【摘要】 目的 觀察腰椎手術(shù)病人圍手術(shù)期應(yīng)用塞來昔布的鎮(zhèn)痛效果。方法 62例腰椎手術(shù)病人隨機(jī)分為兩組,塞來昔布組30例,術(shù)前8 h口服塞來昔布400 mg,術(shù)后6 h禁食禁水期過后再次給藥,每次200 mg,每日2次,術(shù)后3~5 d視病人疼痛情況停藥;鎮(zhèn)痛泵組32例,術(shù)后常規(guī)使用鎮(zhèn)痛泵進(jìn)行鎮(zhèn)痛,維持至術(shù)后第2天,所有病人術(shù)后可根據(jù)需要肌注鹽酸哌替啶以緩解疼痛。觀察兩組病人術(shù)后6、12、24、48、72 h的VAS評(píng)分,并記錄藥物不良反應(yīng)及鹽酸哌替啶援助情況。結(jié)果 兩組病人術(shù)后鎮(zhèn)痛藥物不良反應(yīng)發(fā)生率比較差異有顯著性(χ2=5.37,P<0.05),兩組術(shù)后鎮(zhèn)痛藥物援助情況比較差異無顯著性(P>0.05),鎮(zhèn)痛泵組術(shù)后6、12 h的VAS評(píng)分顯著低于塞來昔布組(t=4.021、4.724,P<0.01),術(shù)后24、48及72 h兩組VAS評(píng)分比較差異無顯著意義(P>0.05)。結(jié)論腰椎手術(shù)病人圍手術(shù)期應(yīng)用塞來昔布有一定鎮(zhèn)痛效果,但其鎮(zhèn)痛效果并不優(yōu)于鎮(zhèn)痛泵。
【關(guān)鍵詞】 塞來昔布;椎管狹窄;椎間盤移位;手術(shù)期間;鎮(zhèn)痛
ANALGESIC EFFECT OF CELECOXIB ON PATIENTS UNDERGOING LUMBAR SURGERY ZHAO FENGGANG, HUANG YIFEI, ZHANG JIALIANG, et al (Xinjiang Medical University, Wulumuqi 830000, China); [ABSTRACT] ob[x]jective To evaluate the analgesic effects of celecoxib on patients undergoing lumbar surgery. MethodsSixtytwo patients undergoing lumbar surgery were randomized to two groups: celecoxib group (30 cases) received oral administration of celecoxib, 400 mg eight hours before surgery, and 200 mg twice a day starting at six hours after the surgery, the pain killer was discontinued at day 3-5 ba[x]sed on patients’ condition; the rest 32 cases were assigned as painrelieving pump (PRP) group, who received routine analgetic after operation, which lasted for two days. All patients were given intramuscular of 50 mg Pethidine Hydrochloride as required. Pain intensity was evaluated with visual analog scale (VAS) at six, 12, 24, 48 and 72 h after the operation, adverse reactions and the Pethidine dosage used were recorded. Results A difference between the two groups in terms of the adverse reactions of painkiller after the operation was significant (χ2=5.37,P<0.05), and that of the dosage of Pethidine used was not significant (P>0.05). The VAS scores at six and 12 h after surgery in PRP group were dramatically lower than that in celecoxib group (t=4.021, 4.724;P<0.01), but the differences were not significant at 24, 48 and 72 h after the surgery(P>0.05). Conclusion Perioperative administration of celecoxib shows a certain analgesia, but does not surpass the efficacy of intravenous analgesic pump.
[KEY WORDS] Celecoxib; Spinal stenosis; Intervertebral disk displacement; Intraoperative period; Analgesia
