24小时错峰使用芬太尼透皮贴剂在带状疱疹性疼痛治疗中的疗效观察

目的：比较24小时错峰使用芬太尼透皮贴剂（多瑞吉）和常规使用多瑞吉对中、重度带状疱疹性疼痛的镇痛效果及不良反应。方法：36例中、重度带状疱疹性疼痛患者经静脉吗啡滴定后,随机分为两组（n=18）,A组使用等效剂量多瑞吉,B组先使用等效剂量一半的多瑞吉,24小时后使用另一半,每贴多瑞吉更换周期均为72 h,以视觉模拟评分（VAS）评定治疗效果。结果：分别于治疗前、使用多瑞吉后3d、7d、14d记录两组患者VAS评分,结果发现两组患者在多瑞吉治疗后3d、7d、14dVAS评分均逐渐降低。但在使用多瑞吉后3d,B组VAS评分明显低于A组（P〈0.01）,用多瑞吉后7d、14d,两组VAS评分无明显差异（P〉0.05）。B组患者在使用多瑞吉7d内恶心、呕吐及头晕不良反应发生率较A组低。结论：多瑞吉24小时错峰使用简单有效,可平稳有效缓解带状疱疹性疼痛,与常规使用多瑞吉相比其不良反应较少。     

手术后PCEA的观察与护理

病人自控镇痛（Patient-Controlled Analgesi-a,PCA）系指在病人体验疼痛时病人自己将镇痛泵内设定的小剂量药物注入体内进行镇痛的方法。采用PCA,病人可根据疼痛程度,自己间断少量给药,从而取得较好的止痛效果。PCA最大的特点是病人不必依赖医护人员,可自行控制给药。当此方法用于硬膜外腔注射药物镇痛时又称为病人自控硬膜外镇痛（Patient Controlled Epidural Analgesia,PCEA）。我科自2003年10月至2005年5月,对196例病人手术后采用PCEA,现报告如下。     

吗啡皮下自控镇痛泵治疗难治性癌痛的前瞻性多中心随机对照研究

摘要 目的：观察吗啡皮下自控镇痛泵治疗难治性癌痛的临床疗效。方法：采用前瞻性多中心随机对照研究,应用治疗方法分为试验组和对照组,其中试验组使用皮下自控阵痛泵给药,对照组口服吗啡片剂,5 d为一疗程,共计观察3疗程。观察两组患者治疗后疼痛积分改善情况;每疗程吗啡日均用量;疼痛起效时间、最佳缓解时间;镇痛维持时间及剂量稳定天数、爆发痛情况;生活质量改善及不良反应发生率;疗程费用情况。结果：两组患者数字疼痛评分法(numerical rating scale,NRS)评分在治疗后均较镇痛前显著降低（P＜0.05）;在吗啡用量比较方面,试验组吗啡用量显著低于对照组同期用量;试验组在疼痛缓解时间、疼痛最佳缓解时间方面均显著优于对照组;治疗期间试验组平均镇痛维持时间明显长于对照组（P＜0.05）;两组患者治疗后体力状况分析标准(performance status,PS)评分较治疗前显著改善;试验组便秘、嗜睡不良反应发生率显著低于对照组（P＜0.05）。试验组每疗程费用明显低于对照组,具有明显经济优势。结论：吗啡皮下自控镇痛泵给药方式控制难治性癌痛临床疗效确切,止痛效果明显。与对照组比较,疼痛起效时间短,疗程较吗啡用量少,不良反应发生率低,改善了患者生活质量,且减轻了患者经济压力。     

