氯胺酮加地塞米松对食管癌术后硬膜外镇痛的影响
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摘要
目的观察术前单次给予小剂量氯胺酮联合地塞米松对食管癌单肺通气开胸手术患者术后硬膜外镇痛的影响。方法选择2016年12月～2017年7月四川省遂宁市中心医院胸外科60例拟行食道癌手术患者,均开胸采用单肺通气,按随机数字表法将其分为空白对照组(S组)、氯胺酮组(K组)、地塞米松组(D组)以及氯胺酮加地塞米松组(KD组),每组各15例。术前进行硬膜外穿刺并置管,在全麻诱导前15 min静脉注射:氯胺酮0.5 mg/kg (K组)、地塞米松10 mg(D组)、氯胺酮0.5 mg/kg+地塞米松10 mg(KD组)、10 m L生理盐水(S组),四组均用生理盐水配成10 m L,记录四组患者术中单肺通气时间、手术时间,并采用术后硬膜外自控镇痛(PCEA),观察术后48 h镇痛评分、自控镇痛按压次数和镇痛药总用量以及术后不良反应情况。结果四组患者单肺通气时间、手术时间长短比较,差异无统计学意义(P> 0.05);与K、D、S组比较,KD组24 h内术后镇痛视觉模拟评分(VAS)及Prince-Henry评分均较低(P <0.05),K、D、S三组48 h VAS及Prince-Henry评分比较,差异无统计学意义(P> 0.05)。与D、S、K组比较,KD组术后自控镇痛追加次数及镇痛药总量较少(P <0.05),KD组恶心呕吐发生率明显低于其他三组(P <0.05);术后谵妄发生率比较,差异无统计学意义(P> 0.05)。结论氯胺酮加地塞米松预防性用于手术前,能有效增加术后24 h PCEA镇痛效果,并减少镇痛药用量和术后不良反应。
Objective To observe the effect of single and small dose of Ketamine combined with Dexamethasone on postoperative epidural analgesia in patients with esophageal cancer with single-lung ventilation. Methods Sixty patients undergoing esophageal cancer surgery with single-lung ventilation in the Department of Thoracic Surgery of Suining Central Hospital were selected. The patients collected from December 2016 to July 2017 were randomly divided into blank control group(S group), Ketamine group(K group), Dexamethasone group(D group) and Ketamine plus Dexamethasone group(KD group) according to random number table method. Preoperative epidural puncture and catheterization. Ketamine 0.5 mg/kg(K group), Dexamethasone 10 mg(D group), Ketamine 0.5 mg/kg + Dexamethasone 10 mg(KD group), 10 m L of normal saline(S group) were administered 15 minutes before induction of general anesthesia, and the four groups were diluted to 10 m L with physiological saline. Intraoperative single-lung ventilation, operation time, postoperative analgesia scores in 48 h, self-controlled analgesic compression times, total dosage of analgesics by patient-controlled epidural analgesia(PCEA) and postoperative adverse reactions of the four groups were all recorded. Results No significant difference in ventilation time and operation time was identified among the four groups(P > 0.05). Compared with K group, D group and S group, the visual analogue score(VAS) and Prince-Henry score of postoperative analgesia in KD group were lower within 24 h(P < 0.05). But no significant difference in VAS score and Prince-Henry score was identified at 48 h among four groups(P > 0.05). The number of compression times and the total dosage of analgesics were less, the rate of nausea and vomiting was lower in KD group compared with group D, group S and group K(P < 0.05). The rate of postoperative delirium was not significantly different among four groups(P > 0.05). Conclusion The prophylactic use of Ketamine plus Dexamethasone before surgery can effectively increase the analgesic effect of PCEA in 24 h after surgery and reduce the dosage of analgesic drugs and postoperative adverse reactions.
Objective To observe the effect of single and small dose of Ketamine combined with Dexamethasone on postoperative epidural analgesia in patients with esophageal cancer with single-lung ventilation. Methods Sixty patients undergoing esophageal cancer surgery with single-lung ventilation in the Department of Thoracic Surgery of Suining Central Hospital were selected. The patients collected from December 2016 to July 2017 were randomly divided into blank control group(S group), Ketamine group(K group), Dexamethasone group(D group) and Ketamine plus Dexamethasone group(KD group) according to random number table method. Preoperative epidural puncture and catheterization. Ketamine 0.5 mg/kg(K group), Dexamethasone 10 mg(D group), Ketamine 0.5 mg/kg + Dexamethasone 10 mg(KD group), 10 m L of normal saline(S group) were administered 15 minutes before induction of general anesthesia, and the four groups were diluted to 10 m L with physiological saline. Intraoperative single-lung ventilation, operation time, postoperative analgesia scores in 48 h, self-controlled analgesic compression times, total dosage of analgesics by patient-controlled epidural analgesia(PCEA) and postoperative adverse reactions of the four groups were all recorded. Results No significant difference in ventilation time and operation time was identified among the four groups(P > 0.05). Compared with K group, D group and S group, the visual analogue score(VAS) and Prince-Henry score of postoperative analgesia in KD group were lower within 24 h(P < 0.05). But no significant difference in VAS score and Prince-Henry score was identified at 48 h among four groups(P > 0.05). The number of compression times and the total dosage of analgesics were less, the rate of nausea and vomiting was lower in KD group compared with group D, group S and group K(P < 0.05). The rate of postoperative delirium was not significantly different among four groups(P > 0.05). Conclusion The prophylactic use of Ketamine plus Dexamethasone before surgery can effectively increase the analgesic effect of PCEA in 24 h after surgery and reduce the dosage of analgesic drugs and postoperative adverse reactions.
