帕瑞昔布超前镇痛对瑞芬太尼全凭静脉麻醉腹腔镜胆囊切除术麻醉药量及术后疼痛的影响
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摘要
目的:探讨术前静脉注射帕瑞昔布超前镇痛对丙泊酚瑞芬太尼全凭静脉麻醉腹腔镜胆囊切除术后疼痛的影响
方法:采用前瞻、双盲、随机、对照研究的方法。拟在丙泊酚、瑞芬太尼全凭静脉麻醉下行腹腔镜胆囊切除术患者60例。年龄18~65岁,男女不限,ASAⅠ级或Ⅱ级,随机分成对照组(A组)、超前镇痛用药组(B组)、术毕用药镇痛组(C组),每组20例。
A组于麻醉诱导前30min生理盐水5ml静脉注射,在术毕缝皮时给予生理盐水5ml静脉注射。
B组于麻醉诱导前30min静脉注射帕瑞昔布40mg (5ml生理盐水溶解),术毕缝皮时给予生理盐水5ml静脉注射。
C组麻醉诱导前30min给予生理盐水5ml静脉注射,在术毕缝皮时给予帕瑞昔布40mg(5ml生理盐水溶解)静脉注射。
观察三组患者手术结束清醒后24h疼痛评分,当术后患者静息状态疼痛程度超过4分时(总分10分),给予肌肉注射芬太尼50μg/次。
记录术后24h阿片类镇痛药使用和副作用的发生情况。分别测定三组患者麻醉前、手术结束时、术后24h血浆P物质(substance P)和白细胞介素6(interleukin 6,IL-6)浓度。结果:
1一般资料比较
三组患者性别、年龄、体重、身高、体重指数(body mass index,BMI)以及手术时间比较,差异无统计学意义,P >0.05,见附表Table 1。
2三组患者术后24h疼痛评分不同处理组间差异无统计学意义, P >0.05,见附图Fig.1。
3三组患者术后阿片类药物需要量比较,差异有统计学意义,超前镇痛组小于空白对照组、术毕镇痛组,P <0.05,见附表Table2。
4血浆IL-6三组间不同时间点间,不同处理组间差异有统计学意义,P <0.05,见附图Fig.2、附图Fig.3、附表Table3
5.血浆P物质不同处理组间比较差异无统计学意义,P >0.05,见附图Fig.4、附表Table4。
结论:
1术前静脉注射帕瑞昔布超前镇痛在维持术后疼痛强度一致的条件下,能够显著减少术后阿片类药物的使用。
2术前静脉注射帕瑞昔布超前镇痛显著降低患者体内IL-6的释放。
3尚不能说明帕瑞昔布超前镇痛明显抑制了手术后血浆P物质的释放,有待进一步进行研究。
Object: To determine The effect of pre-operative parecoxib injected as preemptive analgesia on postoperative pain after laparoscopic cholecystectomy of total intravenous anesthesia.
Methods: A prospective,double-blind,randomized,placebo-controlled study was conducted on 60 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at the Third Hospital of Hebei Medical University, Shijiazhuang, from September 2009 to December 2009. Patients were randomly divided into three groups(n=20), control group (groupA), preemptive analgesia treatment group (group B), normal analgesia treatment group (group C). Patients were randomized to receive eigher normal saline infusion 30 min before induction of anesthesia and 40 mg parecoxib infusion at the time of suturing skin(group C),40 mg parecoxib infusion 30 min before induction of anesthesia and normal saline infusion at the time of suturing skin(group B), or normal saline infusion 30 min before induction of anesthesia and normal saline infusion at the time of suturing skin as a placebo(group A).
The degree of the postoperative pain was assessed in the first 24 h after surgery using visual analog scales(VAS). Fentanil 50μg was injected when the degree of pain exceed 4scale in VAS. The consumption of analgesics ,and the condition of side effect was recorded. Venous blood samples were collected before experiment and at suturing skin, 24h after surgery. Concentrations of substance P in plasma and interleukin 6 in plasma were measuredwith Elisa method.
