术后连续蛛网膜下腔病人自控镇痛的效应及安全性

Safety and efficacy of postoperative intrathecal patient-controlled analgesia

目的 研究连续蛛网膜下腔病人自控镇痛(PCA)的可行性,并比较其不同模式的临床效应。方法60例下肢手术的病人(ASAⅠ～Ⅱ级),随机分为三组,CP组(n=20)和 P组(n=20):在连续腰麻(CSA)术后行连续蛛网膜下腔PCA,镇痛药物为0.08％布比卡因(Bup)+0.0002％芬太尼(Fen),前者PCA采用CP模式,后者仅用P模式;C组(n=20):在腰硬联合麻醉(CESA)术后行PCEA,镇痛药物为0.15％Bup+0.0004％Fen,PCEA采用LCP模式,镇痛时间为48h。观察VAS评分、运动阻滞Bromage’s评级等效果。在CP和P组病人中随机抽取8例在镇痛结束时进行脑脊液(2ml)和蛛网膜下腔导管(前端1.5cm)细菌培养。结果 两组病人镇痛效果均满意,CP组、P组和C组的VAS≤3比例分别为98.3％、93.2％和82.6％,P组、CP组镇痛满意率高于C组(P<0.05);术后4h Bromage’s评级2～3级的比例分别为30％(6例)、10％(2例)和0,C组明显较低(P<0.05),4h以后时点所有病人Bromage’s评级均<2级;P组PCA按压次数显著增多(P<0.05);CP组Bup、Fen用药量高于P组(P<0.05),但均显著性低于C组(P<0.01)。C组2例(10％)诉恶心;P组、CP组各有1例病人(5％)出现术后头痛,均于三日内自愈。细菌培养结果为阴性。结论 术后48h内连续蛛网膜下腔PCA安全、有效。

Objective To investigate the safety and efficacy of postoperative intrathecal patient-controlled analgesia ( PCA) after operation performed under continuous spinal anesthesia ( CSA) . Methods Sixty ASA Ⅰ -Ⅱ patients aged 32-72 yr, undergoing operation on hip joint or femur were included in this study. Exclusion criteria included severe spinal deformity, central nervous system disease and other contraindications for spinal anesthesia. The patients were randomly assigned to one of three groups: groupⅠ (group CP, n = 20); group Ⅱ (group P, n=20) and group Ⅲ (group C, n=20). In group Ⅰ andⅡ operation was performed under CSA with 0.5% bupivacaine (isobaric) using a 24G Spinocathe (catheter-over-needle system B.Braun) and after operation the patients received intrathecal PCA with 0.08% bupivacaine and 0.0002% preservative free fentanyl (bupivacaine 0.8mg + fentanyl 2μg/ml) . Intrathecal PCA included a bolus of 1ml on demand with a 30-minute lockout and one hour dose limit of 3ml. Background infusion (0.5ml/h) was used in group Ⅰ (CP) but not in group Ⅱ (P) . In group Ⅲ (C) operation was performed under combined spinal-epidural anesthesia (CSEA) and after operation the patients received patient-controlled epidural analgesia (PCEA) with 0.15% bupivacaine + 0.0004% preservative free fentanyl ( bupivacaine 1. 5mg + fentanyl 4μg/ml) . PCEA included loading dose 5ml (bupivacaine 7.5 + fentanyl 20μg), background infusion 1ml/h, PCEA bolus 1ml on demand, lockout interval 10min and one hour dose limit 15ml. The patients were assessed for 48 hours after operation for pain ( VAS 0-10), motor blockade (Bromage score 0-3) and adverse effects (respiratory depression, PONV and itching). At the end of 48h cerebrospinal fluid 2ml and the intrathecal tip of the Spinocathe were obtained for cultivation of microorganism in 8 patients randomly selected from group Ⅰ and Ⅱ. ResultsThe three groups were comparable with respect to demographic data. Postoperative analgesia was satisfactory in all three groups. VAS score<3 accounted for 98.3% (group Ⅰ ), 93.2% ( group Ⅱ ) and 82.6% ( group Ⅲ ) respectively. The percentage of excellent analgesia was higher in group Ⅰ and Ⅱ than that in group Ⅲ . The consumption of bupivacaine and fentanyl was smallest in group Ⅱ and largest in group Ⅲ . No significant respiratory or circulatory depression was recorded. There was no significant difference in the percentage of patients with Bromage score> 1 among the groups. There was one patient in both group Ⅰ and Ⅱ (5%) complaining of headache after intrathecal PCA, but no special treatment was needed. The results of cultivation of microorganism were negative. Conclusion With strict aseptic technique postoperative intrathecal PCA for less than 48h is clinically safe and efficient.