右美托咪定联合舒芬太尼用于老年患者全髋关节置换术后自控静脉镇痛

Clinical study of administration of dexmedetomidine combined sufentanil for postoperative analgesia in senile patients with total hip replacement

目的 探讨右美托咪定（dexmedetomidine,Dex）联合舒芬太尼用于老年患者全髋关节置换术后患者自控静脉镇痛（patients controlled infusion analgesia,PCIA）的临床安全性和有效性. 方法 采用随机数字表法将90例择期行全髋关节置换手术的患者（年龄65～89岁,ASA分级Ⅰ～Ⅲ级）分为3组（每组30例）.各组PCIA药物：舒芬太尼组（S组）,舒芬太尼0.04μg· kg^-1 ·h^-1＋托烷司琼5 mg;Dex 1组（D1组）,舒芬太尼0.04 μg· kg^-1·h^-1＋托烷司琼5 mg＋Dex 0.02 μg·kg^-1·h^-1;Dex 2组（D2组）,舒芬太尼0.04 μg·kg^-1·h^-1＋托烷司琼5 mg＋Dex 0.05μg·kg^-1·h^-1;各组药物均用生理盐水稀释至150 ml.所有患者麻醉方式均采用蛛网膜下腔阻滞,穿刺间隙L3～L4.手术结束前10 min,均静脉注射5μg舒芬太尼,术后连接镇痛泵.记录手术和麻醉时间,术中出血量,副作用的发生率,镇痛总体舒适度评分（Bruggrmann comfort scale,BCS）,术后4、8、12、24、48 h VAS评分和Ramsay镇静评分,镇痛48 h后各组单位体重下舒芬太尼的消耗量. 结果 术后8、12、24、48 h,S组Ramsay评分[（1.7±0.5）、（1.6±0.6）、（1.6±0.5）、（1.8±0.5）分]低于D1组[（2.2±0.6）、（2.0±0.5）、（2.2±0.5）、（2.2±0.5）分]和D2组[（2.3±0.5）、（2.3±0.4）、（2.4±0.5）、（2.3±0.5）分]（P＜0.05）;D1组和D2组比较,差异无统计学意义（P＞0.05）.术后12、24 h,D1组VAS评分[（0.7±0.8）、（0.7±0.8）分]低于S组[（1.3±1.1）、（1.4±1.0）分]（P＜0.05）;术后8、12、24、48 h,D2组VAS评分[（0.8±0.6）、（0.8±0.6）、（0.6±0.7）、（0.7±0.7）分]明显低于S组（P＜0.01）.镇痛48 h后,D1组BCS评分[（3.2±0.7）分]明显高于S组[（2.1±0.5）分]（P＜0.01）,D2组BCS评分[（3.6±0.6）分]高于S组与D1组（P＜0.05）;S组[（2.02±0.10） μg/kg]舒芬太尼消耗量大于D1组[（1.96±0.61）μg/kg]和D2组[（1.94±0.39） μg/kg]（P＜0.05）,D1组和D2组比较,差异无统计学意义（P＞0.05）. 结论 Dex0.05μg·kg^-1·h^-1联合舒芬太尼0.04 μg·kg^-1·h^-1 PCIA用于老年患者髋关节置换术后有较好的术后镇痛效果,且降低了舒芬太尼的消耗量,临床应用安全、可行、有效.

Objective Exploring the suitable protocol of dexmedetomidine （Dex） combined sufentanil intravenous infusion for controlled infusion analgesia（PCIA） in senile patients with total hip replacement.Methods The ninety elderly patients（65-89 y）,ASA Ⅰ-Ⅲ,with total hip replacement were randomly divided into 3 groups（n=30）.Group of sufentanil（group S）：sufentanil 0.04 μg·kg^-·h^-1 and tropisetron 5 mg,group of Dex 1 （group D1）：sufentanil 0.04 μg·kg^-1·h^-1,tropisetron 5 mg and Dex 0.02 μ,g·kg^-1 ·h^-1,group of Dex 2 （group D2）：sufentanil 0.04 μg·kg^-1· h^-1,tropisetron 5 mg and Dex 0.05 μg· kg^-1· h^-1,drugs in all groups were dissolved in sterile saline solution with total volume 150 ml.All patients＇ anesthesia were performed by spinal block in L3-L4 Sufentanil with 5 μg intravenous injection was administrated in all of groups 10 min before the end of operation.The time of operation and anesthesia,amount of bleeding during operation,the incidence of adverse reactions （pruritus,nausea and emesis） for postoperative analgesia,the Bruggrmann comfort scale （BCS） scores,and the consumptions of sufentanil for 48 h analgesia were recorded.In addition,VAS scores and Ramsay scores were also recorded at postoperative 4,8,12,24,48 h.Results At the 8-48 h after operation,Ramsay scores of group S[（1.7±0.5）,（1.6±0.6）,（1.6±0.5）,（1.8±0.5）] were lower than Ramsay scores of group D1[（2.2±0.6）,（2.0±0.5）,（2.2±0.5）,（2.2±0.5）] and group D2[（2.3±0.5）,（2.3±0.4）,（2.4±0.5）,（2.3±0.5）] （P〈0.05）.Ramsay scores of group D1 showed no significant difference with Ramsay scores of group D2.VAS scores of group D1 [（0.7±0.8）,（0.7±0.8）] were lower at the 12 h and 24 h after operation than VAS scores of group S[（1.3±1.1）,（1.4±1.0）]（P〈0.05）.But VAS cores of group D2[（0.8±0.6）,（0.8±0.6）,（0.6±0.7）,（0.7±0.7）] were lower at 8-48 h than VAS scores of group S（P〈0.05）.In addition,BCS score for 48 h analgesia,group D1 （3.2±0.7） was higher than score of group S（2.1±0.5）（P〈0.01）.BCS score of group D2（3.6±0.6） was significantly higher than scores of all of group S and group D1 （P〈0.05）.The consumption amount of sufentanil for 48 h analgesia of group S [（2.02±0.10） μg/kg] was apparently much compared with group D1[（1.96±0.61） μg/kg] and group D2 [（1.94±0.39） μg/kg]（P〈0.05）.Consumption amount of sufentanil of group D2 had no significant difference with consumption amount of sufentanil of group D1.Conclusions The protocol of Dex 0.05 μg·kg^-1·h^-1 combined with sufentanil 0.04 μg· kg^-1· h^-1 intravenous infusion for postoperative analgesia in elderly patients with total hip replacement has better analgesic effect,greater patient satisfaction,and reduces the total consumption amount of sufentanil.It is a safe and feasible clinical application.