Ugras Murat Yahya, Toprak Huseyin Ilksen, Gunen Hakan, Yucel Aytac, Gunes Ali
Department of Urology, Inonu University Faculty of Medicine, Malatya, Turkey.
J Endourol. 2007 May;21(5):499-503. doi: 10.1089/end.2006.0335.
Pain after percutaneous nephrolithotomy (PCNL) is well investigated, but no optimal management strategy has yet been defined. Ventilatory changes after uncomplicated PCNL remain obscure. We investigated whether pain can be managed with a combination of a parenteral non-narcotic drug and instillation of a local anesthetic into the operative field. We also measured ventilatory changes early after PCNL to determine whether this analgesic modality improves ventilatory status.
In a randomized blinded study, 34 well-matched patients underwent PCNL with single subcostal access. At the end of the operation, 30 mL of either 0.02% ropivacaine or saline was instilled into the renal puncture site, nephrostomy tract, and skin. Postoperatively, patients received parenteral metamizol (dipyrone) (500 mg/dose) on demand. Pain visual analog score (VAS), peak expiratory flow rate (PEF), and blood-gas analysis were performed at 2, 6, and 24 hours postoperatively. The number of analgesic doses required was recorded.
The VAS at 6 hours, time to first analgesic demand, and total analgesic need were significantly lower (P=0.001, 0.008, and 0.001, respectively) in the ropivacaine group, whereas the PEF at 2 and 6 hours was significantly higher (P=0.001 for each). Analgesic use in the first 12 and 24 hours was lower in this group. Blood-gas analysis was within the normal range in both groups. Time of surgery and hemoglobin decrease were not significantly different.
A decrease in PEF indicating restricted ventilation appears early after PCNL. Because these patients were chosen carefully to have normal function preoperatively, this decrease was attributed to nociception. A combination of ropivacaine instillation with metamizol decreases pain and analgesic use and improves PEF more than use of metamizol alone. Such a multimodal pain-management strategy is effective in minimizing postoperative opioid use with proper pain management, resulting in better ventilation.
经皮肾镜取石术（PCNL）后的疼痛已得到充分研究，但尚未确定最佳管理策略。单纯PCNL后的通气变化仍不清楚。我们研究了胃肠外非麻醉药物与在手术区域注入局部麻醉剂联合使用是否可控制疼痛。我们还在PCNL术后早期测量通气变化，以确定这种镇痛方式是否能改善通气状态。
在一项随机双盲研究中，34例匹配良好的患者接受了经单肋下途径的PCNL。手术结束时，将30 mL 0.02%罗哌卡因或生理盐水注入肾穿刺部位、肾造瘘通道和皮肤。术后，患者按需接受胃肠外安乃近（500 mg/剂量）。在术后2、6和24小时进行疼痛视觉模拟评分（VAS）、呼气峰值流速（PEF）和血气分析。记录所需镇痛剂量的数量。
罗哌卡因组术后6小时的VAS、首次需要镇痛的时间和总的镇痛需求均显著更低（分别为P = 0.001、0.008和0.001），而术后2和6小时的PEF显著更高（均为P = 0.001）。该组在术后最初12和24小时的镇痛药物使用量更低。两组的血气分析均在正常范围内。手术时间和血红蛋白降低情况无显著差异。
PCNL术后早期出现PEF降低，提示通气受限。由于这些患者术前经仔细挑选功能正常，这种降低归因于伤害感受。罗哌卡因注入与安乃近联合使用比单独使用安乃近能减轻疼痛和减少镇痛药物使用，并能更好地改善PEF。这种多模式疼痛管理策略在通过适当的疼痛管理将术后阿片类药物使用降至最低方面是有效的，从而实现更好的通气。
