三种镇痛方法对胸部术后镇痛效果和通气功能影响的比较

Comparison of intravenous fentanyl, thoracic epidural bupivacaine/fentanyl, or intercostal nerve blockade plus intravenous fentanyl for treatment of post-thoracotomy analgesia and ventilation function

目的:比较静脉、硬膜外及肋间神经阻滞合并静脉3种镇痛方法用于胸部手术后的镇痛效果及其对通气功能的影响。方法:45例择期开胸手术患者随机数字表法分为静脉镇痛组(Ⅰ组)、肋间神经阻滞合并静脉镇痛组(II组)及硬膜外镇痛组(Ⅲ组)。术后镇痛:Ⅰ组持续以2.5mL/h静脉泵入芬太尼(15mg/L)+咪唑安定(0.3g/L);Ⅱ组关胸前以2.5g/L布比卡因行切口及上下各2个肋间的肋间神经阻滞,术后以2.5mL/h持续静脉泵入芬太尼(10mg/L)+咪达唑仑(咪唑安定)(0.3g/L);Ⅲ组以2.5mL/h持续硬膜外泵入1.8g/L布比卡因+芬太尼(3mg/L)+咪唑安定(0.2g/L)。患者术后以视觉模拟评分法行痛觉评分(VAS);测量心率、平均动脉压、动脉血氧分压(PaO2)及二氧化碳分压(PaCO2);测定用力肺活量和第一秒用力呼出气量(FEV1)。结果:Ⅰ组术后3h及6hVAS明显高于Ⅱ组(P<0.05),术后0,3,6,12hVAS明显高于Ⅲ组(P<0.05,0.01);Ⅱ组术后12hVAS明显高于Ⅲ组(P<0.05);Ⅱ组术后3,6hFVC及FEV1显著高于Ⅰ组(P<0.01,0.05);Ⅲ组患者术后3hFVC、术后6,12hFVC和FEV1及术后24hFEV1显著高于Ⅰ组(P<0.05);Ⅰ组患者术后0h的PaO2明显低于另外二组(P<0.05),而其PaCO2明显高于Ⅲ组(P<0.05)。

AIM:To compare the efficacy of intravenous fentanyl, thoracic epidural bupivacaine/fentanyl, or intercostal nerve block plus intravenous fentanyl on post thoracotomy analgesia and ventilation function.METHODS:Forty five patients undergoing elective thoracotomy were randomly divided into three groups: intravenous infusion of fentanyl(15 mg/L) at a frequency of 2.5 mL/h plus imidazole(0.3 g/L) after operation (group A,n=15); intraoperative intercostal nerve block using 2.5 g/L bupivacaine plus postoperative intravenous infusion of fentanyl(10 mg/L, 2.5 mL every one hour) and imidazole of 0.3 g/L (group B,n=15); thoracic epidural infusion of 1.8 g/L bupivacaine plus fentanyl(3 mg/L) and imidazole (0.2 g/L) after operation(group C,n=15 ). Visual analogue scales (VAS) were used to assess the postoperative pain. Forced vital capacity (FVC), forced expiratory volume in first second (FEV1), partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in artery (PaCO2), heart rate (HR) and blood pressure were measured at 0 (immediately after arrival in ICU), 3, 6, 12, 24, and 48 postoperative hours.RESULTS:The VAS scores in the group A were significantly higher than those of the group B at 3 and 6 postoperative hours (P < 0.05), and higher than those of the group C at 0,3,6 and 12 postoperative hours (P< 0.01, 0.05). There was no significant difference of VAS scores between the group B and group C except that at 12 postoperative hours (P< 0.05). The FVC and FEV1 in the group B were significantly higher than those of the group A at 3 and 6 operative hours (P< 0.01,0.05,).The FVC in the group A was significantly lower than that of the group C at 3, 6 and 12 postoperative hours, and the FEV1 in the group A was lower than that of the group C at 6, 12 and 24 h after operation (P< 0.05).The PaO2 was lower at 0 h after operation in the group A than in the other two groups (P< 0.05), but the PaCO2 was significantly higher than in the group C (P< 0.05).