术后镇痛在胸外科ICU应用的临床研究
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摘要
目的：对胸外科ICU术后镇痛患者进行临床观察，并通过对各项临床指标的监测与比较，认识术后镇痛的临床意义，同时对不同镇痛方法进行对比。方法：选择胸外科拟行剖胸手术的患者45例并随机分为三组，即两个试验组(术后分别予以吗啡静脉及硬膜外途径镇痛)和对照组(术后应用吗啡肌注镇痛)。对各组患者的术前及术后的循环功能、肺功能、血气分析值、淋巴细胞计数、CD_4~+／CD_8~+值、ICU滞留时间、术后并发症、术后疼痛的视觉模拟评分(VAS评分)等分别予以监测和记录。
结果：三组患者的一般情况无统计学差异。1．术后VAS评分的监测与对比：对三组患者在术后第12小时、24小时、36小时分别进行VAS评分并对比，统计结果显示三个时点之间无显著差异，而吗啡肌注镇痛组的VAS评分显著高于另外两组(P＜0.05)。2．循环功能指标的监测与对比：主要观察指标为术前、术后收缩压、舒张压、心率，测量时点为术前24小时、术后12小时、术后24小时。①收缩压(SBP)：统计结果显示三组患者的术后收缩压均较术前明显升高，并有统计学差异(P＜0.05)：三组之间的比较显示吗啡肌注镇痛组患者的收缩压显著高于另外两组(P＜0.05)；吗啡静脉镇痛组与硬膜外吗啡镇痛组之间无显著差异。②舒张压(DBP)：三组患者术后较术前比较舒张压无显著差异；三组之间比较显示吗啡肌注镇痛组患者术后舒张压较另外两组显著升高(P＜0.05)，另外两组之间无统计学差异。③心率(HR)：各组术后心率均较术前显著升高(P＜0.05)；三组之间比较显示吗啡肌注镇痛组患者术后心率较另两组显著升高(P＜0.05)，另外两组之间无统计学差异。3．肺功能指标的监测与对比：主要观察指标为手术前后的用力肺活量(FVC)、最大通气量(MVV)、第一秒用力呼气量(FEV_1)。各组术后肺功能指标均较术前显著下降(P＜0.05)，其中吗啡肌注镇痛组较另外两组肺功能明显减低(P＜0.05)。4．血气分析指标的监测与对比：主要观察指标为动脉氧分压(PaO_2)、动脉二氧化碳分压(PaCO_2)、血氧饱和度(SaO_2)、肺泡-动脉氧分压差(PA-aO_2)，
天津医科大学硕士研究生学位论文
测量时点为术前24小时、术后12小时、术后24小时。结果显示:术后各组
PaO:较术前均有显著降低(P<0.05)，而吗啡肌注镇痛组氧分压较另外两组
降低更加显著(P<0.05);术前、术后PaCO:和SaOZ无显著差异，而吗啡肌
注镇痛组较另外两组比较Pa02、SaOZ显著降低(P<0.05):术后队一aOZ较术
前均显著升高，吗啡肌注镇痛组较另外两组升高更加显著(P<0 .05)。5‘免
疫功能指标的监测与对比:主要观察指标为淋巴细胞计数、T辅助细胞
(Co4+)、T抑制细胞(CDs+)、CD4+/CDs+比值，测量时点为术前24小时、
术后24小时。统计结果显示:三组患者术后淋巴细胞计数均较术前显著降低，
其中吗啡肌注镇痛组降低更加显著(P<0.05);术后吗啡肌注镇痛组CD4+值
较术前显著降低(P<0.05)，并较另外两组亦有显著差异;术前、术后CDs+
值无显著差异，而术后吗啡静脉镇痛组和硬膜外镇痛组 CDs+值较对照组有显
著升高(P<0.05);CD4十/C Ds+比值三组均显著降低，吗啡静脉镇痛组比值较
另外两组降低更加显著(P<0.05)。6.ICU滞留时间:统计结果显示三组之间
无统计学差异(P>.05)。7.术后并发症:结果显示吗啡肌注镇痛组心律失
常、肺部感染等并发症相对较高。
结论:该项研究表明胸外科术后镇痛可有效的缓解术后疼痛，改善患者的心
肺功能，并减轻手术应激所导致的免疫抑制，从而改善预后，减少术后并发
症的发生。
Objective: To investigate the post-operative analgesia of the patients in the
intensive care unit of thoracic surgery department , and understand the clinical significance through the comparison of the clinical values . At the same time , there also have a contrast among the different analgesia methods .
