多模式镇痛对小儿围术期应激激素水平的影响
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摘要
目的研究小儿术后多模式镇痛的效果及其对血清皮质醇(COR)和促肾上腺皮质激素(ACTH)水平的影响。方法选择2016年3月至2016年8月于新乡医学院第一附属医院行择期全身麻醉手术的患儿80例,将患者随机分为空白对照组(A组)、地佐辛静脉自控镇痛组(B组)、多模式镇痛组(C组)及芬太尼静脉自控镇痛组(D组),每组20例。术毕分别采取不同的镇痛措施,观察并记录各个时间点的生命体征变化及应激激素水平的变化,术后记录患儿视觉模拟评分法(VAS)疼痛评分、Ramsay镇静评分及不良反应发生情况。结果 4组患儿麻醉前心率(HR)、呼吸频率(RR)、平均动脉压(MAP)及血氧饱和度(SpO_2)比较差异均无统计学意义(P>0.05)。A、B、D组患儿术毕拔管时和术毕4 h的MAP、HR均高于C组(P<0.05);A组患儿术毕拔管时、术毕4 h的MAP、HR均高于B、D组(P<0.05);B组与D组患儿各时间点MAP、HR比较差异均无统计学意义(P>0.05)。A组患儿术毕拔管时、术毕4 h的MAP、HR均显著高于组内其他时间点(P<0.05);A组患儿其余各时间点MAP、HR比较差异均无统计学意义(P>0.05);B、C、D组患儿术毕各时间点的MAP、HR比较差异均无统计学意义(P>0.05)。4组患儿的RR及SpO_2各时间点组内及组间比较差异均无统计学意义(P>0.05)。A组患儿术毕各时间点的疼痛评分均高于B、C、D组(P<0.05);B、D组患儿术毕各时间点的疼痛评分高于C组(P<0.05);B、D组患儿术毕各时间点的疼痛评分比较差异均无统计学意义(P>0.05)。A组患儿术毕4 h的疼痛评分显著高于组内其他各时间点的评分(P<0.05);A组患儿其余各时间点疼痛评分比较差异均无统计学意义(P>0.05)。B、C、D组患儿术毕各时间点的疼痛评分比较差异均无统计学意义(P>0.05)。术后4组患儿各时间点均未出现过度镇静。C组患儿术毕4、12 h的镇静评分优于A组(P<0.05);C组和A组患儿其余各时间点镇静评分比较差异均无统计学意义(P>0.05);其余各组之间各时间点比较差异均无统计学意义(P>0.05)。4组患儿组内各时间点镇静评分比较差异均无统计学意义(P>0.05)。4组患儿麻醉前血清COR、ACTH水平比较差异均无统计学意义(P>0.05)。A、B、D组患儿术毕各时间点血清COR、ACTH水平均高于C组(P<0.05);A组患儿术毕4、12、24、48 h的血清COR、ACTH水平均高于B、D组(P<0.05),A组患儿术毕拔管时血清COR、ACTH水平与B、D组比较差异无统计学意义(P>0.05);B组与D组患儿术毕各时间点血清COR、ACTH水平比较差异均无统计学意义(P>0.05)。A组患儿麻醉前、术毕各时间点的血清COR、ACTH水平两两比较差异均有统计学意义(P<0.05)。B、D组患儿术毕拔管时、术毕4、12、24 h血清COR、ACTH水平显著高于麻醉前(P<0.05),B、D组患儿术毕48 h血清COR、ACTH水平与麻醉前比较差异无统计学意义(P>0.05);B、D组患儿术毕48 h血清COR、ACTH水平显著低于术毕拔管时、术毕4、12、24 h(P<0.05);B、D组患儿术毕拔管时、术毕4、12、24 h血清COR、ACTH水平两两比较差异均无统计学意义(P>0.05)。C组患儿麻醉前、术毕各时间点血清COR、ACTH水平两两比较差异均无统计学意义(P>0.05)。A、B、C、D组患儿术后不良反应发生率分别为50%、15%、5%、30%;A组患儿术后不良反应发生率高于B、C、D组(P<0.05);B、C、D组患儿术后不良反应发生率比较差异均无统计学意义(P>0.05)。结论多模式镇痛的患儿术后生命体征平稳,应激激素水平变化明显低于单一镇痛模式,且术后不良反应发生率低。
Objective To investigate the effectiveness of multimodal analgesia and its influence on serum cortisol(COR),adrenocortieotrophic hormone(ACTH) levels.Methods Eighty children who underwent selective operation in the First Affiliated Hospital of Xinxiang Medical University from March 2016 to August 2016 were selected and randomly divided into blank control group(group A),patient-controlled intravenous analgesia of dezocine group(group B),multimodal analgesia group(group C) and patient-controlled intravenous analgesia of fentanyl group(group D),with 20 children in each group.The children in the four groups were given different analgesia measures after operation;then the vital sign and the levels of stress hormone at the different time point were observed and recorded.The visual analog scale(VAS) analgesia score,Ramsay sedation score and adverse reaction of children were recorded after operation.Results There was no statistic difference in the heart rate(HR),respiration rate(RR),mean arterial pressure(MAP) and oxygen saturation(SpO_2) of children among the four groups before anesthesia(P>0.05).The MAP,HR of children in the group A,B,D were significanlty higher than those in the group C at the time point of extubation and 4 h after operation(P<0.05).The MAP,HR of children in the group A were significanlty higher than those in the group B and group D at the time point of extubation and 4 h after operation(P<0.05).There was no statistic difference in MAP,HR of children between the group B and group D at each time point(P>0.05).The MAP,HR of children at the time point of extubation and 4 h after operation were significanlty higher than those at the another time points in the group A(P<0.05);there was no statistic difference in MAP,HR of children among another time points in the group A(P>0.05).There was no statistic difference in MAP,HR of children among each time point at group