Effect of Different Methods for Postoperative Pain Management on Catecholamine Release to Abdominal Surgery<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

曾　莉  吴新民  马　琼  苏　玉
北京大学第一医院麻醉科，北京100034
Li Zeng, Xinmin Wu, Qiong Ma, Yu Su.
Department of Anesthesiology, Peking University First Hospital, Beijing 100034

ABSTRACT

　　Objective：To observe the effect of different analgesic methods and the influence of catecholamine response to elective abdominal surgery.
　　Methods：42 ASAⅠ～Ⅱ patients undergoing elective abdominal surgery were randomly divided into five groups. After receiving combined general and epidural anesthesia, postoperative patient-controlled epidural analgesia was provided in group RF, BF, BM with 0.12% ropivacaine+2μg／ml fentanyl, 0.12%bupivacaine+2μg/ml fentanyl, 0.12% bupivacaine+80μg/ml morphine respectively. Group EM received general-epidural anesthesia and patient-controlled intravenous analgesia with 0.5mg/ml morphine. Score of analgesics (VAS,VRS), plasma concentrations of adrenaline and noradenaline were measured.
　　Results：Effective analgesia could be achieved in all groups. VAS in group BM and M was significantly less than that in group RF(p＜0.05), and VRS in group BM was higher than that in group RF,EM and M(p＜0.05). There were more side effects in group BM, M and EM, the incidence of nausea was highest in group M(5 cases). The adrenaline concentrations in group BM one hour postoperative was lower than that in group BF(p=0.034), and noradrenaline in group EM was lower than that in group RF(p=0.033). The adrenaline and noradrenaline in group M in 24 hour postoperative were higher than preoperative values(p=0.038).
　　Conclusions：Postoperative patient-controlled epidural or intravenous analgesia could provide effective analgesia. Epidural anesthesia during operation or epidural analgesia postoperation could depress stress responses, thus it is more effective analgesic method.
　　Key words：Analgesia, Epidural, Intravenous; Stress

　　腹部手术后的镇痛国内外已有许多研究，硬膜外腔给予局麻药复合阿片类药物病人自控镇痛和静脉给予阿片类药物病人自控镇痛是主要的镇痛方法。本实验拟研究不同局麻药（布比卡因、罗哌卡因）与不同阿片类药物（芬太尼、吗啡）复合的镇痛效果，不同麻醉方法（硬膜外+全麻、单纯全麻）及不同镇痛方法（硬膜外镇痛、静脉镇痛）对术后血浆儿茶酚胺的影响。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

资料和方法

　　选择ASAⅠ～Ⅱ级，择期行腹部手术患者42例，术前无免疫和内分泌系统疾病，手术时间在4小时以内。随机分为五组：RF、BF、BM组术后持续硬膜外镇痛，M、EM组术后持续静脉吗啡镇痛。术前30分钟肌注哌替啶50mg、异丙嗪25mg、东莨菪碱0.3mg，入室后开放静脉，监测心电图、血压（无创袖带血压或直接桡动脉测压）、脉搏氧饱和度和呼吸次数。
　　RF组：采用硬膜外复合全麻的麻醉方法。根据手术部位行硬膜外穿刺置管，硬膜外注入2%利多卡因4ml，5分钟后测出有相对平面，静脉注入异丙酚1.5～2mg／kg、芬太尼0.1mg、维库溴胺0.1mg／kg诱导插管，术中以异氟醚+N₂O、维库溴胺和硬膜外持续泵入2%利多卡因和0.33%的卡因合剂4～6ml维持麻醉。术毕缝皮结束即开启镇痛泵行持续硬膜外镇痛，镇痛液为0.12%罗哌卡因（ropivacaine）+2μg／ml芬太尼，背景输注速度4ml／h，病人自控剂量（PCA）2ml／次，锁定时间20分钟。
　　BF组：麻醉方法及术中维持同前。硬膜外镇痛液为0.12%布比卡因（bupivacaine）+2μg／ml芬太尼，输注设定同前。
　　BM组：麻醉方法及术中维持同前。硬膜外镇痛液为0.12%布比卡因+80μg／ml吗啡，输注设定同前。
　　EM组：麻醉方法及术中维持同前。术毕拔除硬膜外管，予静脉持续镇痛，镇痛液为吗啡0.5mg／ml，背景输注速度1ml／h，PCA2ml／次，锁定时间6分钟。
　　M组：麻醉方法为单纯全麻，静脉诱导用药同前，术中以异氟醚+N₂O和维库溴胺维持麻醉，术毕缝皮结束即开启静脉持续镇痛泵，镇痛液及输注设定同EM组。
　　所有病例采用美国Abbott或英国Graseby9300镇痛泵，术中及术毕不用镇吐药。
　　术后24小时随访病人，采用视觉模拟评分法（VAS）及Keele疼痛描述四分法（VRS）评估镇痛效果。VAS评分法标准：0～完全无痛，10～40轻度疼痛，50～90重度疼痛，100～剧痛，无法忍受。小于40为镇痛有效。VRS评分法标准：0-剧痛，1-平静时轻度疼痛，咳嗽、深呼吸受限，2-平静时不痛，咳嗽及深呼吸觉疼痛，3-完全无痛。评分越高表明镇痛效果越好。
　　随访时纪录24小时用药量、PCA按压次数和有效次数，以及头晕、恶心、呕吐、瘙痒、肢体麻木、嗜睡、呼吸抑制等副作用。
　　患者入室后分别于麻醉前、术毕1小时和术后24小时记录血压、心率、呼吸，同时取静脉血5ml，于2个月内用改良荧光法测定血浆肾上腺素（E）和去甲肾上腺素（NE）。
　　所得结果以均数±标准差表示，计量资料采用单因素方差分析和t检验，计数资料采用x²检验和直接概率法，p＜0.05认为有显著性差异。

