[术后硬膜外镇痛——现状、适应证及管理]

[Postoperative epidural analgesia--current status, indications and management].

作者信息

Hergert M, Rosolski T, Lestin H G, Stranz G

机构信息

Klinik für Anästhesiologie und Intensivtherapie des Klinikums Schwerin.

出版信息

Anaesthesiol Reanim. 2002;27(6):152-9.

DOI:
Abstract

We are reporting on postoperative pain treatment using epidural analgesia in 1,822 patients, performed between 1995 to 2000, following continuous epidural anaesthesia combined with general anaesthesia for operations in various specialized areas (general or visceral surgery, vascular and thoraxic surgery, gynaecology, urology and orthopaedics). A total of 1,727 of these postoperative epidurals were included in a detailed evaluation. The postoperative epidural analgesia consisted of a continuous application of 0.25% bupivacain or 0.2% ropivacain. These local anaesthetics were administered epidurally in an hourly perfusion rate of 7.5 ml. We found "good" pain relief through continuous epidural administering of the local anaesthetics in 1,292 patients (74.8%). "Moderate" pain relief was achieved in 392 patients (22.7%). Sufentanil had to be epidurally administered in addition to local anaesthetics in 262 patients (15.2%) in the wake-up room. The sufentanil doses lay between 5 and a maximum 10 micrograms per hour. An additional epidural application of morphine-boli in a dose of 3 mg every 8-12 hours was necessary in 384 patients (22.2%) in the surgical wake-up stations. In 392 patients (22.7%), the additional systemic administering of antipyretic analgesics such as metamizol or paracetamol or spasmolytica was sufficient. In 43 cases (2.5%), sufficient pain relief could not be achieved with epidural analgesia even with additive applications of systemic functioning pharmaceuticals, so that the postoperative pain therapy had to be completely switched to a PCA. The lying time of the epidural catheter was 2-5 days. It was shortest with the gynaecological patients and longest with patients from general, visceral, thoraxic and vascular surgery areas. An important factor for a sufficient epidural analgesia is the exact epidural positioning of the catheter tip in the area of the spinal cord segments, which are affected by the operation. This reveals the required puncture height. The following side-effects resulting from the epidural analgesia were found: blood pressure loss of more than 20% of the starting value (21%), temporary bladder voiding disorders (8%), temporary sensory disorders of the lower extremities (6.5%), seldom nausea (2.4%) and post-puncture headaches (1.2%). The most important prerequisites for successful postoperative epidural analgesia and thus for increased patient satisfaction are correct selection of the insertion height in relation to the planned operation, constantly available medical pain service, the inclusion of trained care personnel and unequivocal written instructions.

摘要

我们报告了1995年至2000年间对1822例患者进行的术后硬膜外镇痛治疗情况,这些患者在全身麻醉联合连续硬膜外麻醉下接受了各个专科领域(普通外科或内脏外科、血管和胸外科、妇科、泌尿外科和骨科)的手术。其中1727例术后硬膜外镇痛患者纳入了详细评估。术后硬膜外镇痛采用持续输注0.25%布比卡因或0.2%罗哌卡因。这些局部麻醉药以每小时7.5毫升的灌注速度硬膜外给药。我们发现,通过持续硬膜外给予局部麻醉药,1292例患者(74.8%)疼痛缓解“良好”。392例患者(22.7%)疼痛缓解“中等”。在苏醒室,262例患者(15.2%)除局部麻醉药外还必须硬膜外给予舒芬太尼,舒芬太尼剂量为每小时5至最大10微克。在外科苏醒站,384例患者(22.2%)需要每8 - 12小时额外硬膜外注射3毫克吗啡推注。在392例患者(22.7%)中,额外全身给予解热镇痛药如安乃近或对乙酰氨基酚或解痉药就足够了。在43例患者(2.5%)中,即使联合应用全身有效药物,硬膜外镇痛也无法实现充分的疼痛缓解,因此术后疼痛治疗不得不完全改为自控镇痛(PCA)。硬膜外导管留置时间为2至5天,妇科患者最短,普通外科、内脏外科、胸外科和血管外科患者最长。充分硬膜外镇痛的一个重要因素是导管尖端在受手术影响的脊髓节段区域准确的硬膜外定位,这揭示了所需的穿刺高度。发现硬膜外镇痛有以下副作用:血压下降超过起始值的20%(21%)、暂时性膀胱排尿障碍(8%)、下肢暂时性感觉障碍(6.5%)、少见的恶心(2.4%)和穿刺后头痛(1.2%)。成功进行术后硬膜外镇痛从而提高患者满意度的最重要前提是根据计划手术正确选择穿刺高度、随时有医疗疼痛服务、配备经过培训的护理人员以及明确的书面说明。

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