王向陽,趙 晶,張 偉,高成杰
(1.濟(jì)南軍區(qū)總醫(yī)院麻醉科,山東 濟(jì)南 250031;2.濟(jì)南軍區(qū)總醫(yī)院康復(fù)醫(yī)學(xué)科,山東 濟(jì)南 250031)
右美托咪定聯(lián)合舒芬太尼用于術(shù)后鎮(zhèn)痛對宮頸癌根治術(shù)患者心血管穩(wěn)定性及VAS評分的影響
王向陽1,趙 晶2,張 偉1,高成杰1
(1.濟(jì)南軍區(qū)總醫(yī)院麻醉科,山東 濟(jì)南 250031;2.濟(jì)南軍區(qū)總醫(yī)院康復(fù)醫(yī)學(xué)科,山東 濟(jì)南 250031)
目的 觀察右美托咪定聯(lián)合舒芬太尼用于術(shù)后鎮(zhèn)痛對宮頸癌根治術(shù)患者心血管穩(wěn)定性及VAS評分的影響。方法 選取于2014年8月至2016年1月來濟(jì)南軍區(qū)總醫(yī)院行宮頸癌根治術(shù)的宮頸癌患者64例,按照隨機(jī)數(shù)表法將所有患者分為觀察組和對照組,每組各32例。兩組患者術(shù)后鎮(zhèn)痛均使用舒芬太尼,其中觀察組患者術(shù)后鎮(zhèn)痛時加用右美托咪定。在術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時采用視覺模擬評分法(VAS)法對患者的疼痛程度進(jìn)行對比分析,比較兩組患者在各時間點(diǎn)心血管穩(wěn)定性。結(jié)果 術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時,觀察組患者收縮壓、舒張壓、心率和呼吸頻率均低于對照組。術(shù)后觀察組患者術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d各時間點(diǎn)舒張壓明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(t值分別為4.86、4.48、6.75、4.70、5.46,均P<0.01)。術(shù)后觀察組患者術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d各時間點(diǎn)呼吸頻率明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(t值分別為8.39、9.28、10.81、12.24、10.75,均P<0.01)。自術(shù)后6h起,術(shù)后12h、術(shù)后1d和術(shù)后2d時觀察組患者收縮壓明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(t值分別為3.40、3.94、5.07、2.94,均P<0.05)。術(shù)后1h時,對照組患者與觀察組患者VAS評分比較差異無統(tǒng)計(jì)學(xué)意義(t=0.10,P>0.05)。術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時對照組患者VAS評分明顯高于觀察組患者(t值分別為4.89、3.35、3.08、4.21,均P<0.01)。結(jié)論 右美托咪定聯(lián)合舒芬太尼用于宮頸癌根治術(shù)后患者鎮(zhèn)痛比單用舒芬太尼鎮(zhèn)痛的患者心血管穩(wěn)定性和VAS評分更高。
術(shù)后鎮(zhèn)痛;宮頸癌根治術(shù);心血管穩(wěn)定性;右美托咪定;VAS評分
術(shù)后疼痛會嚴(yán)重影響患者的精神和機(jī)體,導(dǎo)致患者煩躁等不適。宮頸癌根治術(shù)要求清掃患者子宮附件和盆腔淋巴結(jié),因此患者術(shù)后疼痛劇烈,妨礙患者盡早活動,延長住院時間,多數(shù)患者在術(shù)后2日內(nèi)都要求鎮(zhèn)痛。良好的鎮(zhèn)痛方法能夠有效緩解術(shù)后疼痛,縮短住院時間,減少并發(fā)癥的發(fā)生,促進(jìn)患者健康恢復(fù)[1]。右美托咪定是一種新型α2腎上腺素能受體激動劑,具有鎮(zhèn)靜、抑制交感神經(jīng)、抗焦慮的作用,同時能夠有效減少麻醉藥的用量,不良反應(yīng)少,已廣泛應(yīng)用于重癥監(jiān)護(hù)室患者的鎮(zhèn)靜[2]。舒芬太尼是一種廣泛應(yīng)用于臨床陣痛的阿片類鎮(zhèn)痛藥,但有明顯的呼吸抑制作用,不良反應(yīng)發(fā)生率高。本次研究通過將右美托咪定聯(lián)合舒芬太尼用于宮頸癌根治術(shù)后鎮(zhèn)痛,觀察其患者的心血管穩(wěn)定性和視覺模擬評分法(visual analogue scale/score,VAS)評分,現(xiàn)將結(jié)果報道如下。
1.1一般資料