Methods: 45 patients scheduled thoracotomy were divided randomly into 3
groups : intravenous-morphine analgesia group , epidural-morphine analgesia group , and the control group which received morphine through intramuscularly-injection . In this research , the preoperative and postoperative values were monitored and recorded , including artery blood gas analysis , lung function measurement , heart function measurement , lymphocyte counting , CD4+ /CD8+ , ICU retention stage , the postoperative complication , visual analogue scales (VAS values) , etc.
Results: The patients in three groups have no statistic difference in the basic
parameters of age , sex , weight and physical condition .1. Monitor and comparison of the postoperative visual analogue scales (VAS values) : Monitored and recorded the VAS values of three groups in three points : the 12th , 24th ,36th hour after the operation . There were no statistic differences among the values of these three points . However , the VAS values of intramuscularly-morphine analgesia group were statistically higher than the other 2 groups . 2. Monitor and comparison of heart function values : The main observation indexes were preoperative and postoperative systolic pressure , diastolic pressure , heart rate , which were measured in three points , the 24th hour before operation . the 1 2th and 24th hour after the operation .(1) Systolic pressure (SBP) : The outcome showed a higher postoperative pressure than the postoperative stage and has statistic
meaning (P<0.05) ; the comparison showed that the SBP of intramuscularly-morphine analgesia group was higher than the other 2 groups , and no statistic difference between the intravenous morphine analgesia group and epidural morphine analgesia group . ( 2 ) Diastolic pressure ( DBF ) : There were no statistic difference among the three observation points ; the comparison showed the diastolic pressure of the intramuscularly-morphine analgesia group was higher than the other 2 groups (P<0.05) , and no statistic difference between the other 2 groups . ( 3 ) Heart rate ( HR ) : The postoperative heart rates were higher than the preoperative values (P<0.05) ; the comparisons among three groups showed that the heart rate of intramuscularly morphine analgesia group was higher than the other 2 groups (P<0.05) , and no statistic difference between the other 2 groups . 3. Monitor and comparison of lung function : The main preoperative and postoperative observation indexes were the forced vital capacity (FVC) , the maximum vital capacity (MVV) , and the first second forced expiratory volume (FEV1) ? All the values of the groups were decreased markedly (P<0.05) , and the intramuscularly-morphine analgesia group was the lowest one . 