双侧阴部神经阻滞对痔切除手术老年患者肛门内压力和术后疼痛的影响
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摘要
目的研究双侧阴部神经阻滞对痔切除手术老年患者肛门内压力和术后疼痛的影响。方法选择ASAI～II级行混合痔切除手术患者40例,随机分为双侧阴部神经阻滞麻醉组(n=20)和局部麻醉组(n=20),观察2组麻醉前后肛门内压力的变化;记录丙泊酚总用量、手术时间、术后第1次镇痛药使用时间;观察2组患者术中心血管不良事件、呼吸抑制发生、术后尿潴留、恶心呕吐、术后再次出血和患者满意度等情况。结果与局麻组比较,双侧阴部神经阻滞麻醉组麻醉前后肛门内压力的变化更大(P<0.01),术后第1次镇痛药使用时间明显后延(P<0.01),患者总体满意度更高(18 vs 14);2组手术时间、尿潴留、恶心呕吐、术后再次大出血发生率等差异均无统计学意义(P>0.05)。与局麻组相比,双侧阴部神经阻滞麻醉组丙泊酚总用量显著减少(P<0.01),发生心血管及呼吸不良事件明显较少。结论双侧阴部神经阻滞可以降低痔切除手术老年患者肛门内压力,延长术后镇痛时间,提高患者满意度,同时减少镇静药使用剂量,降低心血管及呼吸不良事件发生率。
Objective To explore the effect of bilateral pudendal nerve block anesthesia on anal pressure and postoperative pain in the elderly undergoing hemorrhoidectomy. Methods 40 ASAI～II elderly undergoing mixed hemorrhoidectomy were randomly divided into 2 groups: bilateral pudendal nerve block anesthesia group(n=20) and local anesthesia group(n=20); the changes of anus pressure before and after anesthesia were observed and the total dosage of propofol, the operation time length and the time of first application of analgesics after operation were recorded; cardiovascular adverse events, respiratory depression,postoperative urinary retention, nausea and vomiting, postoperative rebleeding and patient satisfaction in both groups were observed. Results The changes of the anus pressure before and after anesthesia was greater in bilateral pudendal nerve block anesthesia group than in local anesthesia group(P<0.001) and the time of first application of analgesics after operation was obviously delayed(P<0.01); the overall satisfaction of patients was higher in bilateral pudendal nerve block anesthesia group than that in local anesthesia group(18 vs. 14); There existed no significant differences in operation time length, urinary retention, nausea and vomiting and the incidence of postoperative massive hemorrhage between the2 groups(P>0.05); Compared with the local anesthesia group, the total dosage of propofol in bilateral pudendal nerve block anesthesia group was significantly less and the occurrence of adverse cardiovascular and respiratory events was significantly lower in bilateral pudendal nerve block anesthesia group than in local anesthesia group(P<0.01). Conclusions Bilateral pudendal nerve block can reduce the pressure of anus,prolong the time of postoperative analgesia application, increase the satisfaction of patients, cut down the application amount of sedative and the occurrence of cardiovascular and respiratory adverse events in the elderly undergoing hemorrhoidectomy.
Objective To explore the effect of bilateral pudendal nerve block anesthesia on anal pressure and postoperative pain in the elderly undergoing hemorrhoidectomy. Methods 40 ASAI～II elderly undergoing mixed hemorrhoidectomy were randomly divided into 2 groups: bilateral pudendal nerve block anesthesia group(n=20) and local anesthesia group(n=20); the changes of anus pressure before and after anesthesia were observed and the total dosage of propofol, the operation time length and the time of first application of analgesics after operation were recorded; cardiovascular adverse events, respiratory depression,postoperative urinary retention, nausea and vomiting, postoperative rebleeding and patient satisfaction in both groups were observed. Results The changes of the anus pressure before and after anesthesia was greater in bilateral pudendal nerve block anesthesia group than in local anesthesia group(P<0.001) and the time of first application of analgesics after operation was obviously delayed(P<0.01); the overall satisfaction of patients was higher in bilateral pudendal nerve block anesthesia group than that in local anesthesia group(18 vs. 14); There existed no significant differences in operation time length, urinary retention, nausea and vomiting and the incidence of postoperative massive hemorrhage between the2 groups(P>0.05); Compared with the local anesthesia group, the total dosage of propofol in bilateral pudendal nerve block anesthesia group was significantly less and the occurrence of adverse cardiovascular and respiratory events was significantly lower in bilateral pudendal nerve block anesthesia group than in local anesthesia group(P<0.01). Conclusions Bilateral pudendal nerve block can reduce the pressure of anus,prolong the time of postoperative analgesia application, increase the satisfaction of patients, cut down the application amount of sedative and the occurrence of cardiovascular and respiratory adverse events in the elderly undergoing hemorrhoidectomy.