選取于2014年8月至2016年1月來濟(jì)南軍區(qū)總醫(yī)院行宮頸癌根治術(shù)的宮頸癌患者64例,年齡46~69歲,平均年齡(57.40±8.60)歲。病程8.7~13.2個月,平均病程(11.70±1.60)個月。按照隨機(jī)數(shù)表法將所有患者分為觀察組和對照組,每組各32例,觀察組患者年齡47~68歲,平均年齡(56.90±8.50)歲;病程8.7~12.9個月,平均病程(11.10±1.70)個月。對照組患者46~69歲,平均年齡(57.70±8.60)歲,病程8.9~13.2個月,平均病程(11.90±1.40)個月。病例納入標(biāo)準(zhǔn):①經(jīng)臨床病例檢查均確診為宮頸癌的患者[3];②美國麻醉醫(yī)師學(xué)會(American Society of Anesthesiologists,ASA)分級Ⅰ級或Ⅱ級的患者。病例排除標(biāo)準(zhǔn):①心臟傳導(dǎo)阻滯的患者;②伴有肝腎功能明顯異常的患者;③近期服用鎮(zhèn)痛鎮(zhèn)靜藥物的患者;④有精神病史和藥物過敏史的患者。兩組患者年齡、病程等一般資料差異無統(tǒng)計(jì)學(xué)意義(均P>0.05),具有可比性。所有患者及家屬均知情同意,均簽署知情同意書。本次研究經(jīng)本院醫(yī)學(xué)倫理學(xué)委員會批準(zhǔn)。
1.2方法
所有患者均于術(shù)前12h開始禁食,進(jìn)入手術(shù)室后,進(jìn)行心率、血壓、血氧飽和度、脈搏等常規(guī)監(jiān)測。均采用經(jīng)氣管插管和經(jīng)靜脈給藥的復(fù)合全身麻醉方法進(jìn)行麻醉。術(shù)前30min常規(guī)使用阿托品0.5mg,苯巴比妥鈉0.1g。術(shù)中靜脈誘導(dǎo)采用舒芬太尼0.3μg/kg、丙泊酚1.5mg/kg、順式阿曲庫胺0.2mg/kg,3min后經(jīng)口明視氣管內(nèi)插管,氣管插管后行機(jī)械通氣。兩組患者術(shù)后鎮(zhèn)痛均使用舒芬太尼(1.00μg·kg-1·d-1),術(shù)后自控靜脈鎮(zhèn)痛(patient controlled intravenous analgesia,PCIA),其中,對觀察組患者術(shù)后鎮(zhèn)痛時加用右美托咪定(1.00μg·kg-1·d-1)。術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時采用VAS法對患者的疼痛程度進(jìn)行對比分析,比較兩組患者在各時間點(diǎn)心血管穩(wěn)定性。
1.3觀察指標(biāo)
采用VAS評分法對患者的疼痛程度進(jìn)行對比分析,0~10分,0分為無痛,10分為劇痛,分?jǐn)?shù)越高表明患者疼痛程度越高。0分為無痛,1~3分為輕微疼痛,4~6分為患者疼痛影響睡眠,尚能忍受,7~10分為劇烈疼痛,患者無法忍受[4]。
1.4統(tǒng)計(jì)學(xué)方法
2.1兩組患者心血管穩(wěn)定性比較
術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時,觀察組患者收縮壓、舒張壓、心率和呼吸頻率均低于對照組。觀察組患者術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d各時間點(diǎn)舒張壓明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(均P<0.01)。觀察組患者術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d各時間點(diǎn)呼吸頻率明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(均P<0.01)。觀察組患者術(shù)后6h、術(shù)后12h、術(shù)后1d和術(shù)后2d時收縮壓明顯低于對照組,差異有統(tǒng)計(jì)學(xué)意義(均P<0.05),見表1。
表1 兩組患者心血管穩(wěn)定性比較
2.2兩組患者VAS評分比較
術(shù)后1h時,對照組患者與觀察組患者VAS評分比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時對照組患者VAS評分明顯高于觀察組患者,差異有統(tǒng)計(jì)學(xué)意義(均P<0.01),見表2。
類別對照組(n=32)觀察組(n=32)tP術(shù)后1h2.23±0.912.21±0.710.100.92術(shù)后6h2.12±0.661.36±0.584.89<0.01術(shù)后12h1.61±0.691.08±0.573.35<0.01術(shù)后1d1.23±0.640.81±0.433.08<0.01術(shù)后2d0.92±0.510.48±0.304.21<0.01
3.1宮頸癌術(shù)后鎮(zhèn)痛概述
宮頸癌是最常見的婦科腫瘤類型之一,約有28%為40歲以下女性。由于宮頸癌手術(shù)范圍大,術(shù)后嚴(yán)重疼痛會影響患者盡早活動,可能引起多種并發(fā)癥,如神經(jīng)應(yīng)激性反應(yīng)、自主神經(jīng)功能紊亂、慢性神經(jīng)病理性疼痛等,導(dǎo)致患者住院時間延長[5-6]。因此,術(shù)后良好的鎮(zhèn)痛能夠極大地減輕應(yīng)激反應(yīng),提高患者術(shù)后康復(fù)。本次研究通過觀察右美托咪定聯(lián)合舒芬太尼用于術(shù)后鎮(zhèn)痛對宮頸癌根治術(shù)患者心血管穩(wěn)定性及VAS評分的影響,為臨床宮頸癌根治術(shù)患者的術(shù)后鎮(zhèn)痛提供理論依據(jù)。
