左旋布比卡因用于良性前列腺增生摘除術(shù)后患者自控硬膜外鎮(zhèn)痛效果

1、左旋布比卡因用于良性前列腺增生摘除術(shù)后患者自控硬膜外鎮(zhèn)痛效果及循環(huán)應(yīng)激反應(yīng)影響    【關(guān)鍵詞】  良性前列腺增生     摘要：目的：研究左旋布比卡因伍用芬太尼在良性前列腺增生摘除術(shù)后患者自控硬膜外鎮(zhèn)痛效果及循環(huán)應(yīng)激反應(yīng)的影響。方法：隨機(jī)選擇ASAI級，年齡5575歲、擇期作良性前列腺增生恥骨上經(jīng)膀胱前列腺摘除術(shù)40例為患者自控硬膜外鎮(zhèn)痛組（PCEA組），另隨機(jī)選擇同類手術(shù)患者40例為哌替啶肌注鎮(zhèn)痛組（PMA組）。在PCEA組鎮(zhèn)痛藥液為芬太尼0.5mg、氟哌利多5mg和左旋布比卡因187.5mg用生理鹽水配至10

2、0ml。PMA組當(dāng)患者疼痛難忍時，每次肌注哌替啶0.8mg/kg。分別采用視覺模擬評分（VAS）評定鎮(zhèn)痛效果，監(jiān)測并記錄麻醉前、術(shù)畢、術(shù)后6、12、24h的BP、HR值，并計算心率收縮壓之積（RPP），同時采肘靜脈血，用高效相色譜法測定血漿去甲腎上腺素（NE）和腎上腺素（E）的濃度，術(shù)后膀胱沖洗量、出血量膀胱痙攣兩組患者例數(shù)，鎮(zhèn)痛期間的不良反應(yīng)。結(jié)果：術(shù)后各時點(diǎn)的VAS評分PCEA組較PMA組顯著低（p0.05或p<0.01）PMA組術(shù)后各時點(diǎn)的HR、SBP、RPP、CA及術(shù)后6、12h的DBP均較麻醉前明顯增高（P0.05P或0.01），PCEA組除NE于術(shù)后6h較麻醉前高外（P<

3、;0.01）,其余指標(biāo)與其麻醉前相比無顯著差異（P0.05），術(shù)后各時點(diǎn)的RPP、血漿CA及術(shù)后6、12h的SBP、DBP、HR值均明顯低于PMA組（P0.05或P0.01）。術(shù)后膀胱沖洗量、出血量、膀胱痙攣例數(shù)PMA組均高于PCEA組（P0.05）。結(jié)論：左旋布比卡因伍用芬太尼在良性前列腺增生摘除術(shù)后患者自控硬膜外鎮(zhèn)痛效果理想對循環(huán)應(yīng)激反應(yīng)的影響較小。 關(guān)鍵詞：  左旋布比卡因；  硬膜外；  鎮(zhèn)  痛；  良性前列腺增生 Effect of PCEA with L-bupivacaine after Benign Prostatectomy

4、 and its Influence on Stress Response of Circulation Abstract: Objective:To study the effect of postoperative patient-controlled epidural analgesia with L- bupivacaine and fentanyl after benign prostatectomy and its influence on the  stress response of circulation.Methods:Forty cases ASA underg

5、one elective prostatectomy,aged from 55 to 75,were randomly enrolled into the patient-controlled epidural analgesia group(PCEA). Forty other cases suffered the similar symptoms  were randomly enrolled into the pethidine intramuscular injection group (PMA).In the PCEA group, 100ml Sodium Chlorid

6、e contains fentanyl 0.5mg, droperidol 5mg and L-bupivacaine187.5mg. In the PMA group, pethidine 0.8mg/kg was injected each time when the patient cant bear.The effect was evaluated by visual analogue pain scales.Blood pressure(BP)and heart rate(HR) was monitored and recorded before aneshtesia,at comp