4. Monitor and comparison of artery blood gas analysis : The main observation indexes were partial artery oxygen pressure (PaO2) ,partial artery carbon dioxide pressure (PaCO2) , oxygen saturation (SaO2) , the difference pressure between the alveolus and artery ( PA-aO2 ) , and measured at three points : the 24th hour before the operation , the 1 2th hour and 24th hour after the operation . The outcome showed that all the post-operation PaO2 of the groups decreased markedly (P<0.05) , and intramuscularly-morphine analgesia group decreased lower than the other 2 groups . There were no statistic difference of among the perioperation PaCO2 and SaO2% , but the values of intramuscularly-morphine analgesia group dropped more markedly than the other 2 groups . The post-operation PA-aO2 increased greatly ( PO.05 ) , however ,the
intramuscularly-morphine analgesia group was the highest . 5. Monitor and comparison of the immunity funct
结果：三组患者的一般情况无统计学差异。1．术后VAS评分的监测与对比：对三组患者在术后第12小时、24小时、36小时分别进行VAS评分并对比，统计结果显示三个时点之间无显著差异，而吗啡肌注镇痛组的VAS评分显著高于另外两组(P＜0.05)。2．循环功能指标的监测与对比：主要观察指标为术前、术后收缩压、舒张压、心率，测量时点为术前24小时、术后12小时、术后24小时。①收缩压(SBP)：统计结果显示三组患者的术后收缩压均较术前明显升高，并有统计学差异(P＜0.05)：三组之间的比较显示吗啡肌注镇痛组患者的收缩压显著高于另外两组(P＜0.05)；吗啡静脉镇痛组与硬膜外吗啡镇痛组之间无显著差异。②舒张压(DBP)：三组患者术后较术前比较舒张压无显著差异；三组之间比较显示吗啡肌注镇痛组患者术后舒张压较另外两组显著升高(P＜0.05)，另外两组之间无统计学差异。③心率(HR)：各组术后心率均较术前显著升高(P＜0.05)；三组之间比较显示吗啡肌注镇痛组患者术后心率较另两组显著升高(P＜0.05)，另外两组之间无统计学差异。3．肺功能指标的监测与对比：主要观察指标为手术前后的用力肺活量(FVC)、最大通气量(MVV)、第一秒用力呼气量(FEV_1)。各组术后肺功能指标均较术前显著下降(P＜0.05)，其中吗啡肌注镇痛组较另外两组肺功能明显减低(P＜0.05)。4．血气分析指标的监测与对比：主要观察指标为动脉氧分压(PaO_2)、动脉二氧化碳分压(PaCO_2)、血氧饱和度(SaO_2)、肺泡-动脉氧分压差(PA-aO_2)，
天津医科大学硕士研究生学位论文
测量时点为术前24小时、术后12小时、术后24小时。结果显示:术后各组
PaO:较术前均有显著降低(P<0.05)，而吗啡肌注镇痛组氧分压较另外两组
降低更加显著(P<0.05);术前、术后PaCO:和SaOZ无显著差异，而吗啡肌
注镇痛组较另外两组比较Pa02、SaOZ显著降低(P<0.05):术后队一aOZ较术
前均显著升高，吗啡肌注镇痛组较另外两组升高更加显著(P<0 .05)。5‘免
疫功能指标的监测与对比:主要观察指标为淋巴细胞计数、T辅助细胞
(Co4+)、T抑制细胞(CDs+)、CD4+/CDs+比值，测量时点为术前24小时、
术后24小时。统计结果显示:三组患者术后淋巴细胞计数均较术前显著降低，
其中吗啡肌注镇痛组降低更加显著(P<0.05);术后吗啡肌注镇痛组CD4+值
较术前显著降低(P<0.05)，并较另外两组亦有显著差异;术前、术后CDs+
值无显著差异，而术后吗啡静脉镇痛组和硬膜外镇痛组 CDs+值较对照组有显
著升高(P<0.05);CD4十/C Ds+比值三组均显著降低，吗啡静脉镇痛组比值较
另外两组降低更加显著(P<0.05)。6.ICU滞留时间:统计结果显示三组之间
无统计学差异(P>.05)。7.术后并发症:结果显示吗啡肌注镇痛组心律失
常、肺部感染等并发症相对较高。
结论:该项研究表明胸外科术后镇痛可有效的缓解术后疼痛，改善患者的心
肺功能，并减轻手术应激所导致的免疫抑制，从而改善预后，减少术后并发
症的发生。
Objective: To investigate the post-operative analgesia of the patients in the
intensive care unit of thoracic surgery department , and understand the clinical significance through the comparison of the clinical values . At the same time , there also have a contrast among the different analgesia methods .
Methods: 45 patients scheduled thoracotomy were divided randomly into 3
groups : intravenous-morphine analgesia group , epidural-morphine analgesia group , and the control group which received morphine through intramuscularly-injection . In this research , the preoperative and postoperative values were monitored and recorded , including artery blood gas analysis , lung function measurement , heart function measurement , lymphocyte counting , CD4+ /CD8+ , ICU retention stage , the postoperative complication , visual analogue scales (VAS values) , etc.
