劉 潔,許愛軍,高 峰,田玉科
與開放性婦科手術(shù)相比,腹腔鏡手術(shù)有切口小、損傷輕、出血少、恢復(fù)快等優(yōu)點(diǎn),因此在臨床上得到了廣泛的應(yīng)用。但術(shù)后疼痛仍是影響腹腔鏡婦科手術(shù)患者術(shù)后恢復(fù)的原因之一,因此對(duì)腹腔鏡婦科手術(shù)術(shù)后鎮(zhèn)痛的研究具有重要意義。
以往有研究人員對(duì)術(shù)中靜脈輸注利多卡因的鎮(zhèn)痛效果進(jìn)行了研究,如Choi等[1]的研究表明術(shù)中靜脈輸注利多卡因能顯著地減輕甲狀腺全切除術(shù)患者術(shù)后疼痛,促進(jìn)術(shù)后恢復(fù);王萍等[2]對(duì)胸腔鏡肺大皰切除術(shù)患者的研究表明,靜脈注射利多卡因可減輕術(shù)后疼痛,降低患者阿片類藥物用量。而利多卡因?qū)Ω骨荤R婦科腫瘤根治術(shù)手術(shù)患者術(shù)后疼痛的影響還缺少相關(guān)研究。筆者所在醫(yī)院將98例擬行腹腔鏡婦科手術(shù)患者隨機(jī)分為對(duì)照組和觀察組,觀察組患者麻醉誘導(dǎo)和麻醉維持期靜脈利用利多卡因;對(duì)照組患者則使用等容量0.9%氯化鈉注射液,該臨床試驗(yàn)是屬前瞻性的、隨機(jī)的、雙盲的、安慰劑對(duì)照的臨床試驗(yàn),研究術(shù)中靜脈輸注利多卡因?qū)Ω骨荤R婦科手術(shù)患者術(shù)后鎮(zhèn)痛的影響。
1.1 一般資料 該研究得到了華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院倫理委員會(huì)的批準(zhǔn) (ID號(hào):20150104)并由患者簽署知情同意書。98例擇期行腹腔鏡婦科腫瘤根治術(shù)手術(shù)患者,年齡30~69歲,BMI 18.5~30 kg/m2,ASA Ⅰ~Ⅱ級(jí)。 排除標(biāo)準(zhǔn):高血壓、冠心病、糖尿病、中樞神經(jīng)系統(tǒng)疾患等病史,鎮(zhèn)痛藥、鎮(zhèn)靜藥成癮史及近期有阿片類藥物服用史,對(duì)局麻藥過敏者。使用隨機(jī)數(shù)字表法將患者分為兩組:觀察組44例(5例轉(zhuǎn)為開放性手術(shù)),對(duì)照組49例。對(duì)兩組患者基本情況進(jìn)行比較,年齡、BMI、ASA分級(jí)和手術(shù)時(shí)間差異無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2 麻醉方法 在麻醉誘導(dǎo)前,觀察組的患者靜脈緩慢推注負(fù)荷劑量的利多卡因(lidocaine hydrochloride injection,上海朝暉藥業(yè)有限公司,批準(zhǔn)文號(hào):國藥準(zhǔn)字 H31021073,規(guī)格 10 ml∶0.2 g) 1.5 mg/kg,最高劑量限制為150 mg。對(duì)照組靜脈推注等容量的生理鹽水。麻醉誘導(dǎo)依次給予舒芬太尼0.6 μg/kg,丙泊酚2 mg/kg和羅庫溴銨0.6 mg/kg,置入氣管導(dǎo)管,行機(jī)械通氣。誘導(dǎo)后觀察組微量泵靜脈輸注利多卡因2 mg/kg·h,對(duì)照組微量泵靜脈輸注等容量生理鹽水,至拔除氣管導(dǎo)管時(shí)停止輸注利多卡因。麻醉維持用雷米芬太尼 0.1 μg/kg·min和七氟烷,術(shù)中間斷追加羅庫溴銨。監(jiān)測(cè)無創(chuàng)動(dòng)脈血壓、ECG、SpO2和 BIS, 術(shù)中維持 SpO2在 99%~100% ,PET CO2在 30~40 mmHg(1 mmHg=0.133 kPa),BIS 值維持在40~55之間。術(shù)中患者體位采用截石頭低位,氣腹壓力維持在12~15 mmHg。術(shù)后患者均接上鎮(zhèn)痛泵(PCA),持續(xù)輸注背景劑量的舒芬太尼,如患者自覺疼痛,可按PCA按鈕,追加相應(yīng)劑量的舒芬太尼。
1.3 觀察指標(biāo) 由一專門的醫(yī)師負(fù)責(zé)數(shù)據(jù)采集和記錄,記錄患者的一般情況、術(shù)后1 h,24 h和48 h視覺模擬疼痛評(píng)分 (visual analogue scale,VAS評(píng)分),患者根據(jù)自己的疼痛情況給出評(píng)分。術(shù)后患者均接上PCA,持續(xù)輸注背景劑量的舒芬太尼,如患者自覺疼痛,可能按PCA按鈕,追加相應(yīng)劑量的舒芬太尼。如 VAS>3分,給予舒芬太尼 5 μg。此外,還需記錄術(shù)后惡心嘔吐的發(fā)生率及術(shù)后住院時(shí)間。術(shù)后PCA按壓次數(shù)和PCA追加劑量由管理鎮(zhèn)痛泵的護(hù)士專門記錄。
1.4 統(tǒng)計(jì)學(xué)方法 數(shù)據(jù)資料采用SPSS 18.0版統(tǒng)計(jì)軟件分析處理。計(jì)數(shù)和計(jì)量資料分別采用卡方檢驗(yàn)和t檢驗(yàn);等級(jí)資料使用秩和檢驗(yàn);P<0.05表示差異有統(tǒng)計(jì)學(xué)意義。
