摘要：
目的 探讨肋间神经阻滞联合氨酚羟考酮治疗开胸术后患者肋间神经痛的安全性及可行性.方法 统计2014年1月至2016年1月湖北省中山医院常规后外侧标准开胸切口术后出现肋间神经痛患者56例,年龄45～76岁,性别不限.采用随机数字表法分为单纯口服药物组和联合治疗组,每组28例.两组患者术后常规给予盐酸曲马多注射液静脉泵止痛3d,撤去镇痛泵后如患者视觉模拟评分(VAS)评分≥4,口服药物组给予氨酚羟考酮1片,每次给药间隔6h;联合治疗组则根据患者受累肋间神经节段,采用肋角处肋间神经阻滞,治疗时间为1次/3d,从第2周起改为1次/周,共治疗4周,治疗期间如患者VAS评分≥4,则给予氨酚羟考酮1片,每次给药间隔6h.记录治疗前1d及治疗1周、4周、90 d时患者VAS评分,记录治疗4周及90 d时患者使用氨酚羟考酮的总量,记录患者肋间神经阻滞和口服氨酚羟考酮药物相关不良反应.结果 联合治疗组治疗1周、4周、90 d时VAS评分均明显低于口服药物组(3.8±0.7比5.2±0.9,2.1±0.5比4.1±0.6,1.6±0.5比3.2±0.6,P＜0.05).联合治疗组治疗4周、90 d时氨酚羟考酮使用剂量明显少于口服药物组(705±163比1308±232,1965±487比4098 526,P＜0.05);治疗1周、4周、90 d时联合治疗组VAS评分0～3的患者分别为15例(54％)、22例(79％)、26例(93％),远高于口服药物组5例(18％)、12例(42％)、20例(71％),差异有统计学意义(P＜0.05).两组患者未见与肋间神经阻滞有关的气胸及局麻药中毒反应.治疗4周内两组均未见头晕不良反应,口服药物组恶心呕吐54例次,便秘208例次,联合治疗组恶心呕吐12例次,便秘60例次.结论 肋间神经阻滞联合氨酚羟考酮治疗开胸术后患者肋间神经痛,可明显减轻疼痛,减少氨酚羟考酮使用剂量,减少药物不良反应,该方法安全有效.%Objective To investigate the clinical safety and feasibility of intercostal nerve block combined with oral compound oxycodone and acetaminophen in treatment of patients with intercostal neuralgia after thoracotomy.Methods Fifty-six patients,both sexes,aged 45-76 years old,with intercostal neuralgia who underwent standard posterolateral thoracotomy in Zhongshan Hospital of Hubei Province from January 2014 to January 2016,were randomly divided into oral drug group and combined treatment group,28 cases in each group.All patients were given postoperative intravenous anesthesia with tramadol hydrochloride in a continuous pump for 3 days.Patients were given oral compound oxycodone and acetaminophen 1 tablet every 6 h in oral drug group if VAS was ≥4 after analgesic pump was removed.The intercostal nerve block at the rib angle was used according to the patient's affected intercostal nerve segment in combined treatment group,once every 3 days,and once a week from the second week for a total of 4 weeks.Oral administration of compound oxycodone and acetaminophen 1 tablet was given if VAS≥4,and the interval between each administration was 6 h.The VAS was recorded at 1 day before the treatment,and 1 week,4 weeks and 90 days after the treatment.The doses of compound oxycodone and acetaminophen were recorded at 4 weeks and 90 days after the treatment.The adverse events related to intercostal nerve block and oral compound oxycodone and acetaminophen were recorded.Results The VAS was significantly lower in combined treatment group than that in oral drug group at 1 week,4 weeks and 90 days after the treatment (3.8±0.7 vs.5.2±0.9,2.1±0.5 vs.4.1± 0.6,1.6±0.5 vs.3.2±0.6,P＜0.05).The doses of oxycodone and acetaminophen in combined treatment group were significantly lower than that in oral drug group at 4 weeks and 90 days after the treatment (705 ± 163 vs.1308±232,1965±487 vs.4098±526,P＜0.05).There were 15 cases (54％),22 cases (79％) and 26 cases (93％) with VAS 0-3 at 1 week,4 weeks,and 90 days after the treatment respectively in combined treatment group,which was much higher than 5 cases (18％),12 cases (42％),and 20 cases (71％) in oral drug group (P＜0.05).No adverse reactions of pneumothorax and local anesthetic poisoning associated with intercostal nerve block in the two groups were found.Within 4 weeks of treatment,there was no dizziness in the two groups.Nausea and vomiting were 54 case-times and constipation 208 case-times in oral drug group,and 12 case-times and constipation 60 case-times in combined treatment group.Conclusion Intercostal nerve block combined with oral administration of compound oxycodone and acetaminophen can significantly relieve intercostal neuralgia after thoracotomy,reduce the oral dosage of oxycodone and acetaminophen and adverse reactions.
