不同剂量地佐辛对全膝关节置换术老年患者吗啡鞘内镇痛的影响

Effects of different doses of dezocine on morphine intrathecal analgesia in elderly patients undergoing total knee arthroplasty

目的探究不同剂量地佐辛联合鞘内吗啡应用对老年全膝关节置换术(TKA)患者镇痛的影响及可能机制。方法选取拟行TKA患者120例,年龄60~80岁,随机分为3组,每组40例。均行腰硬联合麻醉,穿刺前10 min,A组、B组和C组分别给予地佐辛0.2、0.1 mg·kg^(-1)和氯化钠注射液静脉注射,L_(3-4)椎间隙穿刺成功后,均于蛛网膜下腔注入吗啡0.3 mg+重比重布比卡因10 mg。术后均给予吗啡镇痛泵。比较3组感觉阻滞起效时间、手术时间、术后疼痛视觉模拟量表(VAS)及Ramsay镇静评分,记录术后48 h内曲马多补救镇痛率、使用剂量及药物不良反应。检测手术前后血清前列腺素E_(2)(PGE_(2))、P物质、5-羟色胺(5-HT)水平,评估膝关节功能恢复情况。结果3组感觉阻滞起效时间及手术时间比较,差异无显著意义(P>0.05)。术后6、12、24、48 h,A组和B组VAS评分均显著低于C组(P<0.05),术后48 h内A组和B组曲马多补救镇痛率为18%和12%,均显著低于C组(45%,P<0.05),曲马多使用剂量也均显著低于C组(P<0.05);A组和B组同时点VAS评分、曲马多补救镇痛率及使用剂量比较,差异均无显著意义(P>0.05)。术后2、6 h,A组和B组Ramsay评分均显著高于C组(P<0.05),A组术后2 h的Ramsay评分显著高于B组(P<0.05)。术后48 h内,A组和B组皮肤瘙痒发生率为12%和18%,均显著低于C组(38%,P<0.05)。术后12、24、48 h,A组和B组P物质水平均显著低于C组(P<0.05),5-HT水平均显著高于C组(P<0.05)。术后1周,A组和B组膝关节纽约特种外科医院(HSS)评分均显著高于C组(P<0.05),A组、B组间比较无显著差异(P>0.05)。结论地佐辛联合鞘内吗啡应用于TKA老年患者可提高术后镇痛效果、减少皮肤瘙痒的发生,利于早期膝关节功能恢复,可能与血清P物质下调、5-HT水平上调有关。地佐辛0.2 mg·kg^(-1)与0.1 mg·kg^(-1)作用相当,0.2 mg·kg^(-1)剂量可能加深早期镇静状态。

AIM To explore the effects of different doses of dezocine combined with intrathecal morphine on analgesia in elderly patients undergoing total knee arthroplasty(TKA)and its possible mechanism.METHODS A total of 120 elderly patients aged 60-80 years undergoing TKA surgery were selected and divided into three groups with 40 cases in each group by random envelope method.All patients underwent combined spinal-epidural anesthesia,and at 10 min before puncture,group A,group B and group C were injected intravenously with dezocine 0.2,0.1 mg·kg^(-1)(diluted with chloride sodium injection to 5 mL)and the same amount of chloride sodium injection respectively.After successful L_(3-4)intervertebral puncture,the three groups were given subarachnoid injection of morphine 0.3 mg+hyperbaric bupivacaine 10 mg,and they were given morphine analgesic pump after surgery.The onset time of sensory block,surgical time,visual analogue scale(VAS)score of pain and Ramsay sedation score were compared among the three groups after surgery,and the tramadol remedial analgesia rate and dosage and adverse drug reactions were recorded within 48 h after surgery.The levels of serum pain mediators(prostaglandin(PGE_(2)),substance P,5-hydroxytryptamine(5-HT))were detected and the knee joint function was evaluated before and after surgery.RESULTS There were no significant differences in the onset time of sensory block and surgical time among the three groups(P>0.05).At 6,12,24 and 48 h after surgery,the VAS scores in the group A and group B were significantly lower than those in the group C(P<0.05).Within 48 h after surgery,the tramadol remedial analgesia rate with 18%in the group A and 12%in the group B,which was significantly lower than 45%in the group C(P<0.05),and the average dosage of tramadol was significantly lower than that in the group C(P<0.05),but there were no significant differences in VAS score,tramadol remedial analgesia rate and dosage between the group A and group B at the same time point(P>0.05).At 2,6 h after surgery,the Ramsay scores of the group A and group B were significantly higher than those of the group C(P<0.05),and the Ramsay score of the group A was significantly higher than that of the group B at 2 h after surgery(P<0.05).Within 48 h after surgery,the incidence rate of skin itching was 12%in the group A and 18%in the group B,which was significantly lower than 38%in the group C(P<0.05).At 12,24 and 48 h after surgery,the substance P level of the group A and group B was significantly lower than that of the group C(P<0.05),while 5-HT level was significantly higher than that of the group C(P<0.05).At one week after surgery,the New York’s hospital for special surgery(HSS)score of knee joint in the group A and group B was significantly higher than that in the group C(P<0.05),and there were no significant differences between the group A and group B(P>0.05).CONCLUSION Dezocine combined with intrathecal morphine for elderly patients with TKA can enhance the postoperative analgesia effect,reduce skin itching and facilitate early recovery of knee joint function,which may be related to the down-regulation of serum substance P and the up-regulation of 5-HT level.Dezocine 0.2 and 0.1 mg·kg^(-1)have similar effects,but dezocine 0.2 mg·kg^(-1)may deepen the early sedation status.