end of surgery, and then received pareeoxib 40 nag per dose at 12-hour interval until postoperative 72 hours. Patients in M group received normal saline instead of Parecoxib. Incidence rate of delirium was evaluated during 1st to 5th postoperative day（confusion assessment method for the intensive are unit）. The visual analogue seore（VAS）, daily morphine consumption, presence of nausea and vomiting （PONV）, Blood urea nitrogen, serum creatinine, alanine aminotransferase, aspartate aminotransferase, prothrombin time, activated partial throboplastin time,and international normallized ratios on 1st to 3rd postoperative day were recorded and compared between the two groups. Results The delirium incidence during 5 days after operation was 4.3 G （ 11/257） in PM group, and 6.8%（ 17/250 ） in morphine alone group （ P〉0.05）. From 1st to 3rd postoperative day,PM group versus M group showed that VAS was lower（P〈0.01 ）, consumption of Morphine was lower（P〈0.05 ）, incidence of PONV was lower （P〈0.05 ）. Conclusions Parecoxib combined with morphine used in the elderly patients improves postoperative analgesia,reduces morphine consumption and incidence of PONV, but has no significant effect on delirium incidence.