高明濤，周　南

沈陽軍區(qū)總醫(yī)院麻醉科，沈陽 110015

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右美托咪定復(fù)合舒芬太尼術(shù)后鎮(zhèn)痛對子宮切除患者皮質(zhì)醇水平和免疫功能的影響

高明濤，周南*

沈陽軍區(qū)總醫(yī)院麻醉科，沈陽 110015

[摘要]目的探討右美托咪定復(fù)合舒芬太尼術(shù)后鎮(zhèn)痛對子宮切除患者皮質(zhì)醇水平和免疫功能的影響。方法擇期子宮切除術(shù)患者116例，隨機分為2組。A組接受舒芬太尼術(shù)后自控鎮(zhèn)痛，B組接受右美托咪定復(fù)合舒芬太尼術(shù)后自控鎮(zhèn)痛。記錄兩組術(shù)畢0、2、24 h皮質(zhì)醇水平和免疫功能的變化。結(jié)果A組患者皮質(zhì)醇水平明顯高于B組(P<0.05)，IgG、IgA、IgM及CD4+T細胞含量低于B組，CD8+T細胞含量高于B組(P<0.05)。結(jié)論右美托咪定復(fù)合舒芬太尼術(shù)后鎮(zhèn)痛可更好地降低應(yīng)激，改善患者皮質(zhì)醇水平，增強免疫功能。

[關(guān)鍵詞]右美托咪定；舒芬太尼；皮質(zhì)醇；免疫功能

0引言

子宮切除術(shù)后疼痛可誘發(fā)炎癥和應(yīng)激反應(yīng)，進而導(dǎo)致血流動力學(xué)不穩(wěn)定，不利于術(shù)后機體功能的恢復(fù)[1]，因此，子宮切除術(shù)后采取必要的鎮(zhèn)痛措施很重要。圍術(shù)期多模式鎮(zhèn)痛可有效調(diào)控圍術(shù)期應(yīng)激反應(yīng)，提供更有效的鎮(zhèn)痛效果。本研究旨在探討與評價右美托咪定復(fù)合舒芬太尼對子宮切除術(shù)后皮質(zhì)醇水平和免疫功能的影響，以期對全麻術(shù)后提供一個安全、有效的鎮(zhèn)痛鎮(zhèn)靜方法。

1臨床資料

1.1一般資料經(jīng)倫理委員會同意，擇期子宮切除術(shù)患者，接受全身麻醉，年齡45～62歲，ASAⅠ～Ⅱ級。自愿接受術(shù)后靜脈鎮(zhèn)痛治療的患者116例，隨機分為2組，每組58例：A組接受舒芬太尼術(shù)后自控鎮(zhèn)痛，B組接受右美托咪定復(fù)合舒芬太尼術(shù)后自控鎮(zhèn)痛。排除標準：術(shù)前有精神障礙史，術(shù)前服用精神類藥物，區(qū)域阻滯麻醉者，術(shù)后給予切口泵鎮(zhèn)痛者。兩組患者性別、年齡、體重、ASA分級、麻醉維持時間比較差異均無統(tǒng)計學(xué)意義。

1.2治療方法患者入手術(shù)室后采用全身麻醉。麻醉誘導(dǎo)：咪達唑侖0.03 mg/kg，瑞芬太尼2 μg/kg，丙泊酚1.0～2.0 mg/kg，羅庫溴銨0.8 mg/kg。術(shù)中維持：丙泊酚3～8 mg/(kg·h)泵注，瑞芬太尼3～15 μg/(kg·h)泵注，吸入七氟烷1%，羅庫溴銨間斷靜注?？p皮前給予舒芬太尼0.04 μg/kg并連接PCA泵。術(shù)畢拔管后入PACU。A組舒芬太尼PCA泵配方：舒芬太尼3 μg/kg+昂丹司瓊16 mg 加生理鹽水稀釋100 mL。B組配方：舒芬太尼2 μg/kg+右美托咪定2 μg/kg+昂丹司瓊16 mg 加生理鹽水稀釋至100 mL。

1.3檢測項目及方法記錄術(shù)后0、2、24 h皮質(zhì)醇水平和免疫功能的變化。

2結(jié)果

2.1兩組患者皮質(zhì)醇水平變化術(shù)后2、24 h兩組皮質(zhì)醇水平比較，差異有統(tǒng)計學(xué)意義(P<0.05)。見表1。

表1　兩組患者皮質(zhì)醇水平變化(ng/mL)

2.2兩組患者免疫功能比較術(shù)后2、24 h，A組患者的IgG、IgA、IgM含量以及CD4+、CD8+T細胞含量顯著低B組(P<0.05)，見表2、表3。

