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

Clinical Study on Perioperative Analgesia for Thoracic Surgery

丁超  孙莉教授

中国医学科学院中国协和医科大学肿瘤医院麻醉科,北京 100021

Chao Ding and Li Sun

Department Of Anesthesiology,Cancer Institute & Cancer Hospital,Chinese Academy of Medical Sciences,Peking Union Medical College,Beijing 100021

ABSTRACT

　　Objective:To evaluate the effects of preoperative vs. postoperative administration of intravenous tramadol plus intercostal blockade with ropivacaine combing postoperative patient controlled intravenous analgesia (PCIA) for thoracic surgery. 

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

　　Methods:In this prospective and controlled study,thirty-six patients aged 28-66 yrs,ASAⅠ-Ⅲ,undergoing elective pulmonary lobectomy were randomly allocated into two groups. In group A (n=18),preoperative analgesia group,the patients received tramodol 1.5mg/kg-1i.v. before anesthesia induction and intercostal blockade using 0.5% ropivacaine immediately prior to surgery;In group B (n=18),routine analgesia group,the patients received the same doses of tramodol and nerve blockade procedure as in group A at the end of surgery. PCIA using sufentanil (background infusion of 5ml/h-1,concentration1Ug/ml-1,a bolus 3 ml and lock-out interval 30 min) were applied postoperatively in the two groups. Visual analogue scale (VAS) scores for pain at rest and movement,Ramsay sedative scale scores,Bruggrmann comfort scale scores,cumulative volumes of sufentanil,and PCIA pressing times were observed or calculated at 2,4,6,8,12,24,48 and 72 hr after operation,respectively. The vital signs including SpO₂,RR,HR,MAP and side effects (oversedation,nausea,vomiting,itching,respiration depression) were also noted at each observation time point.

　　Results:There were lower pain VAS scores and cumulative volumes of sufentanil,less PCIA pressing times in group A than in group B (P<0.05). Bruggrmann comfort scores and ratio of PCIA pressing times were significantly higher in group A compared with group B (P<0.05). There were no statistically significant differences with respect to vital signs,Ramsay sedative scale scores and incidences of side-effects (P>0.05).

　　Conclusions:Preoperative adminstration of intravenous tramadol plus intercostal blockade with ropivacaine combing postoperative PCIA provides better postoperative analgesia for thoracic surgery than the routine pain-relieving method.

　　Key words:Postoperative analgesia;Intercostal blockade;Patient-controlled analgesia;Tramadol;Multimodal analgesia

　　开胸术后疼痛可显著影响病人早期的呼吸、咳痰，延迟胃肠功能恢复，限制病人早期活动，并增加下肢血栓形成及肺栓塞的风险，因此开胸术后有效镇痛非常重要^[1]。完整的围术期镇痛应包括超前镇痛和术后镇痛，覆盖伤害性刺激激发中枢高兴奋状态的切皮前、术中、术后整个阶段^[2]，通过阻止有害刺激传入以及所导致的外周和中枢敏感化，抑制神经元可塑性变化,从而达到有效镇痛和减少镇痛药用量的目的^[3]。本实验围术期镇痛采用中枢性镇痛药曲马多静脉输注与罗哌卡因肋间神经阻滞技术相结合，术后应用强效阿片类镇痛药舒芬太尼PCIA维持，并于传统术后镇痛方法相对比，为临床提供参考。

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

资料和方法

　　病例选择与分组36例择期行开胸肺叶切除术的病人，ASAⅠ～Ⅲ级，男25例，女11例，年龄28～66岁，体重48～70kg。无精神疾病史和家族史,术前疼痛VAS评分小于3分，并排除术前合并严重心、肺、肝、肾疾病，以及长期使用镇痛药者。

　　随机分为两组：A组(n=18)于麻醉诱导前10分钟经静脉注射曲马多1.5mg/kg，并于切皮前进行一次肋间神经阻滞（每次使用0.5%盐酸罗哌卡因注射液15ml，分别注射开胸肋间及上下各一肋间）；B组(n=18)于术毕时静脉推注曲马多1.5mg/kg并进行一次肋间神经阻滞。两组病人均于手术结束时开始静脉病人自控镇痛（PCIA），使用美国百特AP-PCAⅡ型微电脑镇痛泵。PCIA配制方法：舒芬太尼250μg加入0.9%生理盐水至250ml，持续背景输注速率5ml/h，PCA剂量3ml/次,药物浓度1Ug/ml,锁定时间30min。A组和B组舒芬太尼PCIA均使用至术后48h。