腰硬联合麻醉下术中静脉右美托咪啶对术后硬膜外镇痛的影响

目的：观察腰硬联合麻醉下术中静脉持续输注0．5μg·kg-1．h-1的右关托咪啶对腹式全子宫切除术病人术后吗啡硬膜外自控镇痛（PCEA）的影响及相关不良反应发生的情况。方法：选择ASAI或II级、择期行腹式全子宫切除术病人50例,腰硬联合麻醉成功后,随机分为Ⅰ组（右关托咪啶组）和Ⅱ组（盐水对照组）,每组25例,术后镇痛采用硬膜外镇痛。观察患者术后第一疼痛出现时间,术后24h和术后24--48h吗啡用量、PCEA泵按压次数和有效次数,VAS评分法评估患者术后不同时点的疼痛程度;记录围术期血流动力学的变化和血管活性药物的使用情况;记录镇痛期间恶心呕吐及皮肤瘙痒等不良反应的发生情况。结果：患者术后第一疼痛时间Ⅰ组较Ⅱ组延长（P〈0．05）;术后24小时吗啡用量、PCEA泵按压次数及有效按压次数Ⅰ组较Ⅱ组显著减少（P〈0．05）,24---48小时两组病人无差异（P〉0．05）;病人术后0．5小时、6小时静息和运动VAS评分Ⅰ组较Ⅱ组显著减低（P〈0．05）,其余时点无差异（P〉0．05）;麻醉后15min时Ⅰ组较Ⅱ组心率下降（P〈0．05）,其余各时点比较无差异（P〉0．05）,各时点平均动脉压两组无差异（P〉0．05）;阿托品和麻黄碱Ⅰ组使用量较Ⅱ组增多（P〈0．05）;恶心的发生率Ⅰ组较Ⅱ组降低（P〈0．05）。结论：腰硬联合麻醉下行腹式全子宫切除术,术中静脉持续输注0．5μg·kg-1．h-1的右美托咪啶可在术后24小时内减轻患者的疼痛反应,减少硬膜外镇痛吗啡的用量,且无明显不良反应。     

芬太尼和吗啡在全麻开胸术后病人静脉自控镇痛作用效果的对比研究

目的:探讨芬太尼和吗啡用于开胸术后镇痛效果及不良反应的观察.方法:356例全麻开胸手术病人,随机分成吗啡治疗组(M组)和芬太尼治疗组(F组),每组178例.F组采用芬太尼100μg+利多卡因200mg+异丙嗪25mg,M组采用吗啡20rag+利多卡因200mg+异丙嗪25mg,分别用生理盐水稀释至100ml,术毕接电子泵行静脉自控镇痛(PCA).分别记录手术后6、12、24、48h四个时相点两组病人的视觉模拟疼痛评分(VAS评分)、镇静评分(Ramsay评分)以及恶心、呕吐、瘙痒、呼吸抑制等不良反应的发生情况.结果:各时相点F组VAS评分均低于M组,差异显著(p<0.05),而两组间血压、心率、心率、呼吸频率及SpO2无明显差异.各时相点恶心及呕吐评分F组优于M组,两组间差别显著(p<0.05),镇静效果两组相当.两组均未发生严重不良反应.结论:芬太尼用于全麻开胸术后病人的镇痛效果显著强于吗啡,镇静效果与吗啡相当,但不良反应明显小于吗啡,疗效确切,安全性高,值得在推广使用.     

中药止痛贴与吗啡联合应用于癌症疼痛的镇痛效果及安全性

目的:探讨中药止痛贴与吗啡联合应用于癌症疼痛治疗中的镇痛效果及安全性。方法:选取2016年5月至2017年5月我院收治的100例中重度癌症疼痛患者为研究对象,根据随机数字表方法将入选的患者分为对照组和研究组,每组50例。对照组患者给予吗啡治疗,研究组患者在此基础上联合应用中药止痛贴治疗,连续给药14天。比较两组患者的临床疗效、数字评分法(digital scoring method,NRS)、爆发痛次数、吗啡使用量、中医证候评分。结果:研究组患者治疗总有效率为96.0%,显著高于对照组患者(86.0%,P0.05)。研究组盐酸吗啡缓释片使用剂量[(83.23±23.14)mg/d]低于对照组[(110.13±25.23)mg/d](P0.05)。治疗前,两组患者各中医证候评分比较差异均无统计学意义(P0.05);治疗后,两组患者各中医证候评分均较治疗前明显降低,且研究组显著低于对照组,差异有统计学意义(P0.05)。研究组患者的NRS评分、爆发痛次数显著低于对照组(P0.05),两组患者均未见严重的不良反应。结论:中药止痛贴与吗啡联合应用于癌症疼痛的可有效提高镇痛效果,改善患者的中医证候,减少吗啡使用量,且安全性高。     

一种体内恒速持续给药的方法—微量渗透泵

利用微量渗透泵给药是一种崭新的动物实验性持续给药方法。泵体由３个同心层（由内向外）—贮药池、渗透性套筒及控制渗透泵药物释放速度的半透膜组成。泵在被水激活后,因水可按渗透梯度渗入渗透性套筒部分,压迫泵体以恒定速度持续释放药物几天至若干星期,其渗透速度与被释放药物的理化性质无关,因而适用于多种药物     

