右肺镇痛 [三联镇痛对下腹部手术术后疼痛及肺功能的影响]

　　[摘要] 目的 观察非甾体类抗炎药罗非昔布、局麻药罗哌卡因区域阻滞、氯胺酮三联镇痛对下腹部手术术后疼痛及肺功能的影响。 方法 将我院100例接受腹部大手术的患者分为治疗组和对照组，各50例。治疗组于术前30 min口服50 mg罗非昔布片剂、切皮前0.5%罗哌卡因行区域阻滞、术前5 min静注氯胺酮0.2 mg/kg。对照组则选择常规麻醉方案。按需静脉给予舒芬太尼以控制术后疼痛，记录两组术后24 h舒芬太尼用量。另外，分别记录两组术后的疼痛评分和手术后的肺功能恢复情况。 结果 治疗组较对照组的疼痛评分低，治疗组较对照组使用舒芬太尼镇痛的剂量要少。另外，治疗组患者术后肺功能恢复情况好于对照组。 结论 对下腹部手术患者应用罗非昔布、0.5%罗哌卡因区域阻滞及氯胺酮进行镇痛可以减少术后疼痛和镇痛药的用量，有利于患者术后肺功能的恢复。
　　[关键词] 三联镇痛；罗非昔布；罗哌卡因；氯胺酮；下腹部手术；肺功能
　　[中图分类号] R614 [文献标识码] A [文章编号] 1673-7210（2012）08（b）-0079-03
　　The effect of postoperative analgesia and lung function with triple analgesia in hypogastric laparotomy
　　FANG Jianjun GUO Jisheng GUO Jifeng ZHOU Wei
　　Department of Anesthesiology, Oilfield General Hospital of Puyang City, He′nan Province, Puyang 457001, China
　　[Abstract] Objective To observe the effect of postoperative analgesia and lung function with triple analgesia of Rofecoxib, Ropivacaine, Ketamine for lower abdominaol surgery. Methods 100 patients with lower abdominaol surgery were divided into treatment group and control group, each 50 cases. The patients of treatment group received Rofecoxib, 50 mg po, a field block with 0. 5% Ropivacaine, and Ketamine 0.2 mg/kg iv before incision; control group received a conventional anesthesia program before surgery. Postoperative pain was treated by sufentainyl as required for pain and record the dosage of Sufentainyl for 24 hours of two groups. In addation, the pain scores and lung function of two groups after surgery were recorded. Results Pain scores and sufentanyl analgesic use were lower in the treatment group compared with control group. Lung function of treatment group was superior to control group. Conclusion Analgesics and pain scores are decreased with triple preincisional analgesic therapy in hypogastric laparotomy patients. Triple therapy consistes of a nonsteroidal antiinflammatory, a local anesthetic field block, and an N-methyl-D-aspartate inhibitor before incision. Moreover, Triple therapy is beneficial to restore of lung function postoperation.
　　[Key words] Triple analgesia; Rofecoxib; Ropivacaine; Ketamine; Lower abdominal surgery; Lung function
　　有证据表明，在手术创伤发生之前就给予预防性疼痛治疗可能会比单纯的术后镇痛治疗更有效[1]，这种“预先镇痛”能防止中枢敏化和神经元的过度激活（痛觉上扬），中枢敏化被认为是疼痛刺激作用于中枢神经轴的N-甲基-D-天（门）冬氨酸（NMDA）受体而产生的[2]。有学者认为，局麻药、抗炎药或NMDA抑制剂都可以用于预先镇痛治疗，以抑制伤害性刺激的传递，防止NMDA 受体的激活和中枢敏化的产生。在临床研究中，单一治疗常常不能达到预先镇痛的效果[3]。本研究旨在将这三种药物联合用于镇痛，同时，术前应用镇痛药也可以确保其血药浓度在手术结束时达到治疗水平。本研究选择氯胺酮作为NMDA抑制剂，选择特异性环氧化酶-2抑制剂罗非昔布作为非甾体抗炎药，以避免传统非甾体抗炎药可能导致的血小板功能抑制、出血时间延长等副作用[4]。开腹手术恢复期的患者体位变动时会引起无法忍受的疼痛，影响术后的深呼吸和咳嗽，对患者的康复不利[5]。