Different Concentration Sufentanil Combined with 0.125% Ropivacaine for Postoperative Patient－controlled Epidural Analgesia after Total Knee Replacement and Total hip Replacement<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

倪诚　岳云　戈晓东　赵秋华　吴延

北京大学第三医院麻醉科，北京 100083

首都医科大学附属北京朝阳医院麻醉科，北京 100020

Cheng Ni, Yun Yue, Xiao-dong Ge, et al

Department of Anesthesiology, Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing 100020, China

ABSTRACT<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

Objective：To determine an optimal dose-combination of sufentanil with 0.125% ropivacaine as postoperative epidural analgesics after TKR and THR through comparing the analgesia and side-effects of different concentration sufentanil combined with 0.125% ropivacaine.

Methods：24 ASA II-III patients (6 male, 18 female) aged 53～74 yr weighing 48～80 kg undergoing elective TKR and THR under combined spinal and epidural anesthesia were assigned to groups receiving patient-controlled epidural analgesia(PCEA) with sufentanil 1.0mg/ml(A, n=8), 1.25mg/ml(B, n=8), 1.5mg/ml(C, n=8)+0.125% ropivacaine. Three groups received background infusion of 4 ml／h, and a bolus of 2 ml with a 30 min lock-out interval through patient-controlled analgesia device. Visual analogue scale(VAS) scores at rest and on movement, cumulative volumes of the epidural drugs, PCA press times, vital signs including SpO₂, RR, HR, MAP and side-effects including motor block, sedation, nausea, emesis and pruritus were assessed, ratio of PCA press times (effective/actual) and consumption of sufentanil were calculated at 4, 8, 20, 24 and 48 h after postoperative analgesia.

Results：VAS scores, cumulative volumes of the epidural drugs, PCA press times decreased, and consumption of sufentanil increased when the concentration of sufentanil increased. In 48 h of postoperative analgesia, VAS scores were lower in Group C than Group A (P<0.05), 48 h after postoperative analgesia, VAS scores were lower in Group C than Group A (P<0.05). vital signs including SpO₂, RR, HR, MAP were in the normal range. Side-effects including motor block, sedation, nausea, emesis and pruritus were mild. 4 h after  postoperative analgesia, more patients experienced sedation in Group C than Group A and Group B(P<0.05).

Conclusion：Sufentanil combined with ropivacaine for postoperative PCEA after TKR and THR provides satisfying analgesia, and incidence of adverse events is lower. We advocate that the patients should receive a combination of 0.125% ropivacaine and sufentanil 1.25mg/ml, this combination appears to provide satisfying analgesia with fewer side-effects, and is beneficial for patient early functional practice, so it is suitable for clinical practice.

Key words：Sufentanil、Ropivacaine、Total knee replacement、Total hip replacement、Epidural analgesia, Patient-controlled、Visual analogue scale

Corresponding author：Cheng Ni; E-mail:nicheng83@sohu.com

在全膝以及全髋关节置换术后，早期的关节活动以及相应的物理治疗对最终的功能恢复起到了至关重要的作用^[1]。而在此类手术后早期，由于手术创面剧烈的疼痛，不仅严重影响了病人的活动，甚至对情绪及睡眠产生影响，不利于病人的恢复。舒芬太尼与罗哌卡因配伍应用于关节置换术后硬膜外镇痛是一种安全有效的方式，与单独使用罗哌卡因相比，明显减少了罗哌卡因的用量及运动阻滞的副作用，并且获得了更满意的镇痛效果^[2]。已有研究显示罗哌卡因用于术后硬膜外镇痛的最佳浓度为0.125%^[3]，而舒芬太尼合适的镇痛浓度尚无报道。本研究旨在通过比较不同浓度的舒芬太尼与罗哌卡因配伍应用于关节置换术后病人自控硬膜外镇痛中的镇痛效果及相关副作用，得出最佳的使用方案，为进一步的临床应用提供依据。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

一、资料和方法

病例选择与分组: 24例择期行单侧全膝关节置换及单侧全髋关节置换术后的病人，ASAII～III级，其中男6例，女18例，年龄53～74岁，身高146～176cm，体重48～80 kg。排除术前合并严重心、肺、肝、肾疾病，中度以上贫血，对阿片类药物过敏，既往长期使用阿片类或非阿片类镇痛药，既往存在严重基础疼痛者。采用随机双盲的方法将病人分为3组，使用的术后硬膜外镇痛舒芬太尼浓度分别为1.0mg/ml(A组，n=8)，1.25mg/ml(B组，n=8)及1.5mg/ml(C组，n=8)。

麻醉方法: 采用蛛网膜下腔-硬膜外腔联合阻滞(CSEA)，选L3-4为穿刺点，于蛛网膜下腔向头侧给予1%地卡因+10%葡萄糖+3%麻黄素(1: 1: 1混合液)3 ml，给药后常规置入硬膜外导管并调节感觉阻滞平面至T10±1水平，术中视病人痛觉恢复情况，硬膜外间断给予2%利多卡因8～10ml，手术时间2～3小时。

镇痛方法: 术后病人自控硬膜外镇痛(PCEA)使用美国百特微电脑镇痛泵AP-PCAⅡ型，各组镇痛药配伍浓度为，A组: 舒芬太尼1.0mg/ml(枸橼酸舒芬太尼注射液，德国Impfstoffwerk Dessau-Tornau GmbH公司生产，规格50mg，批号: 030121)+0.125%罗哌卡因(盐酸罗哌卡因注射液，瑞典阿斯利康公司生产，规格75mg/10ml，批号: EC845)，B组: 舒芬太尼1.25mg/ml+0.125%罗哌卡因，C组: 舒芬太尼1.5mg/ml+0.125%罗哌卡因，手术结束前5分钟缓慢静脉注射欧必亭5mg(盐酸托烷司琼注射液)，手术结束时连接硬膜外镇痛泵开始镇痛，给予首次剂量(bolus)5ml，并设定持续输注背景剂量4ml/h，PCA量每次2ml，锁定时间30min。

在本次关注于术后病人疼痛缓解的研究中，我们观察到，舒芬太尼与罗哌卡因配伍应用于关节置换术后病人自控硬膜外镇痛中的镇痛效果明确，副作用发生率低。与舒芬太尼浓度1.0mg/ml及1.5mg/ml组相比较，1.25mg/ml舒芬太尼与0.125%罗哌卡因相配伍在获得最佳镇痛效果的同时，引起相对少的副作用，更利于病人术后早期的功能锻炼，适合在临床应用中推广。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

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