帕瑞昔布联合胸段硬膜外镇痛对胸外科手术后镇痛效果及应激反应的影响
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摘要
目的：观察帕瑞昔布联合胸段硬膜外镇痛,对胸外科手术患者术后急性疼痛的治疗效果及对机体应激反应的影响,并调查术后1个月时切口残余痛的发生情况。
方法：选择ASAⅠ或Ⅱ级胸外科手术患者56例参加此项前瞻性、随机化、双盲及安慰剂对照的研究。两组患者均进行标准化的麻醉诱导,术后接受患者自控硬膜外镇痛(PCEA)至胸管拔除。所有患者被随机分为安慰剂组(C组,n=28)和帕瑞昔布组(P组,n=28),术前30min分别注射帕瑞昔布40mg(生理盐水稀释至4m1)或安慰剂(0.9%NaCl溶液4m1),术后每隔12h再次静脉注射帕瑞昔布40mg(剂量为80mg/d)或安慰剂至术后第3天。记录两组患者术后2h、4h、8h、24h、48h、72h的疼痛强度(VAS评分)、镇痛泵的按压次数、不良反应、72h镇痛满意度评分和符合出院标准的时间。分别于麻醉前(T0)、术后第1天(T1)、术后第3天(T2)观察血浆皮质醇、促肾上腺皮质激素、白细胞介素-6及肿瘤坏死因子-a水平。术后1个月电话问卷调查两组患者切口残余疼痛的发生率、疼痛的特点以及疼痛对日常生活的影响。
结果：(1)帕瑞昔布组在术后2h、4h、8h、24h、48h、72h时的静息和活动VAS疼痛评分均低于安慰剂组(P<0.01),72小时内PCA有效按压次数明显低于对照组(P<0.01),镇痛满意度更高(P<0.01)。两组不良反应及符合出院标准的时间无显著差异。(2)帕瑞昔布组术后第1天血皮质醇水平与术前比较无显著差异,安慰剂组则明显高于术前水平(P<0.01)；术后第3天安慰剂组的皮质醇水平仍高于帕瑞昔布组；两组术后的ACTH值均低于术前水平(P<0.01),且帕瑞昔布组的ACTH水平在术后明显低于安慰剂组(P<0.01)。(3)两组患者血清IL-6、TNF-a水平在术后第1天、术后第3天均无明显变化,两组在各时间点测量结果无明显差别。(4)术后1个月随访时,帕瑞昔布组的切口残余痛发生率为24%,安慰剂组为53.8%,两组差别有显著性。安慰剂组的疼痛总评分明显高于帕瑞昔布组(P<0.05),分别为12.1±1.8及9.04±2.2。帕瑞昔布组与安慰剂组触诱发痛的发生率分别为4%和15.4%,各有3例和10例患者的切口残余疼痛影响到日常生活。
结论：在胸段硬膜外镇痛的基础上,联合使用选择性COX-2抑制剂帕瑞昔布进行多模式镇痛,能够改善胸外科手术患者术后急性疼痛的治疗效果,明显减轻手术创伤激活的过度应激反应,缓解免疫损伤,同时可能在一定程度上控制了慢性疼痛的发展,对胸外科手术后患者的康复具有重要意义。
Objective:To study the analgesia effects of intravenous parecoxib combined with thoracic epidural analgesia (TEA) as well as its effect on stress response after thoracic surgery, and to investigate the residual pain1month postoperatively.
Methods:Fifty-six ASA class I or Ⅱ patients undergoing thoracic surgery were included in this prospective, randomized, double-blind, placebo-controlled study. General anesthesia was standardized. Patient-controlled epidural analgesia (T7-T8) was used until chest tubes were removed. All patients were randomly divided into two groups:placebo group (group C, n=28) or parecoxib sodium group (group P, n=28). Patients in two groups were allocated to receive parecoxib or placebo (normal saline) intravenously just0.5h before the operation and every12h after operation for3days. The intensity of pain was measured by using a VAS (0=no pain,10=worst pain) and recorded at2,4,8,24,48,72h after operation. The actual/effective number of PC A, the side effects, the overall satisfaction to analgesic therapy in72h and the days fit for discharge were recorded. Venous blood samples were taken before operation, the1st and3rd day after operation for detecting cortisol, ACTH, interleukin-6and tumor necrosis factor-a level. The incidences of residual pain, the VAS of pain, the characteristic of pain, the impact on the daily life were questioned with telephone interview1month after surgery.
Results:
(1) Postoperative pain scores at rest and during coughing were lower in the parecoxib group compared to those in placebo group at2,4,8,24,48,72h postoperatively (P<0.01). The effective number of PCA was significantly less and patient satisfaction was greater in the parecoxib group than placebo group (P<0.01). Adverse effect and the days fit for discharge were comparable between two groups.
(2) There were no significant differences in cortisol level between T1and TO in parecoxib group (P>0.05), while cortisol levels were significantly increased in placebo group (P<0.01) at T1. The cortisol levels in placebo group were higher than parecoxib group at T2. The level of ACTH both decreased in two groups after operation but it was significantly lower in parecoxib group than that in placebo group.
(3) There were no changes in plasma IL-6and TNF-a levels before and after analgesia at T1and T2(P>0.05).
(4) The incidence of residual pain were24%and53.8%separately in group P and C1month postoperatively (P<0.05). Parecoxib group had a lower pain score than placebo group (P<0.05). The incidence of allodyna were4%and15.4%separately in group P and S (P<0.05). Three patient in group P and10patients in group C had chronic pain affecting their daily life.