B,C,D(P>0.05).There was no statistic difference in RR,SpO_2 of children among each time point in the four groups and among the four groups(P>0.05).The pain score of children in group A was significanlty higher than that in the group B,C,D at each time point after operation(P<0.05);the pain score of children in group B,D was significanlty higher than that in the group C at each time point after operation(P<0.05);there was no statistic difference in pain score of children between the group B and group D at each time point after operation(P<0.05).The pain score of children in group A at 4 h after operation was significantly higher than that at another time points(P<0.05);there was no statistic difference in pain score of children among another time points in group A(P>0.05).There was no statistic difference in pain score of children among the group B,C,D at each time point after operation(P>0.05).There was no excessive sedation of children in the four groups at each time point after operation.The sedation score of children at 4,12 h after operation in the group C was significanty better than that in the group A(P<0.05);there was no statistic difference in sedation score of children at another time points between the group C and group A(P>0.05);there was no statistic difference in sedation score of children at each time point among the other groups(P>0.05).There was no statistic difference in sedation score of children among each time point in the four groups(P>0.05).There was no statistic difference in the serum levels of COR and ACTH before anesthesia among the four groups(P>0.05).The serum levels of COR and ACTH at each time point after operation in group A,B,D were significanlty higher than those in the group C(P<0.05);the serum levels of COR and ACTH at 4,12,24,48 h in group A were significanlty higher than those in the group B,D(P<0.05);there was no statistic difference in the serum levels of COR and ACTH at the time point of extubation between group A and group B,D(P>0.05);there was no statistic difference in the serum levels of COR and ACTH at each time point after operation between group B and group D(P>0.05).There was statistic difference in the serum level of COR and ACTH among all time points in group A(P<0.05).The serum levels of COR and ACTH at the time point of extubation and 4,12,24 h after operation were significanlty higher than those at the time point of before anesthesia in group B,D(P<0.05);there was no statistic difference in serum levels of COR and ACTH between 48 h after operation and before anesthesia in group B,D(P>0.05);the serum levels of COR and ACTH at 48 h after operation were significanlty higher than those at the time point of extubation and 4,12,24 h after operation in group B,D(P<0.05);there was no statistic difference in serum levels of COR and ACTH among the time point of extubation and 4,12,24 h after operation in group B,D(P>0.05).There was no statistic difference in serum levels of COR and ACTH among all time points in group C(P>0.05).The incidence of adverse reactions of children in group A,B,C,D was 50%,15%,5%,30% respectively;the incidence of adverse reactions of children in group A was significanlty higher than that in group B,C,D(P<0.05);there was no satistic difference in the incidence of adverse reaction of children among the group B,C,D(P>0.05).Conclusion The vital signs of children with multimodal analgesia are stable after operation,and the levels of stress hormones are lower than single analgesic model.The incidence of adverse reactions of children with multimodal analgesia is lower after operation.
