比较全程硬膜外镇痛和单次硬膜外阻滞联合静脉自控镇痛对胸外科手术后急性与慢性疼痛的影响  

The effect of comprehensive epidural analgesia and single epidural block plus intravenous analgesia on acute and chronic pain after thoracic surgery

作　　者：扶超 胡渤 周扬 周巧梅 郄文斌 艾娟 蔡俊强 屠伟峰 Fu Chao;Hu Bo;Zhou Yang;Zhou Qiaomei;Xi Wenbin;Ai Juan;Cai Junqiang;Tu Weifeng(Department of Anesthesiology,General Hospital of Southern Theatre Command,Southern Medical University,Guangzhou City,Guangdong Province 510010,China;Department of Anesthesiology,Shenzhen Hyzen Hospital,Shenzhen City,Guangdong Province 518038,China)

机构地区：[1]南部战区总医院麻醉科,全军临床麻醉中心,广州市510010 [2]深圳禾正医院麻醉科,518038

出　　处：《中华疼痛学杂志》2021年第6期638-644,共7页Chinese Journal Of Painology

基　　金：广东省自然科学基金资助(2014A030311012)。

摘　　要：目的比较全程硬膜外镇痛和单次硬膜外阻滞加静脉自控镇痛对胸外科手术后急性疼痛与慢性疼痛的影响。方法收集南部战区总医院2018年12月1日至2019年7月1月择期行胸外科手术(开胸食管癌根治术、胸腔镜肺叶切除术、胸腔镜肺癌根治术、胸腔镜肺楔形切除术)的患者60例,年龄18~65岁,随机分为全程硬膜外镇痛组(硬膜外组)和单次硬膜外阻滞加静脉自控镇痛组(静脉组),各组30例。两组在术前均行硬膜外穿刺置管术,并给予0.125%罗哌卡因加0.5μg/ml舒芬太尼共8 ml,术中间断以同样浓度药物维持。硬膜外组在关闭胸膜前连接硬膜外镇痛泵(0.125%罗哌卡因437.5 mg加0.5μg/ml舒芬太尼175μg,以生理盐水稀释到350 ml),静脉组关闭胸膜前拔出硬膜外导管连接PCIA泵(1.5μg/ml舒芬太尼300μg,以生理盐水稀释到200 ml)。记录术后3、6、12、24、48、72 h各时点急性疼痛视觉模拟评分(VAS)、恶心呕吐(PONV)例数、镇静评分、补救镇痛药物量和不良反应发生率。记录术后2、4、6个月内伤口慢性疼痛和伤口感觉异常的发生率。结果本研究中共50例患者符合要求,其中男37例,女13例。硬膜外组患者术后3、6、12、24、48、72 h静息时急性疼痛VAS评分和术后6、12、24 h活动时急性疼痛VAS评分均低于静脉组(P均<0.05)。硬膜外组患者术后3、6、12、24、48、72 h静息时患者无痛的比率和术后6、12、24、48 h活动时患者无痛的比率均高于静脉组(P均<0.05)。两组患者术后2、4、6个月时慢性疼痛的发生率和伤口感觉异常的差异均无统计学意义(P均>0.05)。术后72 h内,静脉组补救镇痛3例(12.5%),硬膜外组补救镇痛6例(23.1%),两组差异无统计学意义(P>0.05),但硬膜外组补救药物曲马多的需求量明显低于静脉组[(120.0±34.6)mg比(212.5±44.1)mg,P=0.016]。静脉组PONV者8例(33.3%),硬膜外组PONV者8例(30.8%),两组差异无统计学意义(P>0.05)。两组未观察Objective To observe the effect of comprehensive epidural analgesia and single epidural block plus patient-controlled intravenous analgesia on acute and chronic pain in patients after thoracic surgery.Methods Sixty patients scheduled for thoracic surgery(radical resection of esophageal cancer,thoracoscopic lobectomy,thoracoscopic radical resection of lung cancer,and thoracoscopic wedge resection)from December 1,2018 to July 1,2019,aged 18-65 years old were enrolled in the General Hospital of Southern Theatre Command.Patients were randomly divided into comprehensive epidural analgesia group(epidural group,n=30)and single epidural block plus patient-controlled intravenous analgesia group(intravenous group,n=30).After the thoracic epidural catheter was placed at T4-T5 or T4-T6,all patients were given an experiment dose and 0.125% ropivacaine+0.5μg/ml sufentanil total 8 ml.When closing the thorax,thoracic epidural analgesia(TEA)pump(0.125% ropivacaine+0.5μg/ml sufentanil,background dose 6 ml,bolus 6 ml,lock time 30 min)was connected to the catheter in epidural group;the epidural catheter were removed and the intravenous patient controlled analgesia(PCA)pump(1.5μg/ml sufentanil,background dose 0.05-0.06μg·kg-1·h-1,bolus 2 ml,lock time 15 min)were connected in intravenous group.Visual analogue scale(VAS),postoperative nausea and vomiting(PONV),Ramsay sedation scores,supplementary analgesics,the incidence of adverse reaction at 3,6,12,24,48,72 h after surgery,and the incidence of chronic pain and wound paresthesia at 2,4,6 month after surgery were recorded.Results Ultimately,fifty patients were involved in the analysis(37 males and 13 females,aged 18-65 years).Compared with intravenous group,VAS was lower at 3,6,12,24,48,72 h in rest and at 6,12,24 h in movement after the surgery in epidural group(all P<0.05).Compared with intravenous group,the incidence of pain-free was higher at 3,6,12,24,48,72 h in rest and at 6,12,24,48 h in movement after surgery in epidural group(all P<0.05).The consumption of remedy analges

关 键 词：镇痛 硬膜外 胸外科 急性疼痛 慢性疼痛 舒芬太尼 

分 类 号：R614[医药卫生—麻醉学]