引文
[1] Kim J, Lee DS, Jang SM, et al. The effect of pudendal block on voiding after hemorrhoidectomy[J]. Dis Colon Rectum, 2005,48(3):518-523.
[2] Gabrielli F, Cioffi U, Chiarelli M, et al. Hemorrhoidectomy with posterior perineal block:experience with 400 cases[J]. Dis Colon Rectum, 2000,43(6):809-812.
[3] Kim SH, Song SG, Paek OJ, et al. Nerve-stimulator-guided pudendal nerve block by pararectal approach[J]. Colorectal Dis,2012, 14(5):611-615.
[4] Gupta J, Denson DD, Felner EI, et al. Rapid local anesthesia in humans using minimally invasive microneedles[J]. Clin J Pain,2012, 28(2):129-135.
[5] Hamerschmidt R, Moreira AT, Wiemes GR, et al. Cochlear implant surgery with local anesthesia and sedation:comparison with general anesthesia[J]. Otol Neurotol, 2013, 34(1):75-78.
[6] Mcpherson JS, Dixon SA, Townsend R, et al. Effect of needle design on pain from dental local anesthetic injections[J]. Anesth Prog, 2015, 62(1):2-7.
[7] Hoehener D, Blumenthal S, Borgeat A. Sedation and regional anaesthesia in the adult patient[J]. Br J Anaesth, 2008, 100(1):8-16.
[8] Zhao Y, Ding JH, Yin SH, et al. Predictors of early postoperative pain after stapled haemorrhoidopexy[J]. Colorectal Dis, 2014,16(6):206-211.
[9] Falzone E, Hoffmann C, Keita H. Postoperative analgesia in elderly patients[J]. Drugs Aging, 2013, 30(2):81-90.
[10] Bettelli G. Anaesthesia for the elderly outpatient:preoperative assessment and evaluation, anaesthetic technique and postoperative pain management[J]. Curr Opin Anaesthesiol, 2010, 23(6):726-731.
[11] Li ST, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery[J]. Anesthesiology, 2000, 93(5):1225-1230.
[12] Fueglistaler P, Guenin MO, Montali I, et al. Long-term results after stapled hemorrhoidopexy:high patient satisfaction despite frequent postoperative symptoms[J]. Dis Colon Rectum, 2007,50(2):204-212.
[13] Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids(PPH)and stapled transanal rectal resection(STARR)procedures[J]. Tech Coloproctol,2008, 12(1):7-19.
[14] Khubchandani I, Fealk MH, Reed IJ. Is there a post-PPH syndrome[J]. Tech Coloproctol, 2009, 13(2):141-144.
[15] Correa-Rovelo JM1, Tellez O, Obregón L, et al. Prospective study of factors affecting postoperative pain and symptom persistence after stapled rectal mucosectomy for hemorrhoids:a need for preservation of squamous epithelium.[J]. Dis Colon Rectum,2003, 46(7):955-962.
[16] Thaha MA, Irvine LA, Steele RJ, et al. Postdefaecation pain syndrome after circular stapled anopexy is abolished by oral nifedipine[J]. Br J Surg, 2005,92(2):208-810.
[17] Gabrielli F, De Simone M, Chiarelli M, et al. Manometric study of the anal sphincter during haemorrhoidectomy using posterior perineal block[J]. Chir Ital, 2005, 57(4):495-498.
[18]黄美雄,苏伟,肖刚,等.阴部神经阻滞麻醉的解剖学基础[J].结直肠肛门外科,2006,12(5):275-277.
[19] Read TE, Henry SE, Hovis RM, et al. Prospective evaluation of anesthetic technique for anorectalsurgery[J]. Dis Colon Rectum, 2002, 45(11):1553-1558.
[20] Sun MY, Canete JJ, Friel JC, et al. Combination propofol/ketamine is a safe and efficient anesthetic approach to anorectalsurgery[J]. Dis Colon Rectum, 2006, 49(7):1059-1065.