3.2舒芬太尼與右美托咪定在術(shù)后鎮(zhèn)痛中的應(yīng)用
舒芬太尼是目前臨床上常用的強(qiáng)效阿片類藥物,術(shù)中和術(shù)后鎮(zhèn)痛使用最多、效果最好,但對運(yùn)動性疼痛效果較差,個體差異較大,過量使用會導(dǎo)致患者出現(xiàn)呼吸抑制、尿潴留和惡心嘔吐等[7]。由于誘發(fā)痛覺過敏,術(shù)后阿片類鎮(zhèn)痛藥的鎮(zhèn)痛作用減弱,加大用量,會進(jìn)一步減弱鎮(zhèn)痛效果,同時不良反應(yīng)的發(fā)生率增加[8]。此時,聯(lián)合使用右美托咪定是一個較好的選擇,右美托咪定是一種新型α2腎上腺能受體激動劑,通過抑制去甲腎上腺素的釋放,激動突觸后膜受體,具有鎮(zhèn)痛、鎮(zhèn)靜、降低應(yīng)激反應(yīng)、抗交感神經(jīng)反射的作用,且對呼吸無明顯抑制作用,同時可以穩(wěn)定患者血流動力學(xué)水平,減少術(shù)后的惡心嘔吐、寒戰(zhàn)、躁動,減少鎮(zhèn)痛藥和麻醉藥的用量。右美托咪定具有半衰期短的特點(diǎn),鎮(zhèn)靜水平容易調(diào)節(jié),已廣泛應(yīng)用于ICU長時間的鎮(zhèn)靜,有著較高的安全性和可靠性。同時,患者處于類似正常睡眠的鎮(zhèn)靜狀態(tài),被鎮(zhèn)靜同時可被喚醒,撤除喚醒的刺激患者很快可回到被鎮(zhèn)靜狀態(tài)[9]。
本次研究結(jié)果證明,術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時,觀察組患者收縮壓、舒張壓、心率和呼吸頻率均低于對照組,表明觀察組患者術(shù)后血流動力學(xué)比對照組患者更加穩(wěn)定。同時,術(shù)后6h、術(shù)后12h、術(shù)后1d、術(shù)后2d時觀察組患者VAS評分明顯高于對照組患者(P<0.01)。觀察組患者術(shù)后VAS評分在各時間點(diǎn)逐漸下降,且觀察組術(shù)后血流動力學(xué)狀態(tài)逐漸穩(wěn)定,這一結(jié)果表明右美托咪定聯(lián)合舒芬太尼用于宮頸癌根治術(shù)后鎮(zhèn)痛能夠有效改善患者的心血管穩(wěn)定性和VAS評分,其鎮(zhèn)痛效果和鎮(zhèn)靜效果明顯優(yōu)于單用舒芬太尼的對照組,能夠有效改善患者的預(yù)后和病情。右美托咪定具有半衰期短的特點(diǎn),鎮(zhèn)靜水平容易調(diào)節(jié),聯(lián)合舒芬太尼用于術(shù)后鎮(zhèn)痛能夠有效保證術(shù)后的鎮(zhèn)痛效果,減少鎮(zhèn)痛藥物的用量,因此患者不良反應(yīng)發(fā)生減少[10]。
綜上所述,右美托咪定聯(lián)合舒芬太尼用于宮頸癌根治術(shù)后患者鎮(zhèn)痛比單用舒芬太尼鎮(zhèn)痛的患者心血管穩(wěn)定性和VAS評分更高。
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[專業(yè)責(zé)任編輯:陳 寧]
Influence of postoperative analgesia with dexmedetomidine combining sufentanil on cardiovascular stability and VAS score of patients treated with radical hysterectomy for cervical cancer
WANG Xiang-yang1, ZHAO Jing2, ZHANG Wei1, GAO Cheng-jie1
(1.DepartmentofAnesthesiology; 2.DepartmentofRehabilitationMedicine,JinanMilitaryGeneralHospital,ShandongJinan250031,China)
Objective To observe the influence of postoperative analgesia with dexmedetomidine combining sufentanil on cardiovascular stability and VAS score of patients treated with radical hysterectomy for cervical cancer. Methods Altogether 64 cases of cervical cancer treated with radical hysterectomy for cervical cancer in Jinan Military General Hospital from August 2014 