2.1 術(shù)后疼痛評(píng)分 對(duì)術(shù)后疼痛評(píng)分進(jìn)行比較,觀察組患者術(shù)后1 h、24 h和48 h疼痛評(píng)分均顯著低于對(duì)照組。見表1。
表1 兩組患者術(shù)后不同時(shí)點(diǎn)VAS評(píng)分(±s)
表1 兩組患者術(shù)后不同時(shí)點(diǎn)VAS評(píng)分(±s)
注:與對(duì)照組比較,*P<0.05。
組別 n 1 h 24 h 48 h對(duì)照組 49 3.00±1.29 3.41±1.94 2.68±1.89觀察組 44 1.10±0.65* 1.90±1.07* 1.50±0.83*
2.2 術(shù)后舒芬太尼追加劑量 兩組患者術(shù)后舒芬太尼的背景劑量沒有統(tǒng)計(jì)學(xué)差異;但觀察組患者術(shù)后舒芬太尼的追加劑量顯著低于對(duì)照組。見表2。
表2 兩組患者術(shù)后舒芬太尼使用劑量(±s)
表2 兩組患者術(shù)后舒芬太尼使用劑量(±s)
注:與對(duì)照組比較,*P<0.05。
組別 n 舒芬太尼背景劑量(μg) 舒芬太尼追加劑量(μg)對(duì)照組 49 35.55±6.12 3.10±1.69觀察組 44 35.45±4.50 1.58±1.03*
2.3 術(shù)后24 h恢復(fù)情況及術(shù)后住院時(shí)間 結(jié)果顯示,觀察組和對(duì)照組患者在術(shù)后24 h內(nèi)惡心嘔吐發(fā)生率及住院時(shí)間差異均無統(tǒng)計(jì)學(xué)意義 (P>0.05),見表3。
表3 兩組患者術(shù)后24 h恢復(fù)情況和術(shù)后住院時(shí)間
2.4 不良反應(yīng) 觀察組患者術(shù)中未出現(xiàn)利多卡因相關(guān)的血流動(dòng)力學(xué)改變?nèi)绲脱獕?,心?dòng)過緩和心律失常等。此外,在術(shù)后恢復(fù)時(shí)沒有患者訴頭暈,耳鳴,口周麻木,視覺模糊等利多卡因中毒癥狀。
對(duì)幕上腫瘤手術(shù),復(fù)雜脊柱手術(shù),腰椎手術(shù),腹股溝疝修補(bǔ)術(shù),開放性腹部手術(shù),腹腔鏡膽囊切除術(shù)和胸外科手術(shù)的研究表明[3-11],術(shù)中靜脈輸注利多卡因能顯著減輕患者術(shù)后疼痛、減少術(shù)后鎮(zhèn)痛藥物用量、促進(jìn)胃腸功能恢復(fù)、縮短術(shù)后住院時(shí)間。但另有一些對(duì)乳房切除術(shù),全髖關(guān)節(jié)置換術(shù)和腹腔鏡腎手術(shù)的研究顯示[12-15],靜脈輸注利多卡因?qū)颊咝g(shù)后疼痛和恢復(fù)無顯著作用。因此,術(shù)中靜脈輸注利多卡因?qū)颊咝g(shù)后疼痛的影響可能與其手術(shù)類型有關(guān)。
術(shù)中靜脈輸注利多卡因可能的鎮(zhèn)痛機(jī)制如下:(1)利多卡因具有抗炎特性,能減少炎癥因子的釋放,從而緩解炎性疼痛[16];(2)利多卡因是一種電壓門控鈉通道阻滯藥,能抑制外周疼痛神經(jīng)纖維的傳導(dǎo)[17];(3)利多卡因能減少圍術(shù)期阿片類藥物使用,從而降低術(shù)后痛覺過敏的發(fā)生[18]。
該研究中,術(shù)后1 h、24 h和48 h,兩組患者VAS疼痛評(píng)分均有顯著性差異,分析其原因可能是:(1)腫瘤根治術(shù)手術(shù)時(shí)間較長(zhǎng),因而利多卡因靜脈輸注時(shí)間更長(zhǎng),利多卡因達(dá)到的濃度相對(duì)更高,產(chǎn)生更好的鎮(zhèn)痛效果;(2)腫瘤根治術(shù)手術(shù)創(chuàng)傷相對(duì)大,可能產(chǎn)生更強(qiáng)的炎癥反應(yīng),利多卡因可能發(fā)揮了其抗炎特性,減少炎性疼痛。
該研究也發(fā)現(xiàn),在腹腔鏡婦科手術(shù)患者中,靜脈注射利多卡因,對(duì)術(shù)后24 h惡心嘔吐發(fā)生率、排便通氣時(shí)間及術(shù)后住院時(shí)間沒有顯著的影響。這與以往部分研究的結(jié)果不一致,分析其原因可能是:(1)為避免利多卡因的不良反應(yīng),該研究術(shù)后立刻停止了利多卡因輸注,這與以往部分研究持續(xù)輸注利多卡因到術(shù)后24 h不同;(2)可能與腹腔鏡腫瘤根治術(shù)術(shù)后惡心嘔吐發(fā)生率高等特點(diǎn)有關(guān)。還需要進(jìn)行相關(guān)研究來探討其相關(guān)作用機(jī)制。
術(shù)中靜脈輸注利多卡因有助于減輕腹腔鏡婦科腫瘤根治術(shù)患者術(shù)后疼痛,減少術(shù)后阿片類藥物用量,但對(duì)術(shù)后惡心嘔吐、排便通氣時(shí)間及術(shù)后住院時(shí)間等方面無顯著意義。
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