Results:
1. No significant differences were found in age,body mass index and operation duration among the three groups, P >0.05.
2. The pain scores at each time point statistically insignificant differed among the three groups, P >0.05 .
3. Analgesic consumption was significant difference among the three groups. Compared with group A and group C,Analgesic consumption in group B was obviously reduced(P <0.05).
4. The concentrations of interleukin 6 in three groups were similar and statistically insignificant before surgery(P﹥0.05).The concentrations of interleukin 6 in three groups were similar and statistically insignificant before surgery(P﹥0.05).Plasma interleukin 6 concentrations in three groups during and after operation were significantly higher than those before surgery. there was significant difference of plasma interleukin 6 in three groups during operation and 24h after surgery.
5. The concentrations of substance P in three groups were similar and statistically insignificant before surgery(P﹥0.05).Plasma substance P concentrations in three groups during and after operation were significantly higher than those before surgery. there was insignificant difference of plasma substance P in three groups during operation and 24h after surgery.
Conclusion:
1. Pre-operative infusion 40 mg parecoxib could significantly reduce the postoperative opioid consumption .
2. Pre-operative infusion 40 mg parecoxib could significantly inhibit the production of interleukin 6 in plasma.
3. Pre-operative infusion 40 mg parecoxib could not be proved to inhibite the production of substance P in plasma.
方法:采用前瞻、双盲、随机、对照研究的方法。拟在丙泊酚、瑞芬太尼全凭静脉麻醉下行腹腔镜胆囊切除术患者60例。年龄18~65岁,男女不限,ASAⅠ级或Ⅱ级,随机分成对照组(A组)、超前镇痛用药组(B组)、术毕用药镇痛组(C组),每组20例。
A组于麻醉诱导前30min生理盐水5ml静脉注射,在术毕缝皮时给予生理盐水5ml静脉注射。
B组于麻醉诱导前30min静脉注射帕瑞昔布40mg (5ml生理盐水溶解),术毕缝皮时给予生理盐水5ml静脉注射。
C组麻醉诱导前30min给予生理盐水5ml静脉注射,在术毕缝皮时给予帕瑞昔布40mg(5ml生理盐水溶解)静脉注射。
观察三组患者手术结束清醒后24h疼痛评分,当术后患者静息状态疼痛程度超过4分时(总分10分),给予肌肉注射芬太尼50μg/次。
记录术后24h阿片类镇痛药使用和副作用的发生情况。分别测定三组患者麻醉前、手术结束时、术后24h血浆P物质(substance P)和白细胞介素6(interleukin 6,IL-6)浓度。结果:
1一般资料比较
三组患者性别、年龄、体重、身高、体重指数(body mass index,BMI)以及手术时间比较,差异无统计学意义,P >0.05,见附表Table 1。
2三组患者术后24h疼痛评分不同处理组间差异无统计学意义, P >0.05,见附图Fig.1。
3三组患者术后阿片类药物需要量比较,差异有统计学意义,超前镇痛组小于空白对照组、术毕镇痛组,P <0.05,见附表Table2。
4血浆IL-6三组间不同时间点间,不同处理组间差异有统计学意义,P <0.05,见附图Fig.2、附图Fig.3、附表Table3
5.血浆P物质不同处理组间比较差异无统计学意义,P >0.05,见附图Fig.4、附表Table4。
结论:
1术前静脉注射帕瑞昔布超前镇痛在维持术后疼痛强度一致的条件下,能够显著减少术后阿片类药物的使用。
2术前静脉注射帕瑞昔布超前镇痛显著降低患者体内IL-6的释放。
3尚不能说明帕瑞昔布超前镇痛明显抑制了手术后血浆P物质的释放,有待进一步进行研究。
Object: To determine The effect of pre-operative parecoxib injected as preemptive analgesia on postoperative pain after laparoscopic cholecystectomy of total intravenous anesthesia.
