Wu C T, Yeh C C, Yu J C, Lee M M, Tao P L, Ho S T, Wong C S
Department of Anesthesiology, Tri-Service General Hospital, Taipei, Taiwan, Republic of China.
Acta Anaesthesiol Scand. 2000 Jan;44(1):63-8. doi: 10.1034/j.1399-6576.2000.440112.x.
Previous studies have shown that N-methyl-D-asparate (NMDA) receptor antagonists provide a pre-emptive analgesic effect in humans. This study investigated the benefits of pre-emptive analgesia for upper abdominal surgery, using pre-incisional epidural ketamine + morphine + bupivacaine (K+M+B) treatment for achieving postoperative pain relief.
Sixty ASA 1-2 patients scheduled for upper abdominal surgery were allocated to three groups in a randomized, single-blinded study. Patients in the control group (I) received general anaesthesia followed by an infusion of normal saline. Group II and III patients received general anaesthesia with a continuous epidural infusion of 2% lidocaine. Thirty minutes after the incision in groups I and II, an epidural pain control regimen was administered using ketamine (10 mg) and morphine (1 mg) in 10 ml of 0.085% bupivacaine (K+M+B). Group III patients also received K+M+B, but it was administered 10 min after the 2% lidocaine injection and 30 min before skin incision. All patients received an epidural pain control regimen (q12 h) for 3 days after their first injection. Patient-controlled analgesia (PCA) with morphine was used to control subsequent postoperative pain. During the 3-day period following surgery, duration to PCA trigger (h), morphine consumption (mg), pain intensity at rest and when coughing/moving, and analgesic-related adverse effects were recorded. The VAS scale (0-10) was used to assess pain intensity.
Median times to first PCA trigger were 1.2 (0.5-2.0) h, 3.0 (0.7-4.2) h, and 4.0 (2.5-7.5) h for groups I, II, and III, respectively. Both the incident and resting pain scores were consistently lower for group III patients than groups I and II. The number of PCA triggers (all attempts/successful triggers) during the day following surgery were 14.0 (3-30)/8.0 (3-24) times, 10.0 (3-23)/6.0 (2-20) times, and 7.0 (3-12)/4.5 (1-10) times for groups I, II, and III. Total morphine consumption for the 3-day observation period was 12.5 (3-42) mg, 10.5 (2-29) mg, and 6.0 (1-20) for groups I, II, and III, respectively.
Pre-incisional epidural K+M+B treatment combined with continuous epidural anaesthesia and general anaesthesia provides an ideal pre-emptive analgesic therapy, exhibiting better postoperative pain relief than general anaesthesia and post-incisional K+M+B treatment.
先前的研究表明，N-甲基-D-天冬氨酸（NMDA）受体拮抗剂对人类具有超前镇痛作用。本研究探讨超前镇痛在上腹部手术中的益处，采用术前硬膜外注射氯胺酮+吗啡+布比卡因（K+M+B）治疗以实现术后疼痛缓解。
在一项随机、单盲研究中，将60例计划行上腹部手术的ASA 1-2级患者分为三组。对照组（I组）患者接受全身麻醉，随后输注生理盐水。II组和III组患者接受全身麻醉并持续硬膜外输注2%利多卡因。I组和II组在切口后30分钟，采用在10 ml 0.085%布比卡因中加入氯胺酮（10 mg）和吗啡（1 mg）的硬膜外疼痛控制方案（K+M+B）。III组患者也接受K+M+B，但在注射2%利多卡因后10分钟且皮肤切口前30分钟给药。所有患者在首次注射后接受硬膜外疼痛控制方案（每12小时一次），持续3天。采用吗啡患者自控镇痛（PCA）控制后续术后疼痛。在术后3天内，记录PCA触发时间（小时）、吗啡用量（毫克）、静息和咳嗽/活动时的疼痛强度以及镇痛相关不良反应。采用视觉模拟评分法（VAS，0-10分）评估疼痛强度。
I组、II组和III组首次PCA触发的中位时间分别为1.2（0.5-2.0）小时、3.0（0.7-4.2）小时和4.0（2.5-7.5）小时。III组患者的术中及静息疼痛评分始终低于I组和II组。术后第一天PCA触发次数（所有尝试次数/成功触发次数）I组为14.0（3-30）/8.0（3-24）次，II组为10.0（3-23）/6.0（2-20）次，III组为7.0（3-12）/4.5（1-10）次。3天观察期内吗啡总用量I组为12.5（3-42）毫克，II组为10.5（2-29）毫克，III组为6.0（1-20）毫克。
术前硬膜外K+M+B治疗联合持续硬膜外麻醉和全身麻醉可提供理想的超前镇痛治疗，与全身麻醉和术后K+M+B治疗相比，术后疼痛缓解效果更佳。
