小剂量氢吗啡酮复合纳布啡用于胃肠道手术后患者自控静脉镇痛的效果

Efficacy of small dose of hydromorphone combined with nalbuphine for patient-controlled intravenous analgesia after gastrointestinal surgery

目的对比小剂量或无背景剂量氢吗啡酮复合纳布啡用于胃肠道手术后患者自控静脉镇痛(PCIA)的效果。方法选择择期行胃肠道手术的患者147例,男105例,女42例,年龄18~80岁,BMI 18~35 kg/m 2,ASAⅠ—Ⅲ级。采用随机数字表法将患者分为两组:小剂量氢吗啡酮组(SD组,n=76)和无背景剂量氢吗啡酮组(ND组,n=71)。术后48 h内行PCIA,镇痛药配方为氢吗啡酮10 mg、纳布啡40 mg,加生理盐水稀释至100 ml。镇痛泵参数设患者自控镇痛2 ml,锁定时间10 min,SD组设背景剂量1 ml/h,ND组无背景剂量。记录术后24和48 h静息和活动(咳嗽)时VAS疼痛评分、镇痛泵总按压次数和有效按压次数、镇痛泵用药量、术后48 h内补救镇痛情况和补救止吐情况、术后首次肛门排气时间和术后住院时间。使用线性回归模型进行敏感性分析探讨两种术后镇痛方案在性别、年龄、手术部位和手术方式等不同亚组治疗效果的差异,并分析不同亚组间的交互作用。记录恶心呕吐、头晕、嗜睡、呼吸抑制、瘙痒等不良反应发生情况。结果与ND组比较,SD组术后24和48 h静息和活动时VAS疼痛评分明显降低(P<0.01),镇痛泵总按压次数和有效按压次数明显减少(P<0.01),镇痛泵用药量明显升高(P<0.01),术后48 h补救镇痛率明显降低(P<0.05)。两组术后48 h补救止吐率、术后首次肛门排气时间和术后住院时间差异无统计学意义。亚组分析显示行开腹手术的患者更能从小剂量PCIA镇痛方案中获益。两组术后48 h恶心呕吐、头晕和嗜睡发生率差异无统计学意义。两组无一例发生呼吸抑制和瘙痒。结论与无背景剂量比较,采用氢吗啡酮0.1 mg/h复合纳布啡0.4 mg/h的小剂量PICA输注模式用于胃肠道手术后镇痛效果更佳,且不增加术后不良反应。

Objective To compare the efficacy of a small dose or no background dose of hydromorphone combined with nalbuphine for patient-controlled intravenous analgesia(PCIA)after gastrointestinal surgery.Methods A total of 147 patients scheduled for elective gastrointestinal surgery,105 males and 42 females,aged 18-80 years,BMI 18-35 kg/m 2,ASA physical statusⅠ-Ⅲ,were enrolled.Patients were divided into two groups:the small dose hydromorphone group(group SD,n=76)and the no background dose hydromorphone group(group ND,n=71)using a random number table method.PCIA was carried out within postoperative 48 hours.The analgesic pump solution contained hydromorphone 10 mg and nalbuphine 40 mg,diluted into 100 ml of normal saline.The patient-controlled analgesia dose of the analgesic pump was 2 ml and the lockout time was 10 minutes,with a background dose of 1 ml/h for group SD and no background dose for group ND.VAS pain scores at rest and during movement(coughing),numbers of total and effective delivered doses of the analgesic pump,and analgesics consumption of the analgesic pump at postoperative 24 and 48 hours were recorded.The incidences of patients using rescue analgesics and antiemetics within postoperative 48 hours,postoperative first anal exhaust time,and postoperative length of hospitalization were also recorded.Subgroup analyses using linear regression models were performed to investigate whether the therapeutic effects of the two postoperative analgesia programs varied by gender,age,surgical site,and surgical method.The significance of interaction effects was assessed in each subgroup.Adverse events including nausea and vomiting,dizziness,drowsiness,respiratory depression,and pruritus were recorded.Results Compared with group ND,VAS pain scores at rest and during movement,and the numbers of total and effective delivered doses of the analgesic pump were significantly lower(P<0.01),and analgesics consumption of the analgesic pump was significantly higher in group SD at postoperative 24 and 48 hours(P<0.01).The rescue analgesic rate was significantly lower in group SD than in group ND within postoperative 48 hours(P<0.05).There were no significant differences in the rate of using rescue antemetics within postoperative 48 hours,postoperative first anal exhaust time,and postoperative hospital stay between the two groups.Subgroup analysis showed that patients undergoing open abdominal surgery were more likely to benefit from a small dose PCIA mode.There was no significant difference in the incidence of nausea and vomiting,dizziness,and lethargy during postoperative 48 hours between the two groups,and no respiratory depression or pruritus occurred in the two groups.Conclusion Compared with no background dose,the small dose PICA infusion mode of hydromorphone 0.1 mg/h combined with nalbuphine 0.4 mg/h has a better analgesic effect after gastrointestinal surgery and does not increase the risk of postoperative adverse events.