引文
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[14]Pyo JH,Lee H,Min YW,et al.A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm[J].Gut and Liver,2016,10(4):549-555.
[15]Chen CC,Siddiqui FJ,Chen TL,et al.Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy:meta-analysis of randomized controlled trials[J].World J Surg,2012,36(1):61-68.
[16]Hegeman MA,Hennus MP,Cobelens PM,et al.Dexamethasone attenuates VEGF expression and inflammation but not barrier dysfunction in a murine model of ventilator-induced lung injury[J].PLo S One,2013,8(2):e57 374.
[17]Thangaswamy CR,Rewari V,Trikha A,et al.Dexamethasone before total laparoscopic hysterectomy:a randomized controlled dose-response study[J].J Anesth,2010,24(1):24-30.
[18]王琼华,方晏红,许斌兵,等.氯胺酮联合地塞米松在食管癌开胸手术中对肺损伤的保护作用[J].中国药房,2015(20):2828-2831.
[19]Yang C,Chang H,Zhang T,et al.Pre-emptive epidural analgesia improves post-operative pain and immune function in patients undergoing thoracotomy[J].ANZ J Surg,2015,85(6):472-477.
[20]赵彤,翟文倩,施乙飞,等.胸腔镜下肺叶切除术病人术后3种途径病人自控镇痛效果的比较[J].中华麻醉学杂志,2012,32(3):330-333.
[2]Agam D,Montazer M,Hoseini M,et al.A Comparison of Continuous Thoracic Epidural Analgesia with Bupivacaine Versus Bupivacaine and Dexmedetomidine for Pain Control in Patients with Multiple Rib Fractures[J].Reg Anesth Pain Med,2018,8(2):e60805.
[3]Niesters M,Martini C,Dahan A.Ketamine for chronic pain:risks and benefits[J].Br J Clin Pharmacol,2014,77(2):357-367.
[4]Falci SGM,Lima TC,Martins CC,et al.Preemptive Effect of Dexamethasone in Third-Molar Surgery:A Meta-Analysis[J].Anesth Prog,2017,64(3):136-143.
[5]Waka S,Yamaguchi K,Kumakura S,et al.Effects of anesthesia with sevoflurane and propofol on the cytokine/chemokine production at the airway epithelium during esophagectomy[J].Int J Mol Med,2014,34(1):137-144.
[6]Low DE,Kunz S,Schembre D,et al.Esophagectomy--it's not just about mortality anymore:standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer[J].J Gastrointest Surg,2007,11(11):1395-1402.
[7]Zhou Y,Huang J,Bai Y,et al.Effects of preemptive analgesia with flurbiprofen ester on lymphocytes and natural killer cells in patients undergoing esophagectomy:A randomized controlled pilot study[J].Thoracic Cancer,2017,8(6):649-654.
[8]Erturk E,Aydogdu Kaya F,Kutanis D,et al.The Effectiveness of Preemptive Thoracic Epidural Analgesia in Thoracic Surgery[J].Biomed Res Int,2014,2014:673682.
[9]Tawfic QA.A review of the use of ketamine in pain management[J].J Opioid Manag,2013,9(5):379-388.
[10]Cogan J,Lalumière G,Vargas-Schaffer G,et al.Lowdose Intravenous Ketamine for Postcardiac Surgery Pain:Effect on Opioid Consumption and the Incidence of Chronic Pain[J].Ann Card Anaesth,2017,20(4):395-398.
[11]Radvansky BM,Shah K,Parikh A,et al.Role of Ketamine in Acute Postoperative Pain Management:A Narrative Review[J].Bio Med Research International,2015,2015:749837.
[12]Mathews TJ,Churchhouse AM,Housden T,et al.Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain[J].Interact Cardiovasc Thorac Surg,2012,14(2):194-199.
[13]Waldron NH,Jones CA,Gan TJ,et al.Impact of perioperative dexamethasone on postoperative analgesia and side-effects:systematic review and meta-analysis[J].Br J Anaesth,2013,110(2):191-200.
[14]Pyo JH,Lee H,Min YW,et al.A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm[J].Gut and Liver,2016,10(4):549-555.
[15]Chen CC,Siddiqui FJ,Chen TL,et al.Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy:meta-analysis of randomized controlled trials[J].World J Surg,2012,36(1):61-68.
[16]Hegeman MA,Hennus MP,Cobelens PM,et al.Dexamethasone attenuates VEGF expression and inflammation but not barrier dysfunction in a murine model of ventilator-induced lung injury[J].PLo S One,2013,8(2):e57 374.
[17]Thangaswamy CR,Rewari V,Trikha A,et al.Dexamethasone before total laparoscopic hysterectomy:a randomized controlled dose-response study[J].J Anesth,2010,24(1):24-30.
[18]王琼华,方晏红,许斌兵,等.氯胺酮联合地塞米松在食管癌开胸手术中对肺损伤的保护作用[J].中国药房,2015(20):2828-2831.
[19]Yang C,Chang H,Zhang T,et al.Pre-emptive epidural analgesia improves post-operative pain and immune function in patients undergoing thoracotomy[J].ANZ J Surg,2015,85(6):472-477.
[20]赵彤,翟文倩,施乙飞,等.胸腔镜下肺叶切除术病人术后3种途径病人自控镇痛效果的比较[J].中华麻醉学杂志,2012,32(3):330-333.