Objective To investigate the effectiveness of multimodal analgesia and its influence on serum cortisol(COR),adrenocortieotrophic hormone(ACTH) levels.Methods Eighty children who underwent selective operation in the First Affiliated Hospital of Xinxiang Medical University from March 2016 to August 2016 were selected and randomly divided into blank control group(group A),patient-controlled intravenous analgesia of dezocine group(group B),multimodal analgesia group(group C) and patient-controlled intravenous analgesia of fentanyl group(group D),with 20 children in each group.The children in the four groups were given different analgesia measures after operation;then the vital sign and the levels of stress hormone at the different time point were observed and recorded.The visual analog scale(VAS) analgesia score,Ramsay sedation score and adverse reaction of children were recorded after operation.Results There was no statistic difference in the heart rate(HR),respiration rate(RR),mean arterial pressure(MAP) and oxygen saturation(SpO_2) of children among the four groups before anesthesia(P>0.05).The MAP,HR of children in the group A,B,D were significanlty higher than those in the group C at the time point of extubation and 4 h after operation(P<0.05).The MAP,HR of children in the group A were significanlty higher than those in the group B and group D at the time point of extubation and 4 h after operation(P<0.05).There was no statistic difference in MAP,HR of children between the group B and group D at each time point(P>0.05).The MAP,HR of children at the time point of extubation and 4 h after operation were significanlty higher than those at the another time points in the group A(P<0.05);there was no statistic difference in MAP,HR of children among another time points in the group A(P>0.05).There was no statistic difference in MAP,HR of children among each time point at group B,C,D(P>0.05).There was no statistic difference in RR,SpO_2 of children among each time point in the four groups and among the four groups(P>0.05).The pain score of children in group A was significanlty higher than that in the group B,C,D at each time point after operation(P<0.05);the pain score of children in group B,D was significanlty higher than that in the group C at each time point after operation(P<0.05);there was no statistic difference in pain score of children between the group B and group D at each time point after operation(P<0.05).The pain score of children in group A at 4 h after operation was significantly higher than that at another time points(P<0.05);there was no statistic difference in pain score of children among another time points in group A(P>0.05).There was no statistic difference in pain score of children among the group B,C,D at each time point after operation(P>0.05).There was no excessive sedation of children in the four groups at each time point after operation.The sedation score of children at 4,12 h after operation in the group C was significanty better than that in the group A(P<0.05);there was no statistic difference in sedation score of children at another time points between the group C and group A(P>0.05);there was no statistic difference in sedation score of children at each time point among the other groups(P>0.05).There was no statistic difference in sedation score of children among each time point in the four groups(P>0.05).There was no statistic difference in the serum levels of COR and ACTH before anesthesia among the four groups(P>0.05).The serum levels of COR and ACTH at each time point after operation in group A,B,D were significanlty higher than those in the group C(P<0.05);the serum levels of COR and ACTH at 4,12,24,48 h in group A were significanlty higher than those in the group B,D(P<0.05);there was no statistic difference in the serum levels of COR and ACTH at the time point of extubation between group A and group B,D(P>0.05);there was no statistic difference in the serum levels of COR and ACTH at each time point after operation between group B and group D(P>0.05).There was statistic difference in the serum level of COR and ACTH among all time points in group A(P<0.05).The serum levels of COR and ACTH at the time point of extubation and 4,12,24 h after operation were significanlty higher than those at the time point of before anesthesia in group B,D(P<0.05);there was no statistic difference in serum levels of COR and ACTH between 48 h after operation and before anesthesia in group B,D(P>0.05);the serum levels of COR and ACTH at 48 h after operation were significanlty higher than those at the time point of extubation and 4,12,24 h after operation in group B,D(P<0.05);there was no statistic difference in serum levels of COR and ACTH among the time point of extubation and 4,12,24 h after operation in group B,D(P>0.05).There was no statistic difference in serum levels of COR and ACTH among all time points in group C(P>0.05).The incidence of adverse reactions of children in group A,B,C,D was 50%,15%,5%,30% respectively;the incidence of adverse reactions of children in group A was significanlty higher than that in group B,C,D(P<0.05);there was no satistic difference in the incidence of adverse reaction of children among the group B,C,D(P>0.05).Conclusion The vital signs of children with multimodal analgesia are stable after operation,and the levels of stress hormones are lower than single analgesic model.The incidence of adverse reactions of children with multimodal analgesia is lower after operation.
