序贯式多模式镇痛在甲状腺癌功能性颈部淋巴结清扫术加速康复中的应用

Application of sequential multimodal analgesia in the accelerated rehabilitation of functional neck lymphadenectomy for thyroid cancer

目的:探讨序贯式多模式镇痛对甲状腺癌功能性颈部淋巴结清扫术患者的镇痛效果、费用、恢复指标及并发症的影响。方法:选取甲状腺癌颈部淋巴结清扫术患者88例,采用随机数表将88例患者分为序贯式多模式镇痛组(D组)和传统单一模式镇痛组(T组),每组各44例。D组镇痛方案为:麻醉诱导时给予盐酸帕瑞昔布钠40 mg超前镇痛;插管前在气管导管前端1/3处涂抹1%达克罗宁胶浆2 mL;手术前在B超引导下行双侧颈浅丛阻滞,手术缝合切口前,由外科医生直视下在患侧胸锁乳突肌中点后缘的外侧下方,埋入22G静脉留置套管针于颈浅丛神经点处,对侧在缝合切口后,B超引导下埋入套管针,并追加一次局麻药,术后6 h通过埋入颈浅丛的留置套管再追加一次局麻药并拔除套管针;术后12 h开始口服氨酚羟考酮片。T组镇痛方案为:无超前镇痛,直接缝合切口,术后使用静脉自控镇痛PCIA(地佐辛40 mg+舒芬太尼50μg+托烷司琼4 mg)。分别于术后1、6、12、24 h采用静息与运动疼痛视觉模拟评分法(visual analogue scale,VAS)评价两组患者的镇痛效果;测定两组患者术前、术后24 h的血清IL-6浓度;记录术中瑞芬太尼总量、首次下床时间、首次进食流质时间、住院天数、镇痛费用、自评舒适度(Bruggrmann Comfort Scale,BCS)及不良反应发生率等评价指标。结果:D组患者术后1、6、12、24 h的静息疼痛VAS评分与T组同时间点比较,差异无统计学意义(P>0.05),但颈部活动疼痛VAS评分各同时间点均显著低于传统单一模式镇痛组(P<0.05);术中瑞芬太尼用量、镇痛费用均显著少于T组(P值均<0.05);术后首次下床时间、首次进食流质时间、自评舒适感均显著优于T组(P值均<0.05);两组患者术后24 h的IL-6浓度均明显高于术前,但D组的升高幅度低于T组;D组住院天数、术后不良反应发生率有低于T组的趋势,但差异无统计学意义(P>0.05)。结论:对于甲状腺癌功能性颈部淋巴结清扫术患者,相比传统单一的镇痛模式,ERAS理念下的序贯式多模式镇痛可明显提高患者的满意度,降低患者术后动态疼痛评分和术后的镇痛费用,促进了患者的早期康复。

Objective:To explore the effect of sequential multimodal analgesia on the analgesic effect,cost,recovery index and complications of functional neck lymphadenectomy for thyroid cancer.Methods:A total of 88 patients who underwent functional neck lymphadenectomy for thyroid cancer were included.Random number table was used to divide them into sequential multimodal analgesia group(D group)and traditional single-modal analgesia group(T group),with 44 patients in each group.In group D,40 mg of parecoxib hydrochloride was given for preemptive analgesia during anesthesia induction;before intubation,2 mL of 1%Dyclonine glue to 1/3 of the front end of the tracheal tube was applied;before operation,bilateral superficial cervical plexus block was conducted under the guidance of B-ultrasound.Before suturing the incision,the surgeon placed a 22G intravenous indwelling trocar at the nerve point of the superficial cervical plexus under direct vision below the posterior edge of the midpoint of the sternocleidomastoid muscle on the affected side.After the incision was sutured on the opposite side,a trocar was inserted under the guidance of ultrasound,and a local anesthetic was added.6 hours after the operation,another local anesthetic was added through the indwelling cannula embedded in the superficial cervical plexus and the trocar was removed.Oral administration of paracetamol and oxycodone tablets was started 12 hours after the operation.In group T,there was no preemptive analgesia,the incision was sutured directly,and PCIA was used for intravenous analgesia(dazocine 40 mg+sufentanil 50μg+tropisetron 4 mg)after surgery.At 1,6,12 and 24 hours after operation,visual analog scale VAS was used to evaluate the analgesic effect of the two groups;the serum IL-6 concentration before and 24 hours after operation was measured;the total amount of remifentanil during operation,the first time to get out of bed,the first time to eat fluid,the length of hospitalization,the cost of analgesia and the self-rated Bruggrmann Comfort Scales(BCS)and incidence of adverse reactions were recorded.Results:There was no significant difference in the VAS scores of resting pain at 1,6,12,and 24 h after operation in group D and those in group T at the same time point(P>0.05),but the VAS scores for neck pain at the same time point were significantly lower than that in the traditional single mode analgesia group(P<0.05);Intraoperative remifentanil dosage and analgesia costs were significantly lower than those in the group T(all P values<0.05);the time to get out of bed for the first time after surgery,the time of first eating liquid,and self-evaluation comfort were significantly better than those in the group T(P value all<0.05);The levels of IL-6 at 24 hours after surgery in the two groups were significantly higher than those before surgery,but the increase in group D was lower than that in group T;the length of hospitalization in group D and the incidence of postoperative adverse reactions tended to be lower than those in group T,but the difference was not statistically significant(P>0.05).Conclusion:Compared with the traditional single analgesic mode,the sequential multi-mode analgesia based on ERAS concept can significantly improve the satisfaction of patients,reduce the dynamic pain score and the cost of postoperative analgesia,and promote the early recovery of patients.