目的 观察小剂量氯胺酮联合帕瑞昔布钠是否可以抑制持续大剂量输注瑞芬太尼后引起的术后痛觉过敏.方法 选择在瑞芬太尼复合静脉全麻下行择期腹腔镜下胆囊切除手术患者80例,ASA I-Ⅱ级,年龄21～63岁,性别不限.随机分为4组(n=20),氯胺酮组(A组),帕瑞昔布钠组(B组),氯胺酮+帕瑞昔布钠组(C组),安慰剂组(D组).观察手术结束后苏醒时间、气管拔管时间及记录拔管后5、10、15、30、60 min的口述疼痛评分(VRS),及拔管后2、4、8、12和24 h时视觉模拟评分(VAS),术后病房24 h内要求镇痛例数及各类不良反应.结果 4组患者年龄、性别、体质量、麻醉时间、手术时间及瑞芬太尼用量比较差异无统计学意义(P>0.05).4组患者术后24 h多梦、恶心、呕吐、复视等不良反应少见,无严重并发症.4组患者苏醒时间、气管拔管时间差异无统计学意义(P>0.05),A、D两组VRS与VAS评分各时点差异无统计学意义(P>0.05);拔管后5、15、30 min,VRS评分B组低于D组(P<0.05);C组于拔管后5、10、15、30 minVRS评分低于D组(P<0.05);B、C两组拔管后1h内VRS评分差异无统计学意义(P>0.05);B组于拔管后2、4 h,VAS评分低于D组(P<0.05);C组于拔管后2、4、8、12 h,VAS评分低于D组(P<0.05).C组术后病房内24 h要求镇痛病例数少于其他3组(P<0.05).结论 切皮前静脉注射氯胺酮0.5 mg/kg联合术毕前20 min注射帕瑞昔布钠40mg,相对单独使用氯胺酮或帕瑞昔布钠在抑制大剂量输注瑞芬太尼后引起的术后痛觉过敏方面作用更佳.%Objective To investigate the suppressive effects of low - dose ketamine combined with parecoxib on postoperative hyperalgesia afterremifentanil -based anaesthesia. Methods Eighty ASA Ⅰ or Ⅱ patients aged 21 -63 yr,weighing 45 -82 kg underging undergoing laparoscopic eholecystectomy under remifentanil - propofol anesthesia were randomly assigned to 4 groups. Group A (ketamine - group)、group B ( parecoxib - group) 、group C ( ketamine + parecoxib - group)and group D( comfort - group). The emergence time and trachea extubation time were recorded. The VRS score at 5、10、15、30、60min after trachea extubation and VAS score at 2、4、8、12、24h after operation were recorded. Results There were no difference of emergence time and trachea extubation time in four groups. The VRS score at 5、 15、30min in group B and at 5 、16、15、30min in group C were lower than group D( P ＜0.05 ). The VAS score at 2、4h in group B and at 2、4、8、12h in group C were lower than group D(P ＜ 0.05). Patients requried analgesia after operation in group Cleas than other groups(P ＜ 0.05).Conclusion Before skin incision iv ketamine 0. 5mg/kg and twenty minutes before the end of surgery ivparecoxib 40mg can reduce remifentanel -based anaesthesia, ,and the efficacy is better than that of ketamine or parecoxib alone.
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