超前鎮(zhèn)痛是指在施行手術(shù)等傷害刺激作用于機(jī)體引起的疼痛出現(xiàn)之前,就采用鎮(zhèn)痛措施,以阻止感受性傷害的傳入及中樞神經(jīng)系統(tǒng)敏感化,達(dá)到消除或減輕術(shù)后疼痛的目的。塞來昔布是一種環(huán)氧化酶2(COX2)抑制劑,近年來已有諸多報(bào)道指出其應(yīng)用在骨科圍手術(shù)期具有很好的超前鎮(zhèn)痛效果,且有、經(jīng)濟(jì)、病人易于接受等優(yōu)點(diǎn)。本實(shí)驗(yàn)在腰椎圍手術(shù)期應(yīng)用塞來昔布,以評(píng)估其在腰椎圍手術(shù)期的鎮(zhèn)痛效果?,F(xiàn)將結(jié)果報(bào)告如下。
1 資料與方法
1.1 研究對(duì)象
選取2008年2~11月新疆醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院脊柱外科收治的腰椎管狹窄癥或腰椎間盤突出癥的擬行腰椎手術(shù)病人62例,男28例,女34例,年齡40~70歲,體質(zhì)量(60±10) kg。觀察對(duì)象無嚴(yán)重的呼吸系統(tǒng)疾患,無肝功能損害,無NSAIDs藥物或磺胺藥物過敏史,無胃潰瘍病史或胃腸道并發(fā)癥及凝血功能障礙,術(shù)前1周未服用各種鎮(zhèn)痛藥物,無慢性疼痛疾病史。62例病人隨機(jī)分為塞來昔布組30例和鎮(zhèn)痛泵組32例。兩組病人年齡、性別、體質(zhì)量、麻醉方式及手術(shù)時(shí)間均無顯著差異。
1.2 鎮(zhèn)痛方法
本文塞來昔布組病人在手術(shù)前8 h口服塞來昔布400 mg,術(shù)后禁食禁水期過后常規(guī)給予塞來昔布200 mg,每天2次,術(shù)后3~5 d視病人疼痛情況停藥;鎮(zhèn)痛泵組病人于手術(shù)后麻醉藥作用消失前靜脈應(yīng)用鎮(zhèn)痛泵,維持至術(shù)后第2天。若兩組病人術(shù)后觀察期間出現(xiàn)疼痛不可耐受者,視情況給予肌肉注射鹽酸哌替啶50 mg援助鎮(zhèn)痛。
鎮(zhèn)痛泵藥物配制如下:芬太尼1 mg,迷達(dá)唑侖10 mg,甲氧氯普胺10 mg,加9 g/L氯化鈉注射液配至100 mL,均現(xiàn)配現(xiàn)用。自控靜脈鎮(zhèn)痛泵一般情況下以2 mL/h的流量自動(dòng)輸入,病人全身麻醉清醒后,麻醉師通過病人靜脈輸液三通管接鎮(zhèn)痛泵并開通,自動(dòng)持續(xù)輸入一定量的鎮(zhèn)痛藥以達(dá)到基礎(chǔ)鎮(zhèn)痛的作用。
1.3 觀察指標(biāo)
采用視覺模擬評(píng)分(VAS)的方法來定量描述研究對(duì)象手術(shù)后切口疼痛的程度:0分為無痛,10分為難以忍受的劇痛。記錄兩組術(shù)后援助鎮(zhèn)痛及不良反應(yīng)發(fā)生情況。
1.4 統(tǒng)計(jì)方法
實(shí)驗(yàn)結(jié)果采用PPMS 1.5[1]統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì),計(jì)量資料行兩樣本均數(shù)比較的t檢驗(yàn),計(jì)數(shù)資料比較采用χ2檢驗(yàn)。
2 結(jié) 果
2.1 兩組病人術(shù)后VAS評(píng)分比較
塞來昔布組術(shù)后6、12 h的VAS評(píng)分與對(duì)照組相比,差異有顯著性(t=4.021、4.724,P<0.01);術(shù)后24、48及72 h兩組VAS評(píng)分比較差異無顯著性(P>0.05)。見表1。
2.2 兩組病人不良反應(yīng)比較
塞來昔布組術(shù)后3 d內(nèi)未見不良反應(yīng)發(fā)生,鎮(zhèn)痛泵組有7例出現(xiàn)頭暈、惡心、嘔吐癥狀,不良反應(yīng)發(fā)生率為21.88%。塞來昔布組藥物不良發(fā)生率低于鎮(zhèn)痛泵組,兩組比較差異有顯著意義(χ2=5.37,P<0.05)。
2.3 兩組病人術(shù)后援助鎮(zhèn)痛比較
術(shù)后塞來昔布組有3例需哌替啶援助鎮(zhèn)痛,鎮(zhèn)痛泵組有1例,兩組比較差異無顯著性(P>0.05)。表1 術(shù)后兩組病人VAS評(píng)分比較
3 討 論
手術(shù)后疼痛屬于炎癥性痛,是外周組織損傷引起炎癥所致,包括對(duì)傷害性刺激敏感性增強(qiáng)(損傷區(qū)域的原發(fā)性疼痛和周圍區(qū)域的繼發(fā)性疼痛)和非痛刺激的異常性疼痛,以及在炎癥區(qū)域出現(xiàn)自發(fā)性疼痛。超前鎮(zhèn)痛是在傷害性刺激作用于機(jī)體之前采用一定的措施,防止中樞和外周敏化,減少或消除傷害引起的疼痛[2]。
NSAIDs超前鎮(zhèn)痛效果通過降低免疫應(yīng)答從而降低外周敏化,同時(shí)可能通過抑制中樞麻醉性鎮(zhèn)痛藥,且給藥方式為靜脈持續(xù)泵注,其鎮(zhèn)痛效果優(yōu)于以口服給藥的塞來昔布。但塞來昔布組疼痛大多控制在病人可耐受范圍內(nèi),且術(shù)后24、48及72 h的鎮(zhèn)痛效果與鎮(zhèn)痛泵相似,不良反應(yīng)發(fā)生少,值得臨床進(jìn)一步深入研究并加以推廣。
總之,塞來昔布作為NSAIDs類超前鎮(zhèn)痛藥物的一種,雖具有其他NSAIDs類藥物不可比擬的優(yōu)越性,但作為特異性COX2抑制劑,理論上其單獨(dú)應(yīng)用并不能完全阻斷所有傷害性刺激,應(yīng)通過多種途徑來阻斷外周刺激向中樞神經(jīng)系統(tǒng)的傳遞,以消除外周和中樞敏化的形成,所以復(fù)合多模式的圍手術(shù)期鎮(zhèn)痛應(yīng)是今后發(fā)展的方向。
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