　　麻醉方法  病人入手术室后监测ECG、SPO₂和NIBP。麻醉诱导：依次静脉注射咪唑安定0.1mg/kg、舒芬太尼0.4Ug/kg、维库溴0.1mg/kg和异丙酚2.0mg/kg。行双腔支气管插管准确对位后进行机械通气，潮气量10ml/kg，呼吸频率12次/分，吸呼比为1:2，1?2%异氟烷维持麻醉，并间断使用维库溴铵维持肌松，术中维持PETCO₂在4.7?6.0kpa之间，BIS值40-50。

　　监测指标  分别于术后2h、4h、6h、8h、12h、24h、48h、72h随访病人并记录以下指标：（1）各时间点的镇痛效果：采用VAS评分间接评估静止及活动状态下手术切口的疼痛情况。（2）Ramsay镇静评分：1分为不安静、烦躁；2分为安静合作；3分为嗜睡,能听从指令；4分为睡眠状态,但可唤醒；5分为呼吸反应迟钝；6分为深睡状态,呼唤不醒。其中2～4分镇静满意,5～6分镇静过度。（3）舒适状态评分（BCS Bruggrmann comfort scale）：0分为持续疼痛；1分为安静时无痛,深呼吸或咳嗽时疼痛严重；2分为平卧安静时无痛,深呼吸或咳嗽时轻微疼痛；3分为深呼吸时亦无痛；4分为咳嗽时亦无痛。（4）镇痛药的使用剂量、PCA的实际按压次数及有效按压次数，并计算有效按压次数与实际按压次数之比以及术后各时间点舒芬太尼使用总量[M（Ug）=V（ml）×C（Ug/ml）]。（5）生命体征：SpO₂、RR、HR及MAP。（6）副作用：记录恶心、呕吐、皮肤瘙痒、胸闷等副作用的发生时间及次数，记录病人的排气时间。

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

　　两组病人恶心与呕吐的发生率均较低，可能与本研究的手术病人对消化道干扰较少且以男性为主有关；此外，皮肤瘙痒及胸闷的发生可能与舒芬太尼的使用有关^[10]，但总体发生率较低。

　　本研究表明，开胸术前静脉注射曲马多复合罗哌卡因肋间神经阻滞及术后PCIA联合用于围术期镇痛效果明确，副作用发生率低，并且减少舒芬太尼总的使用量，优于传统的镇痛措施的术后使用。

参考文献

1. Ochroch EA,Gottschalk A. Impact of acute pain and its management for thoracic surgical patients.Thorac Surg Clin.,2005,15:105-21.

2. Doyle E,Bowler GM. Pre-emptive effect of multimodal analgesia  in thoracic surgery. Br J Anaesth,1998,80(2):147-51.

3. Woolf CJ,Chong MS. Preemptive analgesia--treating postoperative pain by preventing the establishment of central sensitization.Anesth Analg，1993，77(2):362-79.

4. Kelly DJ,Ahmad M, Brull SJ. Preemptive analgesia II:recent advances and current trends. Can J Anaesth,2001,48:1091-101.

5. Simpson D, Curran MP,Oldfield V,et al. Ropivacaine:a review of its use in regional anaesthesia and acute pain management. Drugs,2005,65:2675-717.

6. Ng CK,Lirk P,Seymour RA,et al. The efficacy of preemptive analgesia for acute postoperative pain management:a meta-analysis. Anesth Analg,2005,100:754-6.

7. Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg,2005,80:1550-9.

8. Gottschalk A,Freitag M,Burmeister MA,et al. Patient-controlled thoracic epidural infusion with ropivacaine 0.375% provides comparable pain relief as bupivacaine 0.125% plus sufentanil after major abdominal gynecologic tumor surgery. Reg Anesth Pain Med.,2002,27:367-73.

9. Unlugenc H,Ozalevli M,Gunes Y,et al. Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery. Br J Anaesth,2003,91(2):209-13.

10. Bailey PL,Streisand JB,East KA,et al. Differences in magnitude and duration of opioid-induced respiratory depression and analgesia with fentanyl and sufentanil. Anesth analg,1990,70:8-15.