硬膜外注射小剂量吗啡止痛

硬膜外注射小剂量吗啡止痛是近年来发现的一种术后止痛的好方法,自1979年 Behar 等人首次报道以来,世界各地纷纷争相使用阿片类药物注入硬膜外腔,以解除手术后的疼痛,发现它在某些方而优越于一些传统的止痛法。Graham 等报道,在行前列腺切除术中,给病人硬膜外注2毫克吗啡止痛效果为佳,并与用传统的局麻药勃庇伏卡因作了比较。观察了102个接受勃庇伏卡因术后止痛的病人,止痛平均持续的时间为5小时22分,止痛持续时间超过6小时以上者仅占总人数的14%。20名注吗啡止痛者中,平均止痛持续时间超过12小时,差异有非常显著的意义。而且吗啡的止痛不会带来象勃庇伏卡因所致的血压下降等弊端。作者     

长期服用阿片类药物与痛觉过敏的相关性分析

目的:通过简易定量感觉测试对阿片类药物诱发痛觉过敏(OIH)疑似患者是否为真过敏进行判定。方法:选取160例长期服用阿片类药物的疑似OIH患者为实验组(n=160),以160例健康者为对照组(n=160)。对两组患者的疼痛阈值、疼痛中值与疼痛耐受极限值进行评估。同时对受试者给予安慰剂与芬太尼,评估受试者压力性疼痛敏感度。结果:阿片药物日剂量(OME)较高与疼痛中值较低(r=-0.745,P=0.022)、疼痛耐受极限值较低(r=-0.651,P=0.011)高度相关。口服吗啡超过100 mg的患者比口服吗啡少于100 mg的患者有较低的疼痛耐受力(P=0.043)。男性患者对芬太尼制剂引起的疼痛反应更敏感。结论:阿片类药物剂量与疼痛敏感度相关,服用高剂量阿片类药物的患者明显表现更敏感。     

小剂量纳洛酮硬膜外应用对胃癌术后芬太尼静脉自控镇痛效果及胃肠功能的影响

目的:探讨小剂量纳洛酮硬膜外应用对胃癌术后芬太尼静脉自控镇痛效果及胃肠功能的影响。方法:选取我院2010年7月-2015年7月收治的110例胃癌患者为研究对象,将所有患者随机分为试验组和对照组各55例,两组患者均行根治性肿瘤切除术,术后采用芬太尼静脉自控镇痛,试验组于术后硬膜外注入小剂量纳洛酮,对照组注入等量的生理盐水,对两组术后不同时间点(4 h、8 h、12 h、24 h)疼痛程度进行评分,对比两组肠鸣音恢复时间、肛门排气时间、肛门排便时间、胃动力恢复时间,镇痛泵药物消耗量及并发症发生率。结果:术后4 h,试验组疼痛评分明显低于对照组(P0.05),术后8 h、12 h两组患者的疼痛评分均有显著上升(P0.05),且试验组患者的疼痛评分均远低于对照组(均P0.05),术后24 h,试验组与术后12 h比较差异无统计学意义(P0.05),对照组术后24 h疼痛评分与术后12 h分相比有显著差异(P0.01);试验组患者肠鸣音恢复时间、肛门排气时间、肛门排便时间、胃动力恢复时间、镇痛泵药物消耗量、芬太尼用量均远远低于对照组(P0.05);试验组并发症总发生率(7.27%)远远低于对照组(23.64%),差异具有统计学意义(P0.05)。结论:采用小剂量纳洛酮硬膜外应用方法辅助术后镇痛可以有效的减轻患者的疼痛,降低并发症的发生率,促进胃肠功能恢复,疗效显著,值得在临床上推广使用。     

Relief of pain by infusion of morphine after operation: does tolerance develop?

To see whether continuous intravenous infusion of opiates provides more effective postoperative relief of pain than conventional intramuscular injection these regimens were compared in a prospective double blind trial. Thirty patients undergoing elective cholecystectomy were allocated randomly to receive an infusion of morphine or an infusion of placebo (control group) for 24 hours. Both groups were allowed supplementary morphine boluses as requested. During the first 48 hours after operation the degree of pain was almost identical between the groups. Surprisingly, the group that was given the infusion of morphine received as much supplementary morphine as the control group during the first 24 hours and appreciably more during the 24 hours after the infusion had been withdrawn. Nausea and vomiting were more prevalent among the patients given the infusion of morphine. These results suggest that continuous infusion of morphine may be an inferior regimen to intermittent bolus administration in the relief of postoperative pain. This may be explained by the development of tolerance in patients who received the infusion of morphine.     

