围术期使用右美沙芬缓解乳腺癌根治术后疼痛及减少阿片类药物用量

摘要

目的探讨围术期使用N-甲基-D-天门冬氨酸(NMDA)受体拮抗剂右美沙芬(Dextromethor-phan,DM)缓解乳腺根治术后疼痛的效应及对术后阿片类镇痛药物用量的影响.方法40例女性乳腺癌择期手术患者,随机分为四组:A组于切皮前30 min及术毕肌注DM 1 mg/kg;B组仅在切皮前30 min肌注DM 1mg/kg;C组于术毕肌注DM 1 mg/kg;D组为生量盐水对照组,四组病人术后均接受芬太尼肌内缓释自控镇痛措施.记录术毕至PCA泵开放的时间及术后不同时间点的累计消耗量、疼痛记分及镇痛相关的副作用(如恶心、呕吐、嗑睡、头晕、呼吸抑制等).结果从手术结束至PCA泵开放的时间A组明显长于B、C组(P＜0.05)及D组(P＜0.01),B、C两组间无显著差异(P＞0.05),但也均较D组长(P＜0.05).术后各时点芬太尼累计使用量A,B和C三组均较D组明显减少(P＜0.01);4 h后A组用量小于B、C组(P＜0.05);B组与C组比较虽有减小趋势,但无统计学差异(P＞0.05).VAS评分A组在术后2,4,24和48 h较D组明显减小(P＜0.01),8 h时点未见显著差异(P＞0.05),B、C两组在术后48 h时的VAS评分明显小于D组,其它各时点未见明显差异(P＞0.05).各组均未见典型的芬太尼相关副作用.结论围术期使用DM可提高术后镇痛的效果,延迟患者对阿片类药物的需求并减少阿片类药物的用量,并且术前及术后各肌注DM 1 mg/kg的用药方式比单纯术前或术后注射DM 1 mg/kg所达到的效果更加优越.%Objective: To investigate the effects of dextromethorphan (DM) which is an antitussive and a N-methyl-D-aspartate (NMDA) receptor antagonist as well. It is intramuscularly (I.M.) injected in perioperative period, reduces pain and decreases the requirements of opioid analgesic after radical mastectomy (RM). Methods: 40 patients scheduled for radical mastectomy were included and randomly allocated into 4 groups. In group A(n =10), patients received DM (1 mg/kg) I.M. for 2 times respectively, one is at 30 min preoperation and the other at the end of the surgery; while in group B and C(n =10), 1 mg/kg DM was given only once at 30 min preoperation or at the end of the surgery, the other injection was replaced with isovolumic normal saline. In group D(n =10), as the control, the two I.M. injections were both with normal saline. Fentanyl patient controlled intramuscular alagesia (PCIA) (10 μg/h, single dosage: 10 μg, lockout time: 15 min) was switched on when the Visual Algesia Scale (VAS) reached to 3. The time to initiate PCIA from the end of surgery, total fentanyl consumption, pain score and analgesia-related side effects were recorded during 48 h postoperation. Results: The longest lasting time of PCIA started (P＜0.O1) and the lowest fentanyl consumption (P＜0.01) were observed in group A rather than in group B, C and D. The longer time and lower fentanyl consumption (P＜0.01) were also observed in group B and C (P＜0.05) compared with those in group D. There were no statistic significances between group B and C. The VAS of group A was lower than that of group D at 2, 4, 24 and 48 h postoperation , while VAS of group B,C were lower only at 48 h postoperation. No typical analgesia-related side effects were found in all groups. Conclusions: Perioperative DM I.M. injection can improve the analgesic effects of fentanyl and reduce opioid requirements after RM. Moreover, the preoperative and postoperative administration of DM (1 mg/kg) and I.M.injection respectively can receive better analgesic effects than singly use preoperative or postoperative injection.