to January 2016 were selected and randomly divided into observation group and control group with 32 cases in each group. Patients in both groups were given sufentanil for postoperative analgesia. Patients in the observation group were also given dexmedetomidine. Pain degree of patients was compared with visual analogue scale (VAS) at 1h, 6h, 12h, 1d and 2d after operation,and cardiovascular stability in two groups were compared. Results Systolic blood pressure, diastolic pressure, heart rate and respiratory rate of patients in the observation group were lower than those in the control group at 1h, 6h, 12h, 1d and 2d after operation. Diastolic pressure of patients in the observation group at 1h, 6h, 12h, 1d and 2d after operation was significantly lower than that in the control group, and the difference was statistically significant (tvalue was 4.86, 4.48, 6.75, 4.70 and 5.46, respectively, allP<0.01). Respiratory rate of patients in the observation group at 1h, 6h, 12h, 1d and 2d after operation was significantly lower than that in the control group, and the difference was statistically significant (tvalue was 8.39, 9.28, 10.81, 12.24 and 10.75, respectively, allP<0.01). Since 6h after operation, systolic blood pressure in the observation group was significantly lower than that in the control group at 12h, 1d and 2d after operation (tvalue was 3.40, 3.94, 5.07 and 2.94, respectively, allP<0.05). At 1h after operation, there was no significant difference in VAS score between two groups (t=0.10,P>0.05). VAS score in the control group was significantly higher than that in the observation group at 6h, 12h, 1d and 2d after operation (tvalue was 4.89, 3.35, 3.08 and 4.21, respectively, allP<0.01). Conclusion Cardiovascular stability and VAS score of patients provided with dexmedetomidine and sufentanil for postoperative analgesia after radical hysterectomy for cervical cancer are better than those of patients given only sufentanil for postoperative analgesia.
postoperative analgesia; radical hysterectomy for cervical cancer; cardiovascular stability; dexmedetomidine; VAS score
2017-01-13
王向陽(1984-),男,醫(yī)師,主要從事臨床麻醉與術(shù)后鎮(zhèn)痛工作。
高成杰,主任醫(yī)師。
10.3969/j.issn.1673-5293.2017.05.040
R737.33
A
1673-5293(2017)05-0606-03