Methods: A prospective,double-blind,randomized,placebo-controlled study was conducted on 60 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at the Third Hospital of Hebei Medical University, Shijiazhuang, from September 2009 to December 2009. Patients were randomly divided into three groups(n=20), control group (groupA), preemptive analgesia treatment group (group B), normal analgesia treatment group (group C). Patients were randomized to receive eigher normal saline infusion 30 min before induction of anesthesia and 40 mg parecoxib infusion at the time of suturing skin(group C),40 mg parecoxib infusion 30 min before induction of anesthesia and normal saline infusion at the time of suturing skin(group B), or normal saline infusion 30 min before induction of anesthesia and normal saline infusion at the time of suturing skin as a placebo(group A).
The degree of the postoperative pain was assessed in the first 24 h after surgery using visual analog scales(VAS). Fentanil 50μg was injected when the degree of pain exceed 4scale in VAS. The consumption of analgesics ,and the condition of side effect was recorded. Venous blood samples were collected before experiment and at suturing skin, 24h after surgery. Concentrations of substance P in plasma and interleukin 6 in plasma were measuredwith Elisa method.
Results:
1. No significant differences were found in age,body mass index and operation duration among the three groups, P >0.05.
2. The pain scores at each time point statistically insignificant differed among the three groups, P >0.05 .
3. Analgesic consumption was significant difference among the three groups. Compared with group A and group C,Analgesic consumption in group B was obviously reduced(P <0.05).
4. The concentrations of interleukin 6 in three groups were similar and statistically insignificant before surgery(P﹥0.05).The concentrations of interleukin 6 in three groups were similar and statistically insignificant before surgery(P﹥0.05).Plasma interleukin 6 concentrations in three groups during and after operation were significantly higher than those before surgery. there was significant difference of plasma interleukin 6 in three groups during operation and 24h after surgery.
5. The concentrations of substance P in three groups were similar and statistically insignificant before surgery(P﹥0.05).Plasma substance P concentrations in three groups during and after operation were significantly higher than those before surgery. there was insignificant difference of plasma substance P in three groups during operation and 24h after surgery.
Conclusion:
1. Pre-operative infusion 40 mg parecoxib could significantly reduce the postoperative opioid consumption .
2. Pre-operative infusion 40 mg parecoxib could significantly inhibit the production of interleukin 6 in plasma.
3. Pre-operative infusion 40 mg parecoxib could not be proved to inhibite the production of substance P in plasma.
引文
1 Bajaj P, Ballary CC, Dongre NA. Role of parecoxib in pre-emptive analgesia: comparison of the efficacy and safety of pre- and postoperative parecoxib in patients undergoing general surgery. J Indian Med Assoc, 2004 May, 102(5):272, 274, 276-278
2 Woolf CJ. Generation of acute pain: central mechanisms. Br Med Bull, 1991, 47: 523-533
3 Lohsiriwat V, Lert-akyamanee N, Rushatamukayanunt W. Efficacy of pre-incisional bupivacaine infiltration on postoperative pain relief after appendectomy: prospective double-blind randomized trial. World J Surg, 2004, 28: 947-950
4 Gottschalk A, Smith DS. New concepts in acute paintherapy: preemptive analgesia. Am Fam Physician, 2001, 63: 1979-1984
5 Reuben SS. Update on the role of nonsteroidal anti-inflammatory drugs and coxibs in the management of acute pain. Curr Opin Anaesthesiol, 2007, 20: 440-450