Results: The patients in three groups have no statistic difference in the basic
parameters of age , sex , weight and physical condition .1. Monitor and comparison of the postoperative visual analogue scales (VAS values) : Monitored and recorded the VAS values of three groups in three points : the 12th , 24th ,36th hour after the operation . There were no statistic differences among the values of these three points . However , the VAS values of intramuscularly-morphine analgesia group were statistically higher than the other 2 groups . 2. Monitor and comparison of heart function values : The main observation indexes were preoperative and postoperative systolic pressure , diastolic pressure , heart rate , which were measured in three points , the 24th hour before operation . the 1 2th and 24th hour after the operation .(1) Systolic pressure (SBP) : The outcome showed a higher postoperative pressure than the postoperative stage and has statistic
meaning (P<0.05) ; the comparison showed that the SBP of intramuscularly-morphine analgesia group was higher than the other 2 groups , and no statistic difference between the intravenous morphine analgesia group and epidural morphine analgesia group . ( 2 ) Diastolic pressure ( DBF ) : There were no statistic difference among the three observation points ; the comparison showed the diastolic pressure of the intramuscularly-morphine analgesia group was higher than the other 2 groups (P<0.05) , and no statistic difference between the other 2 groups . ( 3 ) Heart rate ( HR ) : The postoperative heart rates were higher than the preoperative values (P<0.05) ; the comparisons among three groups showed that the heart rate of intramuscularly morphine analgesia group was higher than the other 2 groups (P<0.05) , and no statistic difference between the other 2 groups . 3. Monitor and comparison of lung function : The main preoperative and postoperative observation indexes were the forced vital capacity (FVC) , the maximum vital capacity (MVV) , and the first second forced expiratory volume (FEV1) ? All the values of the groups were decreased markedly (P<0.05) , and the intramuscularly-morphine analgesia group was the lowest one . 4. Monitor and comparison of artery blood gas analysis : The main observation indexes were partial artery oxygen pressure (PaO2) ,partial artery carbon dioxide pressure (PaCO2) , oxygen saturation (SaO2) , the difference pressure between the alveolus and artery ( PA-aO2 ) , and measured at three points : the 24th hour before the operation , the 1 2th hour and 24th hour after the operation . The outcome showed that all the post-operation PaO2 of the groups decreased markedly (P<0.05) , and intramuscularly-morphine analgesia group decreased lower than the other 2 groups . There were no statistic difference of among the perioperation PaCO2 and SaO2% , but the values of intramuscularly-morphine analgesia group dropped more markedly than the other 2 groups . The post-operation PA-aO2 increased greatly ( PO.05 ) , however ,the
intramuscularly-morphine analgesia group was the highest . 5. Monitor and comparison of the immunity funct
引文
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3. Chrousos GP, Gold PW. The concepts of stress system disorders. JAMA 1992:Vol 267:1244
4. Pjevic M. Regional technics for postoperative analgesia [J]Med-Pregl, 1997:50(1-2):27-31.
5. Wall PD, Bery J, Saade N. Behavioural and electrophysiological evidence for an analgesic effect of a non-steroidal anti-inflammatory agent, sodium diclofenac. [J]Pain 1988,Dec;35(3):327-39.
6. Carli, Franco, Lattermann, R, Schricker, T . Epidural analgesia and postoperative lipid metabolism: stable isotope studies during a fasted/fed state. Reg-Anesth-Pain-Med. 2002 Mar-Apt; 27(2): 132-8.
7. Munck A.In :Chrousos GP, eds.Steroid Hormone Resistance:Mechanisms and Clinical Aspects.[M]New York,NY:Plenum Press; 1986:81-96.
8．腾金亮。术后镇痛对呼吸功能的影响。《国外医学》麻醉学与复苏分册2000，21(3)，162-163。
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2. Tsigos,-C, Chrousos,-G-P. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J-Psychosom-Res. 2002 Oct; 53(4):865-71
3. Chrousos GP, Gold PW. The concepts of stress system disorders. JAMA 1992:Vol 267:1244
4. Pjevic M. Regional technics for postoperative analgesia [J]Med-Pregl, 1997:50(1-2):27-31.
5. Wall PD, Bery J, Saade N. Behavioural and electrophysiological evidence for an analgesic effect of a non-steroidal anti-inflammatory agent, sodium diclofenac. [J]Pain 1988,Dec;35(3):327-39.
6. Carli, Franco, Lattermann, R, Schricker, T . Epidural analgesia and postoperative lipid metabolism: stable isotope studies during a fasted/fed state. Reg-Anesth-Pain-Med. 2002 Mar-Apt; 27(2): 132-8.
7. Munck A.In :Chrousos GP, eds.Steroid Hormone Resistance:Mechanisms and Clinical Aspects.[M]New York,NY:Plenum Press; 1986:81-96.
8．腾金亮。术后镇痛对呼吸功能的影响。《国外医学》麻醉学与复苏分册2000，21(3)，162-163。
9. Grass, JA. The role of epidural anesthesia and analgesia in postoperative outcome, knesthesiol-Clin-North-America. 2000 Jun; 18(2): 407-28, ⅷ.
10. Kouraklis, G, Glinavou,,A, Raftopoulos, L, et al. Epidural analgesia attenuates the systemic stress response to upper abdominal surgery: a randomized trial. Int-Surg. 2000 0ct-Dec; 85(4): 353-7.
11. Ekatodramis, G. Regional anesthesia and analgesia: their role in postoperative outcome. Curr-Top-Med-Chem. 2001 Aug; 1(3): 183-92.
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