The PINE study: rationale and design of a randomised comparison of epidural injection of local anaesthetics and steroids versus care-as-usual to prevent postherpetic neuralgia in the elderly [ISRCTN32866390]

BACKGROUND: Postherpetic neuralgia (PHN) is by far the most common complication of herpes zoster (HZ) and one of the most intractable pain disorders. Since PHN is seen most often in the elderly, the number of patients with this disorder is expected to increase in our ageing society. PHN may last for months to years and has a high impact on the quality of life. The results of PHN treatment are rather disappointing. Epidural injection of local anaesthetics and steroids in the acute phase of HZ is a promising therapy for the prevention of PHN. Since randomised trials on the effectiveness of this intervention are lacking, the PINE (Prevention by epidural Injection of postherpetic Neuralgia in the Elderly) study was set up. The PINE study compares the effectiveness and cost-effectiveness of a single epidural injection of local anaesthetics and steroids during the acute phase of HZ with that of care-as-usual (i.e. antivirals and analgesics) in preventing PHN in elderly patients. METHODS / DESIGN: The PINE study is an open, multicenter clinical trial in which 550 elderly (age >/= 50 yr.) patients who consult their general practitioner in the acute phase of HZ (rash < 7 days) are randomised to one of the treatment groups. The primary clinical endpoint is the presence of HZ-related pain one month after the onset of the rash. Secondary endpoints include duration and severity of pain, re-interventions aiming to treat the existing pain, side effects, quality of life, and cost-effectiveness. CONCLUSION: The PINE study is aimed to quantify the (cost-) effectiveness of a single epidural injection during the acute phase of HZ on the prevention of PHN.     

Multimodal analgesia protocol for pain management after total knee arthroplasty: comparison of three different regional analgesic techniques

Objectives:To evaluate three different analgesic techniques, continuous epidural analgesia (EA), continuous intra-articular (IA) infusion analgesia and continuous femoral nerve block (FNB) in postoperative pain management, length of hospital stay (LOS), and time of patient mobilization after total knee arthroplasty (TKA).Methods:Seventy-two patients undergoing TKA were randomly allocated into three groups according to the analgesic technique used for postoperative pain management. Group EA patients received epidural analgesia (control group), group IA received intra-articular infusion and group FNB received femoral nerve block.Results:Upon analyzing the Numerical Rating Scale (NRS) scores at rest, at passive and active movement, up to 3 days postoperatively, we observed no statistically significant differences at any time point among the three groups. Similarly, no association among these analgesic techniques (EA, IA, FNB) was revealed regarding LOS. However, significant differences emerged concerning the time of mobilization. Patients who received IA achieved earlier mobilization compared to FNB and EA.Conclusions:Both IA and FNB generate similar analgesic effect with EA for postoperative pain management after TKA. However, IA appears to be significantly more effective in early mobilization compared to EA and FNB. Finally, no clinically important differences could be detected regarding LOS among the techniques studied.     

Postoperative analgesia: a comparison of intravenous on-demand fentanyl with epidural bupivacaine.

In a randomised trial postoperative pain relief was provided by either epidural injections of bupivacaine or an infusion of fentanyl adjusted by the patient to achieve adequate pain relief. Both techniques produced satisfactory analgesia without respiratory depression after peripheral arterial surgery. The technique of infusing intravenously a potent analgesic in a dose adjusted by the patient appears to offer several advantages in postoperative care.     

Epidural Co-Administration of Dexmedetomidine and Levobupivacaine Improves the Gastrointestinal Motility Function after Colonic Resection in Comparison to Co-Administration of Morphine and Levobupivacaine

Gastrointestinal motility may be impaired after intestinal surgery. Epidural morphine is effective in controlling postoperative pain, but can further reduce gastrointestinal motility. Here, we aimed to investigate the effects of epidural dexmedetomidine on gastrointestinal motility in patients undergoing colonic resection. Seventy-four patients undergoing colonic resection were enrolled in this clinical trial and allocated randomly to treatment with dexmedetomidine (D group) or morphine (M group). The D group received a loading dose epidural administration of 3 ml dexmedetomidine (0.5 μg kg^-1) and then a continuous epidural administration of 80 μg dexmedetomidine in 150 ml levobupivacaine (0.125%) at 3 ml h^-1 for two days. The M group received a loading dose epidural administration of 3 ml morphine (0.03 mg kg^-1) and then a continuous epidural administration of 4.5 mg morphine in 150 ml levobupivacaine at 3 ml h^-1 for two days. Verbal rating score (VRS), postoperative analgesic requirements, side effects related to analgesia, the time to postoperative first flatus (FFL) and first feces (FFE) were recorded. VRS and postoperative analgesic requirements were not significantly different between treatment groups. In contrast, the time to FFL and time to FFE were significant longer in M group in comparison to D group (P < 0.05). Moreover, patients in M group had a significantly higher incidence of nausea, vomiting, and pruritus (P < 0.05). No patients showed neurologic deficits in either group. In comparison to morphine, epidural dexmedetomidine is safe and beneficial for the recovery of gastrointestinal motility after colonic resection when used as an adjunct with levobupivacaine for postoperative pain control.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-TRC-14004644     