6 Tiippana E, Bachmann M, Kalso E. Effect of paracetamol and coxib with or without dexamethasone after laparoscopic cholecystectomy. Acta Anaesthesiol Scand, 2008, 52: 673-680
7 Papadima A, Lagoudianakis EE, Antonakis PT. Parecoxib vs. lornoxicam in the treatment of postoperative pain after laparoscopic cholecystectomy: a prospective randomized placebo-controlled trial. Eur J Anaesthesiol, 2007, 24: 154-158
8 Puolakka PA, Puura AI, Pirhonen RA. Lack of analgesic effect of parecoxib following laparoscopic cholecystectomy. Acta AnaesthesiolScand, 2006, 50: 1027-1032
9 Gan TJ, Joshi GP, Zhao SZ. Presurgical intravenous parecoxib sodium and followup oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects. Acta Anaesthesiol Scand, 2004, 48: 1194-1207
10 Gan TJ, Joshi GP, Viscusi E. Preoperative parenteral parecoxib and follow-up oral valdecoxib reduce length of stay and improve quality of patient recovery after laparoscopic cholecystectomy surgery. Anesth Analg, 2004, 98:1665-1673, table of contents
11 Joshi GP, Viscusi ER, Gan TJ. Effective treatment of laparoscopic cholecystectomy pain with intravenous followed by oral COX-2 specific inhibitor. Anesth Analg , 2004, 98: 336-342, table of contents
12 Reuben SS, Buvenandran A, Katz B. A prospective randomized trial on the role of perioperative celecoxib administration for total knee arthroplasty: improving clinical outcomes. Anesth Analg, 2008, 106: 1258-1264, table of contents
13 Jensen MP, Mendoza T, Hanna DB.The analgesic effects that underlie patient satisfaction with treatment. Pain,2004 Jul ,110(1-2):480-487
14 Katz J, Jackson M. Pre-emptive analgesia: evidence, current status and future directors.Eur J Anesthesiol, 1995, 12:8-13
15 Goto T. Nitrous oxide induces preemptive analgesia in the rat that is antagonized by halothane.Anaesthesiology, 1994, 80:409-416
16 Laboureyras E, Chateauraynaud J, RichebéP. Long-term pain vulnerability after surgery in rats: prevention by nefopam, an analgesic with antihyperalgesic properties. Anesth Analg, 2009 Aug, 109(2):623-631
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20 Thawatchai Akaraviputh, Charay Leelouhapong, Varut Lohsiriwat .Efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy: A prospective,randomized study. World Journal of Gastroenterology, 2009 April 28, 15(16): 2005-2008
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29 Elhakim M, Amine H, Kamel S. Effects of intraperitoneal lidocaine combined with intravenous or intraperitoneal tenoxicam on pain relief and bowel recovery after laparoscopic cholecystectomy. Acta Anaesthesiol Scand, 2000, 44: 929-933
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6 Engquist A, Brandt MR, Fernandes A, et a1.The blocking effect of epidural analgesia on the adrenocortical and hyperglycemic responses to surgery.Acta Anaesthesiol Scand, 1977,21:330-335
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25 Jensen MP, Mendoza T, Hanna DB.The analgesic effects that underlie patient satisfaction with treatment. Pain, 2004 Jul,110(1-2):480-487
26 Gan TJ, Joshi GP, Zhao SZ.Presurgical intravenous parecoxib sodium and follow-up oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects. Acta Anaesthesiol Scand, 2004 Oct,48(9):1194-1207
27 Papadima A, Lagoudianakis EE, Antonakis PT.Parecoxib vs. lornoxicam in the treatment of postoperative pain after laparoscopic cholecystectomy: a prospective randomized placebo-controlled trial. Eur J Anaesthesiol, 2007 Feb, 24(2):154-158
28 Puolakka PA, Puura AI, Pirhonen RA.Lack of analgesic effect of parecoxib following laparoscopic cholecystectomy. Acta Anaesthesiol Scand, 2006 Sep, 50(8):1027-1032
29 Katz J, Jackson M.Pre-emptive analgesia:evidence,current status and future directors.Eur J Anesthesiol,1995,12:8-13