[21] Kinirons BP, Bouaziz H, Paqueron X, et al. Sedation with Sufentanil and midazolam decreases pain in patients undergoing upper limb surgery under multiple nerve block[J]. Anesth Analg,2000, 90(5):1118-1121.
[2] Gabrielli F, Cioffi U, Chiarelli M, et al. Hemorrhoidectomy with posterior perineal block:experience with 400 cases[J]. Dis Colon Rectum, 2000,43(6):809-812.
[3] Kim SH, Song SG, Paek OJ, et al. Nerve-stimulator-guided pudendal nerve block by pararectal approach[J]. Colorectal Dis,2012, 14(5):611-615.
[4] Gupta J, Denson DD, Felner EI, et al. Rapid local anesthesia in humans using minimally invasive microneedles[J]. Clin J Pain,2012, 28(2):129-135.
[5] Hamerschmidt R, Moreira AT, Wiemes GR, et al. Cochlear implant surgery with local anesthesia and sedation:comparison with general anesthesia[J]. Otol Neurotol, 2013, 34(1):75-78.
[6] Mcpherson JS, Dixon SA, Townsend R, et al. Effect of needle design on pain from dental local anesthetic injections[J]. Anesth Prog, 2015, 62(1):2-7.
[7] Hoehener D, Blumenthal S, Borgeat A. Sedation and regional anaesthesia in the adult patient[J]. Br J Anaesth, 2008, 100(1):8-16.
[8] Zhao Y, Ding JH, Yin SH, et al. Predictors of early postoperative pain after stapled haemorrhoidopexy[J]. Colorectal Dis, 2014,16(6):206-211.
[9] Falzone E, Hoffmann C, Keita H. Postoperative analgesia in elderly patients[J]. Drugs Aging, 2013, 30(2):81-90.
[10] Bettelli G. Anaesthesia for the elderly outpatient:preoperative assessment and evaluation, anaesthetic technique and postoperative pain management[J]. Curr Opin Anaesthesiol, 2010, 23(6):726-731.
[11] Li ST, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery[J]. Anesthesiology, 2000, 93(5):1225-1230.
[12] Fueglistaler P, Guenin MO, Montali I, et al. Long-term results after stapled hemorrhoidopexy:high patient satisfaction despite frequent postoperative symptoms[J]. Dis Colon Rectum, 2007,50(2):204-212.
[13] Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids(PPH)and stapled transanal rectal resection(STARR)procedures[J]. Tech Coloproctol,2008, 12(1):7-19.
[14] Khubchandani I, Fealk MH, Reed IJ. Is there a post-PPH syndrome[J]. Tech Coloproctol, 2009, 13(2):141-144.
[15] Correa-Rovelo JM1, Tellez O, Obregón L, et al. Prospective study of factors affecting postoperative pain and symptom persistence after stapled rectal mucosectomy for hemorrhoids:a need for preservation of squamous epithelium.[J]. Dis Colon Rectum,2003, 46(7):955-962.
[16] Thaha MA, Irvine LA, Steele RJ, et al. Postdefaecation pain syndrome after circular stapled anopexy is abolished by oral nifedipine[J]. Br J Surg, 2005,92(2):208-810.
[17] Gabrielli F, De Simone M, Chiarelli M, et al. Manometric study of the anal sphincter during haemorrhoidectomy using posterior perineal block[J]. Chir Ital, 2005, 57(4):495-498.
[18]黄美雄,苏伟,肖刚,等.阴部神经阻滞麻醉的解剖学基础[J].结直肠肛门外科,2006,12(5):275-277.
[19] Read TE, Henry SE, Hovis RM, et al. Prospective evaluation of anesthetic technique for anorectalsurgery[J]. Dis Colon Rectum, 2002, 45(11):1553-1558.
[20] Sun MY, Canete JJ, Friel JC, et al. Combination propofol/ketamine is a safe and efficient anesthetic approach to anorectalsurgery[J]. Dis Colon Rectum, 2006, 49(7):1059-1065.
[21] Kinirons BP, Bouaziz H, Paqueron X, et al. Sedation with Sufentanil and midazolam decreases pain in patients undergoing upper limb surgery under multiple nerve block[J]. Anesth Analg,2000, 90(5):1118-1121.