Conclusions:Parecoxib in multimodal analgesia improves postoperative analgesia provided by TEA, relieves stress response after thoracic surgery, and may restrain the development of chronic pain.
方法：选择ASAⅠ或Ⅱ级胸外科手术患者56例参加此项前瞻性、随机化、双盲及安慰剂对照的研究。两组患者均进行标准化的麻醉诱导,术后接受患者自控硬膜外镇痛(PCEA)至胸管拔除。所有患者被随机分为安慰剂组(C组,n=28)和帕瑞昔布组(P组,n=28),术前30min分别注射帕瑞昔布40mg(生理盐水稀释至4m1)或安慰剂(0.9%NaCl溶液4m1),术后每隔12h再次静脉注射帕瑞昔布40mg(剂量为80mg/d)或安慰剂至术后第3天。记录两组患者术后2h、4h、8h、24h、48h、72h的疼痛强度(VAS评分)、镇痛泵的按压次数、不良反应、72h镇痛满意度评分和符合出院标准的时间。分别于麻醉前(T0)、术后第1天(T1)、术后第3天(T2)观察血浆皮质醇、促肾上腺皮质激素、白细胞介素-6及肿瘤坏死因子-a水平。术后1个月电话问卷调查两组患者切口残余疼痛的发生率、疼痛的特点以及疼痛对日常生活的影响。
结果：(1)帕瑞昔布组在术后2h、4h、8h、24h、48h、72h时的静息和活动VAS疼痛评分均低于安慰剂组(P<0.01),72小时内PCA有效按压次数明显低于对照组(P<0.01),镇痛满意度更高(P<0.01)。两组不良反应及符合出院标准的时间无显著差异。(2)帕瑞昔布组术后第1天血皮质醇水平与术前比较无显著差异,安慰剂组则明显高于术前水平(P<0.01)；术后第3天安慰剂组的皮质醇水平仍高于帕瑞昔布组；两组术后的ACTH值均低于术前水平(P<0.01),且帕瑞昔布组的ACTH水平在术后明显低于安慰剂组(P<0.01)。(3)两组患者血清IL-6、TNF-a水平在术后第1天、术后第3天均无明显变化,两组在各时间点测量结果无明显差别。(4)术后1个月随访时,帕瑞昔布组的切口残余痛发生率为24%,安慰剂组为53.8%,两组差别有显著性。安慰剂组的疼痛总评分明显高于帕瑞昔布组(P<0.05),分别为12.1±1.8及9.04±2.2。帕瑞昔布组与安慰剂组触诱发痛的发生率分别为4%和15.4%,各有3例和10例患者的切口残余疼痛影响到日常生活。
结论：在胸段硬膜外镇痛的基础上,联合使用选择性COX-2抑制剂帕瑞昔布进行多模式镇痛,能够改善胸外科手术患者术后急性疼痛的治疗效果,明显减轻手术创伤激活的过度应激反应,缓解免疫损伤,同时可能在一定程度上控制了慢性疼痛的发展,对胸外科手术后患者的康复具有重要意义。
Objective:To study the analgesia effects of intravenous parecoxib combined with thoracic epidural analgesia (TEA) as well as its effect on stress response after thoracic surgery, and to investigate the residual pain1month postoperatively.
Methods:Fifty-six ASA class I or Ⅱ patients undergoing thoracic surgery were included in this prospective, randomized, double-blind, placebo-controlled study. General anesthesia was standardized. Patient-controlled epidural analgesia (T7-T8) was used until chest tubes were removed. All patients were randomly divided into two groups:placebo group (group C, n=28) or parecoxib sodium group (group P, n=28). Patients in two groups were allocated to receive parecoxib or placebo (normal saline) intravenously just0.5h before the operation and every12h after operation for3days. The intensity of pain was measured by using a VAS (0=no pain,10=worst pain) and recorded at2,4,8,24,48,72h after operation. The actual/effective number of PC A, the side effects, the overall satisfaction to analgesic therapy in72h and the days fit for discharge were recorded. Venous blood samples were taken before operation, the1st and3rd day after operation for detecting cortisol, ACTH, interleukin-6and tumor necrosis factor-a level. The incidences of residual pain, the VAS of pain, the characteristic of pain, the impact on the daily life were questioned with telephone interview1month after surgery.
Results:
(1) Postoperative pain scores at rest and during coughing were lower in the parecoxib group compared to those in placebo group at2,4,8,24,48,72h postoperatively (P<0.01). The effective number of PCA was significantly less and patient satisfaction was greater in the parecoxib group than placebo group (P<0.01). Adverse effect and the days fit for discharge were comparable between two groups.
(2) There were no significant differences in cortisol level between T1and TO in parecoxib group (P>0.05), while cortisol levels were significantly increased in placebo group (P<0.01) at T1. The cortisol levels in placebo group were higher than parecoxib group at T2. The level of ACTH both decreased in two groups after operation but it was significantly lower in parecoxib group than that in placebo group.
(3) There were no changes in plasma IL-6and TNF-a levels before and after analgesia at T1and T2(P>0.05).
(4) The incidence of residual pain were24%and53.8%separately in group P and C1month postoperatively (P<0.05). Parecoxib group had a lower pain score than placebo group (P<0.05). The incidence of allodyna were4%and15.4%separately in group P and S (P<0.05). Three patient in group P and10patients in group C had chronic pain affecting their daily life.
Conclusions:Parecoxib in multimodal analgesia improves postoperative analgesia provided by TEA, relieves stress response after thoracic surgery, and may restrain the development of chronic pain.
引文
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