30 Goto T.Nitrous oxide induces preemptive analgesia in the rat that is antagonized by halothane.Anaesthesiology, 1994,80:409-416
31 Forest tenant.Using objective signs of severe pain to guide opioid prescribing. Pain Treatment Topics, June 2008,[Epub ahead of print]
32 Thawatchai Akaraviputh, Charay Leelouhapong, Varut Lohsiriwat .Efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy: A prospective, randomized study. World Journal of Gastroenterology, 2009 April 28, 15(16): 2005-2008
33 Jabbour-Khoury SI, Dabbous AS, Gerges FJ. Intraperitoneal and intravenousroutes for pain relief in laparoscopic cholecystectomy. JSLS2005, 9: 316-321
34 Elhakim M, Amine H, Kamel S.Effects of intraperitoneal lidocainecombined with intravenous or intraperitoneal tenoxicam on pain relief and bowel recovery after laparoscopic cholecystectomy. Acta Anaesthesiol Scand, 2000, 44: 929-933
35 Buvanendran A, Kroin JS.Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol, 2009 Oct, 22(5):588-593
36 Burke S, Shorten GD. When pain after surgery doesn't go away... Biochem Soc Trans, 2009 Feb, 37(Pt 1):318-322
37 Katz J, McCartney CJ.Current status of preemptive analgesia. Curr Opin Anaesthesiol, 2002 Aug, 15(4):435-441
2 Woolf CJ. Generation of acute pain: central mechanisms. Br Med Bull, 1991, 47: 523-533
3 Lohsiriwat V, Lert-akyamanee N, Rushatamukayanunt W. Efficacy of pre-incisional bupivacaine infiltration on postoperative pain relief after appendectomy: prospective double-blind randomized trial. World J Surg, 2004, 28: 947-950
4 Gottschalk A, Smith DS. New concepts in acute paintherapy: preemptive analgesia. Am Fam Physician, 2001, 63: 1979-1984
5 Reuben SS. Update on the role of nonsteroidal anti-inflammatory drugs and coxibs in the management of acute pain. Curr Opin Anaesthesiol, 2007, 20: 440-450
6 Tiippana E, Bachmann M, Kalso E. Effect of paracetamol and coxib with or without dexamethasone after laparoscopic cholecystectomy. Acta Anaesthesiol Scand, 2008, 52: 673-680
7 Papadima A, Lagoudianakis EE, Antonakis PT. Parecoxib vs. lornoxicam in the treatment of postoperative pain after laparoscopic cholecystectomy: a prospective randomized placebo-controlled trial. Eur J Anaesthesiol, 2007, 24: 154-158
8 Puolakka PA, Puura AI, Pirhonen RA. Lack of analgesic effect of parecoxib following laparoscopic cholecystectomy. Acta AnaesthesiolScand, 2006, 50: 1027-1032
9 Gan TJ, Joshi GP, Zhao SZ. Presurgical intravenous parecoxib sodium and followup oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects. Acta Anaesthesiol Scand, 2004, 48: 1194-1207
10 Gan TJ, Joshi GP, Viscusi E. Preoperative parenteral parecoxib and follow-up oral valdecoxib reduce length of stay and improve quality of patient recovery after laparoscopic cholecystectomy surgery. Anesth Analg, 2004, 98:1665-1673, table of contents
11 Joshi GP, Viscusi ER, Gan TJ. Effective treatment of laparoscopic cholecystectomy pain with intravenous followed by oral COX-2 specific inhibitor. Anesth Analg , 2004, 98: 336-342, table of contents
12 Reuben SS, Buvenandran A, Katz B. A prospective randomized trial on the role of perioperative celecoxib administration for total knee arthroplasty: improving clinical outcomes. Anesth Analg, 2008, 106: 1258-1264, table of contents
13 Jensen MP, Mendoza T, Hanna DB.The analgesic effects that underlie patient satisfaction with treatment. Pain,2004 Jul ,110(1-2):480-487
14 Katz J, Jackson M. Pre-emptive analgesia: evidence, current status and future directors.Eur J Anesthesiol, 1995, 12:8-13
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35 Buvanendran A, Kroin JS.Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol, 2009 Oct, 22(5):588-593
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