鞘内注射吗啡和舒芬太尼超前镇痛的效果比较

摘要

目的 观察鞘内注射吗啡、舒芬太尼超前镇痛对术后疼痛的影响及不良反应情况,同时观察阿片类药物鞘内注射超前镇痛与传统硬膜外给药在术后镇痛方面的区别.方法 选择60例全子宫切除术患者,随机分成3组,每组20例,均实施腰-硬联合麻醉.采用双盲法鞘内注药:吗啡组(M组):罗哌卡因20 mg+吗啡0.3 mg;舒芬太尼组(S组):罗哌卡因20 mg+舒芬太尼8 μg;对照组(R组):罗哌卡因20 mg,3组均加10%葡萄糖至3 ml.患者自控硬膜外镇痛泵(PCEA)配方:各组均为0.16%罗哌卡因+0.0025%氟哌利多+0.9%氯化钠溶液至100 ml,其中R组在PCEA中添加吗啡6 mg(浓度为0.006%).镇痛泵设置:背景剂量2 ml/h,自控镇痛1 ml,锁定时间15 min,每小时限量6 ml,镇痛时间24 h.随访记录术后2、4、6、8、24、36、48 h时患者的镇痛情况,采用视觉模拟评分(VAS)和普瑞斯-亨利(P-H)评分进行评价;比较3组患者PCEA总按压次数和有效按压次数,并记录围术期不良反应.结果 各组VAS及P-H评分呈现一致性,M组于各时点VAS分别为(10±7)、(13±8)、(11±8)、(16±8)、(10±8)、(6±6)、(3±4)分,均明显低于R组各时点VAS:(25±13)、(32±10)、(40±9)、(39±12)、(28±10)、(20±9)、(13±11)分(P＜0.05);S组各时点评分为(2±2)、(9±11)、(19±15)、(25±9)、(19±8)、(12±6)、(8±7)分,均明显低于R组(P＜0.05);S组VAS于术后2 h低于M组(P＜0.05),后5个时点VAS M组低于S组(P＜0.05).PCEA泵的使用情况:M组与S组总按压次数和有效按压次数在各时间点与R组相比,差异均有统计学意义(P＜0.05).围术期不良反应:M组、S组及R组发生恶心者分别为17、2、17例;发生呕吐者分别为11、1、8例;出现瘙痒者分别为6、12、5例.3组不良反应发生率间差异有统计学意义(P＜0.05).结论 鞘内注入吗啡0.3 mg或舒芬太尼8 μg用于超前镇痛的效果明显优于传统镇痛方式.其中鞘内注射吗啡的镇痛作用强而持久但不良反应多,可用于中长手术的术后镇痛;鞘内注射舒芬太尼的镇痛时效短、作用强,且副作用少,可应用于剖宫产术等时间较短手术的术后镇痛.%Objective To observe the effect of preemptive analgesia by intrathecal injections of morphine and sufentanil on postoperative pains and its adverse reactions,and to analyze the difference between preemptive analgesia by intrathecal opioids injection and postoperative analgesia by traditional epidural analgesia.Methods Sixty ASAⅠorⅡpatients undergoing elective hysterectomy were randomly divided into 3 groups,20 in each.All patients received combined spinal and epidural anesthesia.By double blind method,morphine group(M group) were injected intrathecally with ropivacaine (20 mg)+morphine (0.3 mg),sufentanil group(S group) with ropivacaine (20 mg)+sufentanil(8 μg),control group(R group) with ropivacaine(20 mg);10% glucose solution was added up to 3 ml in three groups.Prescription for PCEA pump was 0.16% ropivacaine plus 0.0025% droperidol plus sodium chloride up to 100 ml,and 6 mg of 0 006% morphine was added to PCEA in R group.In analgesia pump settings,basal dose was 2 m/h,PCA dose 1 ml,lockout time 15 min,hour limit 6 ml,analgesia time 24 hours.Postoperative analgesic effects at hours 2,4,6,8,24,36,48 were estimated by visual analogue scores(VAS) and Prius-Henry(P-H);PCEA total or effective pressing frequencies were compared in three groups,and perioperative adverse reactions were recorded.Results VAS and P-H scores of three groups showed consistency,VAS scores at hours 2,4,6,8,24,36,48 were significantly lower in M group (10±7,13±8,11±8,16±8,10±8,6±6,3±4,respectively) than in R group(25±13,32±10,40±9,39±12,28±10,20±9,13±11,respectively),lower in S group(2±2,9±11,19±15,25±9,19±8,12±6,8±7,respectively) than in R group(P＜0.05);VAS scores were lower in S group than in M group 2 h after operation(P＜0.05),but lower in M group than in S group at the last 5 time points(P＜0.05).Groups M and S were significantly different from group R in total or effective pressing frequencies at different time points(P＜0.05).Of groups M,S,R,perioperative nausea occurred in 17,2,17 patients,respectively;vomiting in 11,1,8,respectively,itching in 6,12,5,respectively,the difference was significant(P＜0.05).Conclusion The effect of preemptive analgesia by intrathecal injection of morphine(0.3 mg) or sufentanil(8 μg) is obviously superior to traditional analgesic methods.Intrathecal morphine injection,having strong effect and lasting long with more adverse reactions,can be used in postoperative analgesia in medium or long surgeries;intrathecal sufentanil injection,having shorter expiry time but being strong with fewer adverse reactions,can be used in postoperative analgesia in shorter surgeries such as cesarean section.