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

　　1、各组病人的性别、年龄、身高、体重、手术时间、手术种类无显著性差异。
　　2、镇痛效果和副作用（表1）
　　PCA按压次数及有效次数BM组最少，而RF组和EM组最多，按压次数BM组最大值为10次，RF组和EM组分别为31次、32次。有效次数BM组最大值为7次，RF组和EM组分别为27次、29次。
　　VAS评分以BM、M组最低，与RF组相比有显著性差异（均为p=0.005）。RF组VAS评分最高，但也在有效镇痛范围(＜40)。
　　VRS评分以BM组最高，与RF、EM、M组相比有显著性差异（p值分别为0.02、0.02、0.008）。
　　24小时药量硬膜外各组间（RF、BF、BM组）、静脉各组间（M、EM组）无显著性差异。
　　镇痛液中含吗啡的BM、M、EM组副作用较多。恶心、瘙痒的发生率最高，各有8例，其中以M组恶心发生率最高（5/8），与BF组相比有显著性差异（γ=0.0009，γ＜γ'=0.0045)。
　　所有患者术后24小时均留置导尿管，故未观察到尿潴留的发生。所有患者均未观察到呼吸抑制。
　　3、血液动力学变化及儿茶酚胺测定（表2）
　　各组血液动力学变化均在正常范围。各组间平均动脉压（MAP）、心率（HR）、呼吸频率（R）均无显著性差异。BM组MAP与术前相比，术后24小时下降9.3%，有显著性差异（p=0.015）。BM组HR在术后24小时比术前升高7.43%，统计学上无显著性差异。
　　术前肾上腺素（E）和去甲肾上腺素（NE）各组间比较无显著性差异。术后1小时BM组的肾上腺素数值最低，BF组最高，两组间比较有显著性差异（p=0.034）；而EM组去甲肾上腺素在术后1小时最低，RF组最高，两组间比较有显著性差异（p=0.033）。
　　术后24小时各组间肾上腺素和去甲肾上腺素无显著性差异。M组术后24小时肾上腺素和去甲肾上腺素均高于术前，组内比较有显著性差异（p=0.038）。其余各组术后24小时肾上腺素和去甲肾上腺素均接近或低于术前水平，组内比较无显著性差异。

　　通过实验我们可以得出结论，目前常用的局麻药（0.12%布比卡因、罗哌卡因）复合阿片类（吗啡80μg／ml、芬太尼2μg／ml）硬膜外病人自控镇痛或吗啡0.5mg／ml^-1静脉病人自控镇痛的方法都有明确的镇痛效果，术中复合硬膜外腔阻滞以及术后施行硬膜外镇痛可以显著减轻术后应激反应的程度，是更有效的术后镇痛方法。布比卡因复合吗啡硬膜外病人自控镇痛的镇痛效果更佳，但是副反应亦最多。

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