Mann C, Pouzeratte Y, Boccara G, Peccoux C, Vergne C, Brunat G, Domergue J, Millat B, Colson P
Department of Anesthesia, Centre Hospitalier Universitaire Montpellier, France.
Anesthesiology. 2000 Feb;92(2):433-41. doi: 10.1097/00000542-200002000-00025.
Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient.
Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores.
Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups.
After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.
静脉注射吗啡的患者自控镇痛（PCA）和使用阿片类药物单独或联合局部麻醉药的患者自控硬膜外镇痛（PCEA）是大手术后疼痛管理的两大主要进展。然而，这些技术在老年人中的评估较差。这项前瞻性随机研究比较了老年患者腹部大手术后PCEA和PCA对术后疼痛的有效性和安全性。
70例年龄大于70岁且接受腹部大手术的患者被随机分配，一组接受硬膜外镇痛联合全身麻醉，术后使用0.125%布比卡因和舒芬太尼混合液进行PCEA（PCEA组），另一组接受全身麻醉后静脉注射吗啡进行PCA（PCA组）。每天使用视觉模拟量表测试三次疼痛强度。术后评估包括精神状态、心肺和胃肠功能以及患者满意度评分。
术后5天内，PCEA组在休息时（P = 0.001）和咳嗽后（P = 0.002）的疼痛缓解更好。PCEA组的满意度评分更高。虽然PCA组和PCEA组谵妄的发生率相当（分别为24%和26%），但PCEA组在术后第4天和第5天精神状态有所改善。PCEA组肠道功能恢复比PCA组更快。两组心肺并发症相似。
老年患者腹部大手术后，无论采用何种途径（硬膜外或胃肠外）的患者自控镇痛都是有效的。使用局部麻醉药和阿片类药物的硬膜外途径能提供更好的疼痛缓解，并改善精神状态和肠道活动。