3討論

實施有效的術(shù)后鎮(zhèn)痛是子宮切除術(shù)后康復(fù)的重要因素。臨床中常用的鎮(zhèn)痛藥物包括：阿片類受體激動劑、阿片類受體激動-拮抗劑、非阿片類鎮(zhèn)痛藥和非甾體抗炎藥等。舒芬太尼是在芬太尼基礎(chǔ)上發(fā)展而來的阿片類麻醉性鎮(zhèn)痛藥物，具有極強的阿片受體激動作用，脂溶性較強，更容易穿過神經(jīng)細胞膜并作用于脊髓上的阿片受體，其鎮(zhèn)痛作用是芬太尼的10倍[2]。近年來，舒芬太尼被廣泛應(yīng)用于術(shù)后鎮(zhèn)痛[3-4]，鎮(zhèn)痛效果明顯，但同時出現(xiàn)了呼吸抑制和惡心、嘔吐等不良反應(yīng)。α2腎上腺素受體激動劑右美托咪定，可作用于大腦藍斑核，產(chǎn)生鎮(zhèn)痛、鎮(zhèn)靜、遺忘、抗焦慮等作用，作用于脊髓后角產(chǎn)生抗傷害效應(yīng)[5-7]，也可作用于外周與中樞發(fā)揮抗交感活性效應(yīng)[8-9]。有研究表明，右美托咪定能夠增加阿片類藥物的鎮(zhèn)痛作用[10-12]。因此，右美托咪定復(fù)合舒芬太尼可發(fā)揮協(xié)同作用，實現(xiàn)術(shù)后鎮(zhèn)痛的平衡鎮(zhèn)痛，通過抑制感受傷害的神經(jīng)遞質(zhì)釋放和神經(jīng)纖維沖動的傳導(dǎo)，一定程度上抑制應(yīng)激反應(yīng)發(fā)生，以達到改善鎮(zhèn)靜、鎮(zhèn)痛的效果。

表2　兩組患者IgG、IgA、IgM比較(g/L)

表3　兩組患者CD4+、CD8+ T細胞含量比較(%)

Guneli等[13]研究表明，右美托咪定(μg)和曲馬多(mg)的鎮(zhèn)痛ED50比為1∶1，曲馬多和舒芬太尼的鎮(zhèn)痛ED50比為2∶1，即右美托咪定(μg)和舒芬太尼(μg)的鎮(zhèn)痛ED50比為2∶1，2 μg/kg右美托咪定對應(yīng)1 μg/kg舒芬太尼的鎮(zhèn)痛劑量，因此，本試驗中，鎮(zhèn)痛泵中加入右美托咪定2 μg/kg的同時相應(yīng)減少舒芬太尼1 μg/kg。

患者手術(shù)治療造成的組織損傷致局部釋放某些致痛物質(zhì)，這些物質(zhì)作用于神經(jīng)末梢產(chǎn)生痛覺，激活下丘腦-垂體系統(tǒng)，從而促進腎上腺皮質(zhì)束狀帶合成并釋放皮質(zhì)醇。皮質(zhì)醇是應(yīng)激反應(yīng)的主要調(diào)節(jié)激素，可負反饋作用于下丘腦和垂體，抑制促皮質(zhì)素釋放激素和促腎上腺皮質(zhì)激素的進一步分泌[14]。手術(shù)創(chuàng)傷及疼痛除了增加皮質(zhì)醇外，在急性應(yīng)激反應(yīng)時細胞因子可以增強細胞間信息傳遞，加速創(chuàng)傷愈合，提高免疫活性[15]。

本研究顯示，隨著藥物作用時間的延長，右美托咪定復(fù)合舒芬太尼組皮質(zhì)醇水平明顯低于舒芬太尼組，而免疫功能指標明顯高于舒芬太尼組。表明舒芬太尼復(fù)合右美托咪定鎮(zhèn)痛模式可阻斷來自軀體或內(nèi)臟傳入中樞神經(jīng)系統(tǒng)的抑制反射，明顯降低傷害性刺激反應(yīng)，從而有效地抑制創(chuàng)傷所致的傷害性刺激對垂體-腎上腺皮質(zhì)軸的激惹，使血皮質(zhì)醇產(chǎn)生減少，同時由于對交感神經(jīng)-腎上腺髓質(zhì)和下丘腦-垂體-腎上腺皮質(zhì)應(yīng)激軸的抑制，也可使圍術(shù)期細胞因子產(chǎn)生減少，增強免疫功能。

綜上所述，婦科子宮切除術(shù)后給予舒芬太尼復(fù)合右美托咪定鎮(zhèn)痛可明顯抑制皮質(zhì)醇的產(chǎn)生，抑制手術(shù)創(chuàng)傷及疼痛所致的機體過度的應(yīng)激反應(yīng)，減輕術(shù)后免疫抑制，加強免疫功能。

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Effect of postoperative analgesia of dexmedetomidine combined with sufentanil on cortisol levels and immune function of patients with hysterectomyGAO Ming-tao,ZHOU Nan*(Department of Anesthesiology,General Hospital of Shenyang Military Region,Shenyang 110016,China)

[Abstract]ObjectiveTo explore the effect of postoperative analgesia of dexmedetomidine combined with sufentanil on cortisol levels and immune function in patients with hysterectomy.MethodsA total of 116 patients with hysterectomy were divided into two groups randomly according to different patient-controlled intravenous analgesia scheme.Patients in group A recieved sufentanil patient-controlled intravenous analgesia,and patients in group B accepted dexmedetomidine combined with sufentanil patient-controlled intravenous analgesia.Cortisol levels and immune function were compared between the two groups at 0,2 and 24 h after operation.ResultsCompared with group B,the cortisol level in group A was higher (P<0.05),and the contents of IgG,IgA,IgM and CD4+T cells were lower with higher level of CD8+T cells (P<0.05).ConclusionPostoperative analgesia of dexmedetomidine combined with sufentanil can decrease the stress,improve the cortisol levels,and enhance immune function.

Key words：Dexmedetomidine;Sufentanil;Cortisol;Immune function

DOI:10.14053/j.cnki.ppcr.201602016

*通信作者

收稿日期：2015-10-11