7、letion of operation and 6 hours, 12 hours, 24 hours postoperatively.The result of HR multiplied by systolic BP was also recorded.At the same time blood sample was taken through ulnar vein.The concentration of plasma NE and E was detected by high performance liquid chromatography .Flushing dose of bl

8、adder,hemorrhage volume, the number of patients suffered bladder spasm and adverse reaction postoperatively were recorded in detail.Results:VAS of the PCEA group was significantly lower than that of the PMA group  (P<0.05 or P<0.01 ) at each period postoperatively.In the PMA group HR,SBP,

9、RPP,CA at every period and DBP at 6 hours,12 hours postoperatively was significantly higher(P<0.05 or P<0.01) than that of before aneshtesia.Compared with the parameter before aneshtesia , there is no significant different in the PCEA group.Only the NE is significant higher than that of before

10、 aneshtesia in the PCEA group.In the PCEA group RPP, plasma CA at every period and SBP,DBP , HR at 6 hours,12 hours postoperatively was significantly lowerer than that of the PMA group (P<0.05 or p<0.01 ). Flushing dose of bladder,hemorrhage volume, the number of patients suffered bladder spas

11、m in the PMA group was significant higher than that of the PCEA group(p<0.05 ).Conclusion: Patient-controlled epidural analgesia with L-bupivacaine and fentanyl postoperatively after benign prostatectomy is highly effective and has little  influence on stress response of circulation. Key wor

12、ds:  L-bupivacaine;  Epidural;  Analgesia;  Begin prostate 硬膜外腔持續(xù)泵入芬太尼和布比卡因混合液，產(chǎn)生節(jié)段性鎮(zhèn)痛，效果確切，現(xiàn)已廣泛用于術(shù)后鎮(zhèn)痛1。本研究旨在探討左旋布比卡因伍用芬太尼在良性前列腺增生摘除術(shù)后患者自控硬膜外鎮(zhèn)痛效果及循環(huán)應(yīng)激反應(yīng)的影響。 1  資料與方法 1.1  一般資料：選擇ASAI級，年齡5575歲、擇期作良性前列腺增生恥骨上經(jīng)膀胱前列腺摘除術(shù)80例，隨機(jī)分為患者自控硬膜外鎮(zhèn)痛組（PCEA組）和哌替啶肌注鎮(zhèn)痛組（PMA組）各40例。所有患者術(shù)前心肺功能正

13、常，無內(nèi)分泌及嚴(yán)重肝、腎疾患，無硬膜外穿刺禁忌癥。 1.2  麻醉方法：術(shù)前30min肌注苯巴比妥鈉0.1g、阿托品0.5mg。全部病人術(shù)中均用連續(xù)硬膜外麻醉。選擇23行硬膜外穿刺置管。0.33的卡因維持術(shù)中麻醉，酌情靜注杜非合劑1.52ml，術(shù)中維持生命體征平穩(wěn)。手術(shù)結(jié)束后將患者送回病房，接監(jiān)護(hù)儀監(jiān)測生命體征。 1.3  術(shù)后鎮(zhèn)痛：PCEA組于術(shù)畢給予0.25左旋布比卡因4ml，接PCAD泵作PCEA。鎮(zhèn)痛藥液為芬太尼0.5mg、氟哌利多5mg和左旋布比卡因187.5mg用生理鹽水配至100ml。常規(guī)液速2ml/h，追加量為0.5ml/次，鎖定時間15min，鎮(zhèn)痛時間為2

14、448h。PMA組：當(dāng)患者疼痛難忍時，每次肌注哌替啶0.8mg/kg。 1.4  觀察指標(biāo)：鎮(zhèn)痛效果：采用視覺模擬評分（VAS）評定鎮(zhèn)痛效果。0分為無痛，3分為鎮(zhèn)痛良好，35分為基本滿意，5分為鎮(zhèn)痛不滿意，10分為劇痛。術(shù)后作6、12、24h的疼痛評分。循環(huán)及兒茶酚胺（CA）：監(jiān)測并記錄麻醉前、術(shù)畢、術(shù)后6、12、24h的BP、HR值，并計算心率收縮壓之積（RPP），同時采肘靜脈血，用高效相色譜法測定血漿去甲腎上腺素（NE）和腎上腺素（E）的濃度。術(shù)后膀胱沖洗量、出血量、膀胱痙攣兩組患者例數(shù)。鎮(zhèn)痛期間的不良反應(yīng)。2  結(jié)果兩組患者的年齡、身高、體重、ASA分級、麻醉用藥、術(shù)

