ERAS理念下不同手术患者静脉自控镇痛时间的探讨

Discussion on patient-controlled intravenous analgesia time with different operations under ERAS concept

目的通过对多模式镇痛(MMA)下不同手术患者使用静脉镇痛泵的时间与效果分析,探讨加速康复外科(ERAS)理念下患者静脉自控镇痛(PCIA)的合理使用时间。方法随机选择我院2017年1月至2018年1月采用MMA方案下使用PCIA的剖宫产手术患者(CS组,40例)、腹腔镜胆囊手术患者(LC组,40例)、经尿道前列腺电切手术患者(TURP组,40例)、全髋关节置换手术患者(THR组,40例),PCIA设定使用时间均为48 h。比较四组患者术后6、12、24、48、72 h各时间点静息及活动VAS评分,镇痛泵的有效按压次数和总按压次数,辅助镇痛药的使用情况以及术后并发症的发生情况。结果术后48、72 h,LC组和CS组的静息VAS及运动VAS评分均低于其他时间点(P<0.05)。术后72 h,THR组的静息VAS及运动VAS评分低于其它时间点(P<0.05)。TURP组5个时间点的静息VAS及运动VAS评分比较,差异无统计学意义(P>0.05)。术后0～12、12～24 h,四组患者PCIA镇痛泵有效按压次数及总按压次数比较,差异均无统计学意义(P>0.05)。术后24～48 h,TURP组和THR组PCIA镇痛泵总按压次数多于0～12、12～24 h(P<0.05)。术后24～48、48～72 h,LC和CS组术后辅助镇痛药使用率低于0～12、12～24 h(P<0.05)。术后48～72 h,THR组辅助镇痛药使用率低于其它3个时间段(P<0.05)。术后48～72 h时,TURP组辅助镇痛药使用率高于其它3个时间段(P<0.05)。LC组和CS组皮肤瘙痒发生率高于其它两组(P<0.05);CS组恶心呕吐的发生率高于其它三组(P<0.05)。结论ERAS理念下MMA方案中LC患者及CS患者PCIA时间可设定为术后24 h内,THR患者PCIA时间为术后48 h内,而TURP患者术后48 h内PCIA效果不好,应适当将PCIA时间延长至术后72 h内或更长。

Objective To discusse the rational use time of patient-controlled intravenous analgesia (PCIA) in the concept of enhanced recovery after surgery (ERAS) by analysing the time and effection of PCIA in patients with different operations under multimodal analgesia (MMA).Methods Cesarean section surgery patients (CS group,40 cases),laparoscopic cholecystectomy patients (LC group,40 cases),transurethral resection of prostate patients (TURP group,40 cases) and total hip replacement surgery patients (THR group,40 cases) in our hospital from January 2017 to January 2018 using the MMA program with PCIA were randomly selected.The time of PCIA was set as 48 h.The resting and active VAS scores at 6,12,24,48 and 72 h after operation,the effective compression times and the total compression times of the analgesic pumps,the use of auxiliary analgesics and the occurrence of postoperative complications of the four groups were compared.Results At 48 and 72 h after operation,the resting VAS and exercise VAS scores of the LC group and CS group were lower than those at other time points (P<0.05).At 72 h after operation,the resting VAS and exercise VAS scores in the THR group were lower than those at other time points (P<0.05).There were no significant differences in resting VAS and exercise VAS scores at 5 time points in the TURP group (P>0.05).At 0-12 and 12-24 h after operation,there were no significant differences in the number of effective compressions and total compressions among the four groups of patients with PCIA analgesia pump (P>0.05).At 24-48 h after operation,the total number of compressions of PCIA analgesia pump in the TURP group and THR group were more than those at 0-12 and 12-24 h (P<0.05).At 24-48 h and 48-72 h after operation,the use rates of adjuvant analgesics in the LC and CS group were lower than those at 0-12 and 12-24 h (P<0.05).At 48-72 h after operation,the use rate of adjuvant analgesic in the THR group was lower than that in the other three time periods (P<0.05).At 48-72 h after operation,the use rate of adjuvant analgesics in the TURP group was higher than that in the other three time periods (P<0.05).The incidence of pruritus in the LC group and CS group was higher than that in the other two groups (P<0.05).The incidence of nausea and vomiting in the CS group was higher than that in the other three groups (P<0.05).Conclusion Under the ERAS concept,the PCIA time of LC patients and CS patients in the MMA program can be set within 24 hours after surgery.The PCIA time of THR patients is within 48 hours after surgery,while the PCIA effect of TURP patients within 48 hours after surgery is not good,the PCIA time is extended to 72 hours after surgery or longer.