摘要
应激反应是指机体在受到各种内外环境因素刺激时所出现的以神经内分泌系统反应为主的、多个系统参加的一系列非特异性全身反应。它是机体整个适应、保护机制的一个重要的组成部分,它可以提高机体的准备状态和增强机体的适应能力。但是应激反应一旦过于强烈或者持久,超过机体负荷的限度,可导致内环境平衡失调,对机体造成损害,并引起严重的并发症,加重病情,甚至威胁生命。全髋关节置换术患者以老年患者居多。而老年人又常合并多系统功能障碍和潜在的心血管系统疾病,即使是健康老年人,心血管系统和重要脏器的结构和功能也发生衰老性退变。手术创伤,术后切口疼痛又恰可增加机体应激反应疼痛可以导致交感神经-肾上腺髓质系统兴奋和下丘脑-垂体-肾上腺皮质分泌增多,出现不同程度的血压增高、心率增快、心肌耗氧量增加,并引发神经、内分泌、免疫反应极易引起心血管并发症,良好的术后镇痛,不仅减轻患者痛苦,更有利于循环呼吸稳定,减少并发症的发生,进而提高康复速度和质量。因此,术后镇痛十分必要。而传统术后镇痛常用方法为静脉镇痛和硬膜外镇痛,静脉镇痛应用药物主要为阿片类药物,而大量应用阿片类药物,容易发生恶心、呕吐、皮肤瘙痒、尿潴留、嗜睡等不良反应,甚至可以引起呼吸抑制；硬膜外镇痛的效果较好,但容易发生低血压、增加感染机率,且容易出现运动神经阻滞。如何既能有效的防止术后疼痛,抑制围术期过度应激反应又能减少相关不良反应是术后镇痛研究的热点。多模式镇痛是近年来是围手术期镇痛的一个新概念,多模式镇痛就是联合应用不同作用机制的多种镇痛药物或采用机制不同的多种镇痛措施,以达到更好的镇痛效果,同时将不良反应降至最低,是术后镇痛技术的主要发展方向。而超前镇痛在多模式镇痛中是非常重要的环节,超前镇痛是指伤害性刺激作用于机体之前采取措施,防止外周和中枢神经的敏感化,达到减少或消除伤害性刺激引起疼痛的目的。目前关于超前镇痛的研究很多,而注射用帕瑞昔布钠作为全球第一种注射用选择性COX-2抑制剂在镇痛领域已经开始应用。根据国外文献报道,帕瑞昔布的疗效已在各种手术术后疼痛的短期治疗中得到确认。本实验旨在探讨帕瑞昔布对老年患者全髋关节置换术术后血浆应激激素水平的影响及静脉自控镇痛的效果及安全性。
Objective:To observe the effects of parecoxib preemptive analgesia on plasma stress hormone levels and safty of PCA in elderly patients undergoing total hip replacement.
Method:Sixty ASAⅠ～Ⅱelderly patients undergoing total hip replacement under spinal combined epidural anesthesia were randomly divided into three groups: Control group (Group A)、parecoxib preemptive analgesiaⅠ(group B) and parecoxib preemptive analgesiaⅡ(group C) each group had 20 cases. Group A:Received intravenous normal sal in 2 ml 30 min before anesthesia.Group B:Received intravenous parecoxib 40 mg 30 min before anesthesia. Group C:Received intravenous parecoxib 40 mg 30 min before anesthesia and immediately after surgery. The patients in each group received PCIA immediately after surgery. The vital signs such as SpO2, blood pressure and pulse rate were observed during operation and PCA. Serum cortisol, epinephrine, blood sugar and norepinephrine levels were measured at T1 (before operation)、T2 (12 h after the end of operation)、T3(24h after the end of operation). Pain intensity was meassured by visual analog scale (VAS) score at 4,8,12,24 and 48 h after operation. The total consumption of sufentanil. the total number and the valid number of pressing PCA pump were recorded at 48 h after operation. Meanwhile, the score of MMSE sedation scale and the adverse effects such as nausea and vomiting, pruritus and respiratory depression were observed after operation
Results:Serum cortisol and epinephrine at T2、T3 in each group were significantly higher than T1(P<0.05). At the same time Serum cortisol and epinephrine at T2、T3 in group A were significantly higher than those in group B and group C(P<0.01). Parecoxib preemptive analgesia can restrain the plasma stress hormone levels. The valid number of pressing PCIA pump and adverse effects at T2、T3 in group A were significantly higher than those in group B and group C(P<0.01). Parecoxib combined PCIA can reduce the acute opiod consumption and have less side reactions than control group.
Conclusions:Parecoxib administered preemptively can improve the quality of postoperative analgesia and reduce consumption of opioid analgesics postoperatively in elder patients undergoing total hip replacement.
引文
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