经皮硝酸甘油对骨科手术后脊髓S(+)-氯胺酮镇痛作用的影响。

The effect of transdermal nitroglycerin on spinal S(+)-ketamine antinociception following orthopedic surgery.

作者信息

Lauretti G R, Oliveira A P, Rodrigues A M, Paccola C A

机构信息

Hospital das Clínicas, Department of Biomechanical and Medical Rehabilitation of the Locomotor Members, University of São Paulo, São Paulo, Brazil.

出版信息

J Clin Anesth. 2001 Dec;13(8):576-81. doi: 10.1016/s0952-8180(01)00333-6.

DOI:10.1016/s0952-8180(01)00333-6

PMID:11755327

Abstract

STUDY OBJECTIVES

To determine whether combination of transdermal nitroglycerine (a nitric oxide generator) would enhance analgesia from epidural S(+)-ketamine (a N-methyl-D-aspartate antagonist) in patients undergoing orthopedic surgery with combined spinal anesthesia.

DESIGN

Randomized, double-blind study.

SETTING

Orthopedic surgery unit of a teaching hospital.

PATIENTS

60 ASA physical status I and II patients scheduled for minor orthopedic knee surgery.

INTERVENTIONS

Patients were randomized to one of five groups (n = 12) to receive combined epidural/intrathecal anesthesia. A 10-mL epidural injection was first administered to all patients (study drug or normal saline). Intrathecal anesthesia consisted of 15 mg bupivacaine. Twenty to 30 minutes after the spinal puncture, a transdermal patch of either nitroglycerin 5 mg or placebo was applied. The control group (CG) received epidural saline and transdermal placebo. The nitroglycerin group (NG) received epidural saline and transdermal nitroglycerine patch. The 0.1 mg/kg S(+)-ketamine epidural group (1 KG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal placebo. The 0.2 mg/kg S(+)-ketamine epidural group (2 KG) received 0.2 mg/kg epidural S(+)-ketamine and transdermal placebo. Finally, the nitroglycerin/0.1 mg/kg S(+)-ketamine epidural group (1 NKG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal nitroglycerin. Pain and adverse effects were evaluated using a 10-cm visual analog scale (VAS).

MEASUREMENTS AND MAIN RESULTS

The groups were demographically the same. Sensory anesthetic level and VAS score for pain at the time of first rescue medication were similar among groups. The time to first rescue analgesic (min) was less in both the CG and the NG groups compared with the other groups (p < 0.05). Epidural S(+)-ketamine resulted in analgesia to both groups (1 KG < 2 KG; p < 0.05). The 1 NKG and the 2 KG displayed similar analgesia (p > 0.05). The CG required more rescue analgesics in 24 hours compared with the patients who received epidural S(+)-ketamine (p < 0.02).

CONCLUSIONS

Epidural S(+)-ketamine resulted in antinociception, which was enhanced by transdermal nitroglycerin.

摘要

研究目的

确定在接受腰麻联合硬膜外麻醉的骨科手术患者中，经皮硝酸甘油（一种一氧化氮生成剂）与硬膜外S(+)-氯胺酮（一种N-甲基-D-天冬氨酸拮抗剂）联合使用是否会增强镇痛效果。

设计

随机双盲研究。

地点

一家教学医院的骨科手术科室。

患者

60例拟行小型骨科膝关节手术的ASA身体状况I级和II级患者。

干预措施

患者被随机分为五组（n = 12），接受硬膜外/鞘内联合麻醉。首先给所有患者注射10 mL硬膜外注射液（研究药物或生理盐水）。鞘内麻醉采用15 mg布比卡因。腰穿后20至30分钟，应用5 mg硝酸甘油或安慰剂的透皮贴剂。对照组（CG）接受硬膜外生理盐水和透皮安慰剂。硝酸甘油组（NG）接受硬膜外生理盐水和透皮硝酸甘油贴剂。0.1 mg/kg S(+)-氯胺酮硬膜外组（1 KG）接受0.1 mg/kg硬膜外S(+)-氯胺酮和透皮安慰剂。0.2 mg/kg S(+)-氯胺酮硬膜外组（2 KG）接受0.2 mg/kg硬膜外S(+)-氯胺酮和透皮安慰剂。最后，硝酸甘油/0.1 mg/kg S(+)-氯胺酮硬膜外组（1 NKG）接受0.1 mg/kg硬膜外S(+)-氯胺酮和透皮硝酸甘油。使用10厘米视觉模拟评分量表（VAS）评估疼痛和不良反应。

测量指标和主要结果

各组在人口统计学上相同。首次使用急救药物时的感觉麻醉平面和疼痛VAS评分在各组之间相似。与其他组相比，CG组和NG组首次使用急救镇痛药的时间（分钟）更短（p < 0.05）。硬膜外S(+)-氯胺酮对两组均产生镇痛作用（1 KG < 2 KG；p < 0.05）。1 NKG组和2 KG组的镇痛效果相似（p > 0.05）。与接受硬膜外S(+)-氯胺酮治疗的患者相比，CG组在24小时内需要更多的急救镇痛药（p < 0.02）。