Azad S C, Groh J, Beyer A, Schneck D, Dreher E, Peter K
Klinik für Anästhesiologie, Klinikum Grosshadern, Ludwig-Maximilians-Universität München.
Anaesthesist. 2000 Jan;49(1):9-17. doi: 10.1007/s001010050003.
Continuous epidural analgesia (EA) and patient-controlled intravenous analgesia (PCA) are widely used for postoperative pain control. Studies indicate that both analgesic regimens provide good analgesia after major surgery. However, because of the following reasons it is still unclear whether one of the two modes of application is superior. First, there are conflicting data regarding the differences in pain relief and drug use between epidural and intravenous administration of opioids. Second, in many studies epidural analgesia is performed by a combination of local anaesthetics and opioids. Third, reduced morbidity was observed only in some of the studies, in which epidural analgesia provided better pain relief than systemic opioid supply. Despite these conflicting results, EA with local anaesthetics and fentanyl as well as PCA with piritramid, a highly potent mu-agonist, are routinely used in Germany. The purpose of this study was to compare these two treatments for analgesic efficacy, pulmonary function, incidence of side effects and complications in patients undergoing thoracotomy.
In this prospective randomized trial 50 patients were included. For postoperative pain control 25 patients (EA group) received thoracic epidural infusion of local anaesthetics (bupivacaine 0.125% or ropivacaine 0,2%) and fentanyl 4,5 microg/ml with a flow rate of 4-10 ml/h. 25 patients received intravenous PCA with piritramid (bolus 2, 5 mg, lock out 15 minutes, maximum of 25 mg/4 h, no background infusion).
Analgesia at rest and while coughing, as evaluated by visual analogue scale, was significantly better in the EA group. EA also resulted in superior values of pulmonary function tests, general condition and a lower incidence of sedation and nausea. In contrast, patients with EA reported distinctly more pruritus than patients with PCA. Duration of hospital stay was shorter in the EA group, but this difference did not reach statistical significance. There was one atelectasis in the EA group. No major complications related to EA or PCA were observed.
In this study EA with local anaesthetics and fentanyl provided superior postoperative pain control and a lower incidence of sedation and nausea compared to intravenous PCA with piritramid, but there was no superiority as to pulmonary complications and duration of hospital stay.
连续硬膜外镇痛（EA）和患者自控静脉镇痛（PCA）广泛用于术后疼痛控制。研究表明，两种镇痛方案在大手术后均能提供良好的镇痛效果。然而，由于以下原因，两种应用方式中哪种更具优势仍不明确。首先，关于硬膜外和静脉注射阿片类药物在疼痛缓解和药物使用方面的差异，存在相互矛盾的数据。其次，在许多研究中，硬膜外镇痛是通过局部麻醉药和阿片类药物联合进行的。第三，仅在部分研究中观察到发病率降低，其中硬膜外镇痛比全身阿片类药物给药能提供更好的疼痛缓解。尽管有这些相互矛盾的结果，但在德国，含局部麻醉药和芬太尼的EA以及含强效μ激动剂匹米诺定的PCA仍被常规使用。本研究的目的是比较这两种治疗方法在开胸手术患者中的镇痛效果、肺功能、副作用和并发症发生率。
在这项前瞻性随机试验中，纳入了50例患者。为控制术后疼痛，25例患者（EA组）接受胸段硬膜外输注局部麻醉药（0.125%布比卡因或0.2%罗哌卡因）和4.5μg/ml芬太尼，流速为4 - 10 ml/h。25例患者接受匹米诺定静脉PCA（单次剂量2.5 mg，锁定时间15分钟，最大剂量25 mg/4 h，无背景输注）。
通过视觉模拟评分评估，EA组静息和咳嗽时的镇痛效果明显更好。EA还使肺功能测试、一般状况的数值更优，且镇静和恶心的发生率更低。相比之下，EA组患者报告的瘙痒明显多于PCA组患者。EA组的住院时间较短，但这种差异未达到统计学意义。EA组有1例肺不张。未观察到与EA或PCA相关的重大并发症。
在本研究中，与含匹米诺定的静脉PCA相比，含局部麻醉药和芬太尼的EA提供了更优的术后疼痛控制，且镇静和恶心的发生率更低，但在肺部并发症和住院时间方面并无优势。
