肋间神经阻滞联合羟考酮或吗啡用于胸腔镜手术患者术后镇痛的效果

Combination of intercostal nerve blockade and oxycodone or morphine for postoperative analgesia after thoracoscopic surgery

目的研究肋间神经阻滞(intercostal nerve blockade,INB)联合羟考酮或吗啡用于胸腔镜手术(VATS)患者术后镇痛的效果。方法选取2017年3月—2018年9月在中国人民解放军联勤保障部队第九〇四医院择期行VATS的患者90例,采用随机数字表法将患者分为INB联合羟考酮组(羟考酮组)和INB联合吗啡组(吗啡组),每组45例。两组均采用双腔管插管全凭静脉麻醉,在关闭胸腔前行INB,切口缝合前分别给予羟考酮0.03 mg/kg或吗啡0.03 mg/kg+帕洛诺司琼0.05 mg缓慢静脉推注。术后患者均行自控静脉镇痛(PCIA),分别给予羟考酮0.6 mg/kg或吗啡0.6 mg/kg+帕洛诺司琼0.2 mg,以0.9%氯化钠溶液100 mL稀释后静脉泵注。观察并记录两组患者的麻醉时长,术后4、12、24、48 h各时间点静息和咳嗽时的疼痛VAS评分、Ramsay镇静评分,术后48 h内PCIA的有效自控按压次数,以及术后呼吸抑制、头晕、恶心呕吐和皮肤瘙痒等不良反应的发生情况。结果羟考酮组患者术后12、24 h时静息和咳嗽时的疼痛VAS评分均显著低于吗啡组同时间点(P值均<0.05);两组患者术后各时间点Ramsay镇静评分的差异均无统计学意义(P值均>0.05);羟考酮组患者术后PCIA的有效自控按压次数显著少于吗啡组患者(P<0.05),恶心呕吐、皮肤瘙痒发生率均显著低于吗啡组患者(P值均<0.05)。结论VATS患者使用INB联合羟考酮行术后镇痛效果显著,无明显呼吸抑制,可减少患者PCIA使用次数,且能有效减少阿片类药物引起的不良反应,值得临床推广应用。

Objective To investigate the analgesic effect of oxycodone or morphine combined with intercostal nerve blockade(INB)after video-assisted thoracic surgery(VATS).Methods A total of 90 patients underwent selective VATS in our hospital from March 2017 to September 2018 and were randomly divided into two groups(45 each)according to random number table.Oxycodone combined with INB was assigned to group oxycodone and morphine combined with INB was assigned to group morphine.In both groups,patients were intubated with double-lumen tube and given total intravenous anesthesia.In addition,all patients received INB before chest closure and patient-controlled intravenous analygesia(PCIA)at the end of surgery.Patients in group oxycodone received oxycodone 0.03 mg/kg plus palonosetron 0.05 mg and patients in group morphine received morphine 0.03 mg/kg plus palonosetron 0.05 mg before skin closure.PCIA in group oxycodone used oxycodone 0.6 mg/kg plus palonosetron 0.2 mg and PCIA in group morphine used morphine 0.6 mg/kg plus palonosetron 0.2 mg,diluted to 100 mL with 0.9%NaCl solution.The duration of anesthesia,VAS scores at rest and on coughing,Ramsay scores in 4,12,24,48 h postoperatively,effective press frequency of PCIA during 48 h postoperatively,postoperative respiratory depression,dizziness,nausea,vomiting and pruritus were observed and recorded in the two groups.Results The VAS scores at rest and on coughing in group oxycodone at 12 h and 24 h after surgery were lower than those in group morphine(all P<0.05).There was no significant difference in the Ramsay scores of the two groups at each observation time point after surgery(all P>0.05).Effective press frequency of PCIA in group oxycodone was lower than that in group morphine(P<0.05).The incidence rates of nausea,vomiting and pruritus in group oxycodone were lower than that in group morphine(all P<0.05).Conclusion Oxycodone combined with INB has better analgesic effect in VATS patients.It can reduce the press frequency of PCIA without obvious respiratory depression and can effectively reduce the incidence of side effects of opioids,making it a better analgesic choice worthy of clinical application after VATS.