帕瑞昔布在肺癌手术多模式镇痛效果及其对凝血功能的影响

目的:研究帕瑞昔布在胸部肺癌手术后多模式镇痛效果及其对凝血功能的影响。方法:自2012年1月到2013年12月期间,全麻复合硬膜外麻醉下实施肺癌手术病人120例,分为3组,对照组(C组)和不同帕瑞昔布钠处理组(P1组和P2组)。对照组采用硬膜外镇痛,P1此基础上术前静脉用帕瑞昔布,P2组在P1基础上术后加用帕瑞昔布。观察三组手术时间、术中出血量、术中瑞芬太尼及术后吗啡用量、不同时间段VAS和术前术后凝血功能。结果:C组、P1和P2组术中出血量三组间的差异有统计学意义,P2组出血量最少(p0.05)。C组、P1和P2组术中瑞芬太尼和术后吗啡使用剂量差异有统计学意义(P均0.05)。C组、P1组和P2组术后6个月时间内疼痛发生率和6个月时间内疼痛发生天数差异有统计学意义(P均0.05)。术中PT、APTT在三组间的差异有统计学意义(P0.05)。结论:帕瑞昔布可降低病人开胸术后慢性疼痛综合征的发生,增加凝血功能,减少吗啡用量,且不增加不良反应发生几率,临床应用安全性可靠。     

Morphine: controlled trial of different methods of administration for postoperative pain relief.

Forty-five patients who had undergone major operations were given a slow intravenous injection of morphine sulphate (1 mg/ml saline) until their pain was relieved and were then randomly divided into three equal groups to receive different regimens of morphine sulphate over the next 72 hours. Patients in group A received 3.5 times the pain-relieving dose (28-63 mg, mean 36 mg) by continuous intravenous infusion; those in group B received the pain-relieving dose (90-160 mg, mean 110 mg) intramuscularly, four-hourly for the first 24 hours, six-hourly for the next 24 hours, and then eight and 20 hours later; and those in group C received the pain-relieving dose (80-280 mg, mean 140 mg) intramuscularly as required. Pain was assessed on a linear analogue scale and vital capacity and peak expiratory flow rate measured 12-hourly. The mean pain score was significantly lower and respiratory function significantly better in group A than in groups B and C. Only one patient (in group A) required extra morphine. Thus morphine administered by continuous intravenous infusion is superior to other regimens, giving better pain relief at a lower dosage.     

Effects of epidural morphine and transdermal fentanyl analgesia on physiology and behaviour after abdominal surgery in pigs

The objective of this work was to evaluate the physiological and behavioural effects of opioid analgesic treatment in pigs subjected to abdominal surgery. Ten Swedish Landrace x Yorkshire pigs (20 +/- 4 kg b.w.) were submitted for intestinal cannulation. The pigs were allocated into two groups during one preoperative, one surgical and two postoperative days. All pigs were anaesthetized with medetomidine, tiletamine and zolazepam. One group was treated with epidural morphine (0.1 mg/kg) preoperatively, and transdermal fentanyl patches (50 microg/kg/h) were applied behind the ear immediately after surgery. The other group received epidural saline (equivalent volume) and placebo patches. All pigs were regularly weighed and clinically examined and repeated blood samples were analysed for serum concentrations of cortisol, beta-endorphin and fentanyl. Pre- and postoperative behaviours were evaluated by a swine specialist blinded to the treatment, three times a day, and were also videotape recorded for a total of 84 h per pig. No differences in behaviour were noted by the observer. During the first postoperative 12 h, treated pigs did not differ in activity compared with preoperative recordings, while untreated pigs were found to be less active. The treated group started to show interest in eating immediately after anaesthesia recovery, whereas the placebo group did not. During the 12-60 h postoperative period, the treated group had lower activity levels compared with the preoperative levels, which were similar to those in the placebo group. Treated pigs gained 0.5 +/- 0.2 kg during the subsequent two postoperative days, whereas the untreated pigs lost weight throughout the experiment. Cortisol concentration differed immediately after the surgery: Group P had 325 +/- 120 nmol/L and Group M 159 +/- 49 nmol/L. beta-endorphin concentration did not differ between groups. The highest serum fentanyl concentration (0.37 +/- 0.3 ng/mL) was measured 24 h postoperatively. Preoperative epidural morphine in combination with postoperative transdermal fentanyl resulted in earlier return to normal activity levels and an immediate weight gain after surgery.