罗哌卡因复合舒芬太尼蛛网膜下腔阻滞在混合痔外剥内扎术患者中的应用价值

Application value of ropivacaine combined with sufentanil subarachnoid block in patients with mixed hemorrhoids operation

目的评价蛛网膜下腔注射罗哌卡因复合不同剂量舒芬太尼用于混合痔外剥内扎术的麻醉与术后镇痛效果。方法收集2020年6月至2020年9月北京市肛肠医院肛肠外科择期行混合痔外剥内扎术患者90例,采用随机数字表法分为3组(n=30):Ⅰ组蛛网膜下腔注射0.75%罗哌卡因9 mg,Ⅱ组在Ⅰ组基础上+舒芬太尼3μg,Ⅲ组在Ⅰ组基础上+舒芬太尼5μg。所有患者均使用自控静脉镇痛(PCIA)进行术后镇痛,镇痛泵药物配方:舒芬太尼0.1 mg+托烷司琼10 mg,以0.9%氯化钠注射液稀释至100 ml。持续输注1 ml/h,PCIA单次剂量1.5 ml,锁定时间20 min,镇痛泵持续至术后24 h。记录患者一般资料,感觉阻滞平面,运动阻滞(Bromage)分级,麻醉效果分级,术后2、4、6、12、24 h时VAS评分情况,首次自控的时间,24 h自控按压次数,24 h舒芬太尼总用量以及不良反应。结果3组患者感觉阻滞平面、运动阻滞程度和麻醉效果分级比较,差异均无统计学意义(P均>0.05)。术后2 h和4 h时VAS评分,Ⅰ组为(0.5±0.3)分和(3.2±0.6)分,Ⅱ组为0分和(2.3±0.3)分,Ⅲ组为0分和(2.1±0.4)分;Ⅱ组和Ⅲ组VAS评分均较Ⅰ组降低(P均<0.05);术后6 h和12 h时VAS评分,Ⅲ组为(2.3±0.5)分和(2.7±0.3)分,Ⅱ组为(3.3±0.5)和(3.4±0.6)分,Ⅲ组VAS评分均较Ⅱ组低(P均<0.05);余时点VAS评分比较差异均无统计学意义(P均>0.05)。Ⅰ组、Ⅱ组和Ⅲ组首次自控镇痛时间分别为(3.1±0.4)h、(5.9±0.8)h和(7.9±0.5)h;Ⅰ组、Ⅱ组和Ⅲ组24 h自控镇痛按压次数分别为(24.1±5.3)次、(12.6±3.8)次和(6.4±1.4)次;Ⅰ组、Ⅱ组和Ⅲ组24 h舒芬太尼总用量分别为(59±11)ml、(35±8)ml和(26±6)ml;Ⅱ组和Ⅲ组首次自控镇痛的时间、24 h自控镇痛按压次数、24 h舒芬太尼总用量与Ⅰ组比较,差异均有统计学意义(P均<0.05);Ⅲ组首次自控镇痛时间、24 h自控按压次数及舒芬太尼总用量与Ⅱ组比较,差异均有统计学意义(P均<0.05)。3组患者呼吸抑制、恶心、呕吐、尿潴留等不良反应比较差异均无统计学意义(P均>0.05)。结论罗哌卡因9 mg复合舒芬太尼3μg或5μg行蛛网膜下腔阻滞用于混合痔外剥内扎术麻醉,可明显增强术后自控镇痛的效果并延长镇痛时间,减少术后静脉自控镇痛舒芬太尼用量,且不良反应未见增多;复合舒芬太尼5μg较3μg术后镇痛时间长。

Objective To evaluate the anesthetic and postoperative analgesic efficacy of spinal anesthesia with ropivacaine combined with different doses of sufentanil for patients undergoing external dissection and internal ligation operation of mixed hemorrhoids.Methods From June to September 2020,90 patients with mixed hemorrhoids undergoing external dissection and internal ligation operation in the Department of Anorectal Surgery of Beijing Anorectal Hospital were divided into three groups(n=30)randomly.The patients received subarachnoid injection of 0.75%ropivacaine 9 mg in groupⅠ,while received the same drug plus sufentanil 3μg or 5μg in groupⅡand groupⅢrespectively.Patient controlled intravenous analgesia(PCIA)was used for postoperative analgesia in all patients.The analgesic pump was composed of sufentanil 0.1 mg+tropisetron 10 mg,diluted to 100 ml with 0.9%sodium chloride injection.PCIA was continuously infusion of 1 ml/h for 24 h after the operation,bolus dose 1.5 ml,locking time 20 min.The sensory block level,Bromage grade,anesthetic effect grade,VAS at 2,4,6,12 and 24 hours after the operation,the time of first self-control,the number of self-control compressions,the total dosage of sufentanil in 24 hours,and the occurrence of adverse reactions were recorded.Results There were no significant differences in sensory block plane,motor block degree and anesthetic effect(all P>0.05).The VAS was 0 and(2.3±0.3)in groupⅡ,0 and(2.1±0.4)in groupⅢ,and was(0.5±0.3)and(3.2±0.6)in group I respectively at 2 hours and 4 hours after the operation(all P<0.05).The VAS was(2.3±0.5)and(2.7±0.3)in groupⅢ,(3.3±0.5)and(3.4±0.6)in groupⅡ,which showed that VAS was lower in groupⅢthan that in groupⅡ,at 6 hours and 12 hours after the operation(all P<0.05).VAS was not statistically significant in other time points(all P>0.05).The time of first PCIA was(5.9±0.8)hours in groupⅡ,(7.9±0.5)hours in groupⅢand(3.1±0.4)hours in groupⅠ.The numbers of pressing were(24.1±5.3)in groupⅠ,(12.6±3.8)in groupⅡand(6.4±1.4)in groupⅢrespectively.The total dosage of sufentanil in 24 h was(59±11)ml in groupⅠ,(35±8)ml in groupⅡand(26±6)ml in groupⅢ.The time of first patient-controlled analgesia,the number of pressing and the total dosage of sufentanil in 24 h were significantly longer or lower in groupⅡand groupⅢthan those in groupⅠ(all P<0.05),and in groupⅢthan those in groupⅡ(all P<0.05).There was no significant difference in the incidence of adverse reactions such as respiratory depression,nausea,vomiting and urinary retention among the three groups(all P>0.05).Conclusion Subarachnoid block with ropivacaine 9 mg combined with sufentanil 3μg or 5μg can significantly enhance the effect of postoperative patient-controlled analgesia and prolong the analgesic duration,reduce the dosage of intravenous sufentanil,and do not increase the adverse reactions.The postoperative analgesic time is longer with 5μg sufentanil than with 3μg.