引文
[1]黄俊伟,伍淑韫,曾彩红,等.儿童腹腔镜术后多模式镇痛的应用[J].广东医学,2013,34(18):2840-2842.
[2]覃英,黄泽汉,官英勇,等.多模式镇痛对小儿腹股沟疝修补术后的镇痛效果观察[J].广西医学,2016,38(7):1018-1019,1022.
[3]GROENEWALD C B,RABBITTS J A,SCHROEDER D R,et al.Prevalence of moderate-severe pain in hos-pitalized children[J].Paediatr Anaesth,2012,22(7):661-668.
[4]吴运芹,杨志明,彭小明,等.危重足月儿皮质醇、促肾上腺皮质激素水平变化的意义[J].中华实用儿科临床杂志,2015,30(23):1821-1824.
[5]FRANCESCO CARLI M D.Physiologic considerations of enhanced recovery after surgery(ERAS)programs:implications of the stress response[J].Ann Card Anaesth,2015,62(2):110-119.
[6]HEGARTY M,CALDER A,DAVIES K,et al.Does take-home analgesia improve postoperative pain after elective day case surgery[J].Paediatr Anaesth,2013,23(5):385-389.
[7]王志刚,宫本晶.地佐辛超前镇痛对小儿疝囊高位结扎术后躁动及疼痛的影响[J].现代医药卫生,2012,28(17):2612-2614.
[8]杨吉安,夏中元,周显琎,等.地佐辛与芬太尼用于术后静脉自控镇痛临床效果及安全性Meta分析[J].医药导报,2014,33(7):899-905.
[9]刘涛,熊源长,王英伟,等.芬太尼静脉镇痛对血浆胃动素的影响[J].临床麻醉学杂志,2004,20(5):274.
[10]SENDASQUPTA C,MAKHIJA N,KIRAN U,et al.Caudal epidural sufentanil and bupivacaine decresses stress responses in paediatric cardiac surgery[J].Ann Card Anaesth,2009,12(1):27-33.
[11]刘阳,张书峰.手术应激对腹部肿瘤患儿血清促肾上腺皮质激素、皮质醇、心钠素及白细胞介素-6水平的影响[J].实用儿科临床杂志,2009,24(23):1811-1825.
[2]覃英,黄泽汉,官英勇,等.多模式镇痛对小儿腹股沟疝修补术后的镇痛效果观察[J].广西医学,2016,38(7):1018-1019,1022.
[3]GROENEWALD C B,RABBITTS J A,SCHROEDER D R,et al.Prevalence of moderate-severe pain in hos-pitalized children[J].Paediatr Anaesth,2012,22(7):661-668.
[4]吴运芹,杨志明,彭小明,等.危重足月儿皮质醇、促肾上腺皮质激素水平变化的意义[J].中华实用儿科临床杂志,2015,30(23):1821-1824.
[5]FRANCESCO CARLI M D.Physiologic considerations of enhanced recovery after surgery(ERAS)programs:implications of the stress response[J].Ann Card Anaesth,2015,62(2):110-119.
[6]HEGARTY M,CALDER A,DAVIES K,et al.Does take-home analgesia improve postoperative pain after elective day case surgery[J].Paediatr Anaesth,2013,23(5):385-389.
[7]王志刚,宫本晶.地佐辛超前镇痛对小儿疝囊高位结扎术后躁动及疼痛的影响[J].现代医药卫生,2012,28(17):2612-2614.
[8]杨吉安,夏中元,周显琎,等.地佐辛与芬太尼用于术后静脉自控镇痛临床效果及安全性Meta分析[J].医药导报,2014,33(7):899-905.
[9]刘涛,熊源长,王英伟,等.芬太尼静脉镇痛对血浆胃动素的影响[J].临床麻醉学杂志,2004,20(5):274.
[10]SENDASQUPTA C,MAKHIJA N,KIRAN U,et al.Caudal epidural sufentanil and bupivacaine decresses stress responses in paediatric cardiac surgery[J].Ann Card Anaesth,2009,12(1):27-33.
[11]刘阳,张书峰.手术应激对腹部肿瘤患儿血清促肾上腺皮质激素、皮质醇、心钠素及白细胞介素-6水平的影响[J].实用儿科临床杂志,2009,24(23):1811-1825.