鞘内小剂量吗啡术后镇痛对罗哌卡因单次脊椎麻醉下髋部骨折老年患者的影响

Effect of postoperative low-dose intrathecal morphine analgesia in elderly patients with hip fracture undergoing surgery under single-shot spinal anesthesia with ropivacaine

目的 观察鞘内小剂量吗啡术后镇痛对罗哌卡因单次脊椎麻醉下老年髋部骨折患者的影响。方法选择高邮市中医医院2021年5月至2022年1月择期于单次脊椎麻醉下行髋关节置换术的老年患者60例,年龄70~85岁,ASAⅠ~Ⅲ级,以随机数表法分为鞘内吗啡组(观察组,n=30)与舒芬太尼患者术后静脉自控镇痛(PCIA)组(对照组,n=30)。两组患者均以25G脊椎麻醉针行单次脊椎麻醉,观察组患者以0.5%重比重罗哌卡因2.5 ml+100μg吗啡鞘内注射;对照组患者以0.5%重比重罗哌卡因2.5 ml鞘内注射,术后继以舒芬太尼2μg/kg+100 ml生理盐水,以2 ml/h背景量行PCIA。分别于术后6、12、24和48 h记录两组患者视觉模拟疼痛(VAS)评分及布氏舒适度(BCS)评分,以谵妄评定法(CAM)对患者术后精神状态进行评估,并同时记录两组患者术后瘙痒、恶心呕吐、镇静嗜睡及呼吸抑制等不良反应。结果 与对照组比较,观察组患者术后24 h内VAS与BCS评分均优于对照组,差异有统计学意义(P <0.05)。术后48 h时,观察组VAS评分高于对照组、BCS评分低于对照组,但差异无统计学意义(P> 0.05)。观察组CAM评估术后谵妄(POD)2例,低于对照组的9例(6.67%vs. 30.00%),差异有统计学意义(P <0.05)。术后皮肤瘙痒者观察者多于对照组(P <0.05);两组术后恶心呕吐及嗜睡情况比较,差异无统计学意义(P> 0.05);两组患者未出现严重的呼吸抑制反应及呼吸系统并发症。结论 鞘内小剂量吗啡术后镇痛操作简单,费用低廉,镇痛效果较好,可减少高龄患者POD的发生率,在有效的监测下,可安全用于单次脊椎麻醉下髋部骨折老年患者。

Objective To observe the effect of postoperative low-dose intrathecal morphine analgesia in elderly patients with hip fracture undergoing surgery under single-shot spinal anesthesia with ropivacaine.Methods A total of 60 ASAⅠtoⅢelderly patients aged 70 to 85 years who underwent elective hip replacement under single-shot spinal anesthesia in Gaoyou Hospital of Traditional Chinese Medicine from May 2021 to January 2022 were selected and divided into the intrathecal morphine group(the observation group,n=30)and the postoperative patient-controlled intravenous analgesia(PCIA)group(by sufentanil,the control group,n=30)by the random number table method.Both groups of patients received single-shot spinal anesthesia with a 25G spinal anesthesia needle:patients in the observation group were intrathecally injected with 0.5%hyperbaric ropivacaine 2.5 ml+100μg morphine;patients in the control group were injected with 0.5%hyperbaric ropivacaine 2.5 ml intrathecally,followed by postoperative sufentanil 2μg/kg+100 ml normal saline and PCIA at 2 ml/h background dose.The visual analogue scale(VAS)score and Brinell comfort scale(BCS)score were recorded at 6,12,24 and 48 hours after operation respectively.The mental state of the patients after operation was evaluated by the confusion assessment method(CAM),and the postoperative adverse reactions such as pruritus,nausea and vomiting,sedation and lethargy,and respiratory depression were recorded at the same time.Results The VAS and BCS scores in the observation group were better than those in the control group within 24 hours after operation,with statistically significant differences(P<0.05).At 48 h after operation,the VAS score of the observation group was higher than that of the control group,and BCS score is lower than the control group,but the difference was not statistically significant(P>0.05).The incidence of postoperative delirium(POD)assessed by CAM in the observation group(2 cases)was lower than that in the control group(9 cases),with statistically significant difference(6.67%vs.30.00%)(P<0.05).Patients with postoperative skin pruritus in observation group was more than that of control group(P<0.05);there were no statistically significant differences in postoperative nausea,vomiting and lethargy between the two groups(P>0.05);there were no severe respiratory depression and respiratory complications in the two groups.Conclusion Postoperative low-dose intrathecal morphine analgesia has the advantages of simple operation,low cost and satisfactory analgesic effect,and may reduce the incidence of POD in elderly patients.Under effective monitoring,such analgesia method can be safely used in elderly patients with hip fracture undergoing su rgery under single-shot spinal anesthesia.