15、中及術(shù)后輸液量均無顯著性差異（P0.05）。PMA組術(shù)后6及12h的VAS評分和術(shù)畢相比明顯增高，尤以術(shù)后6h評分最高，術(shù)后各時點(diǎn)的VAS評分PCEA組較PMA組顯著低（P0.05或P<0.01)，見表1。兩組患者術(shù)畢時HR、RPP、SBP值及CA濃度較麻醉前均明顯增高（P0.05或P0.01），且PMA組術(shù)后各時點(diǎn)的HR、SBP、RPP、CA及術(shù)后6、12h的DBP均較麻醉前明顯增高（P0.05或P0.01），而PCEA組除NE于術(shù)后6h較麻醉前高外（P<0.01）,其余指標(biāo)與其麻醉前相比無顯著差異（P0.05）且術(shù)后各時點(diǎn)的RPP、血漿CA及術(shù)后6、12h的SBP、DBP、HR

16、值均明顯低于PMA組（P0.05或P0.01)，見表2。術(shù)后膀胱沖洗量、出血量、膀胱痙攣例數(shù)PMA組均高于PCEA組（P0.05)，見表3。兩組患者鎮(zhèn)痛期間，PMA組有4例出現(xiàn)惡心嘔吐，PCEA組有5例輕度嗜睡。 表1  術(shù)后VAS評分（略） 與術(shù)畢比*P0.01；與PMA組比P0.05  P<0.01 表2  血漿CA和循環(huán)的變化（略）與麻醉前比，*P0.05*P0.01；與PMA組比，P0.05P<0.01 表3  術(shù)后膀胱沖洗量、出血量、膀胱痙攣例數(shù)（略） 組間比較：*P0.05 3  討論國人良性前列腺增生癥的發(fā)病率隨著人均

17、壽命的延長，呈逐年上升與歐美國家的發(fā)病情況已很相近2。其手術(shù)摘除為主要治療方法，甚至被認(rèn)為是唯一有效的方法3術(shù)后膀胱沖洗、后尿道手術(shù)創(chuàng)傷可能誘導(dǎo)陣發(fā)性膀胱痙攣。表現(xiàn)為恥骨、會陰部及尿道外口不適，尿意急迫，肛門墜脹，部分患者出現(xiàn)膀胱尿道的陣發(fā)性收縮痛，膀胱痙攣性疼痛發(fā)作導(dǎo)致膀胱內(nèi)壓增高，膀胱壁靜脈回流障礙，膀胱頸及前列腺窩創(chuàng)緣反復(fù)被牽拉，不但增加患者痛苦，也可能引起繼發(fā)性出血，延長術(shù)后膀胱沖洗及留置導(dǎo)尿時間，不利于術(shù)后恢復(fù)4。左旋布比卡因的優(yōu)點(diǎn)是體內(nèi)分布廣，清除慢故作用時間長，游離血藥濃度低，故中樞神經(jīng)系統(tǒng)和心臟毒性較小，且心律失常的閾值高，臨床安全范圍較大5。本研究提示：左旋布比卡因伍用芬太尼行PCEA解除了前列腺摘除術(shù)后病人的疼痛不適、減弱了術(shù)后應(yīng)激反應(yīng)、減少膀胱痙攣和術(shù)后膀胱沖洗量、出血量，值得臨床應(yīng)用。 參考文獻(xiàn)： 1  Sandler AN，strig D，Panos L.A randomized double-blind comparison of lumbar epidural and intravenous fentanyl infusion for postthoracotomy pain relief，analgesic，ph