Tripi Paul A, Kuestner Matthew E, Poe-Kochert Connie S, Rubin Kasia, Son-Hing Jochen P, Thompson George H, Tobias Joseph D
Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA.
Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.
J Pain Res. 2015 Sep 22;8:637-40. doi: 10.2147/JPR.S88687. eCollection 2015.
The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion.
We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong-Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours.
The demographics of the two study groups were similar. There were no differences in the Wong-Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively).
In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.
瑞芬太尼独特的药代动力学特性，其背景敏感半衰期不受输注时间长短影响，这促使其在儿童和青少年后路脊柱融合术的麻醉管理中频繁使用。然而，术中使用瑞芬太尼会导致术后镇痛需求增加，据推测这是急性阿片类药物耐受性增强以及脊髓 N - 甲基 - D - 天冬氨酸受体功能增强的结果。尽管预防或减少耐受性的策略包括联合使用长效阿片类药物或氯胺酮，但这些研究大多显示益处甚微或没有益处。本研究回顾性评估鞘内注射吗啡（ITM）预防瑞芬太尼输注后痛觉过敏的疗效。
我们回顾性分析了 54 例行后路脊柱融合术并采用节段性脊柱内固定的患者，以评估 ITM 对瑞芬太尼所致痛觉过敏的影响。根据手术期间是否接受瑞芬太尼，将患者分为两组：未接受瑞芬太尼组（对照组）（n = 27）和接受瑞芬太尼组（研究组）（n = 27）。数据包括人口统计学资料、瑞芬太尼剂量和持续时间、Wong - Baker 视觉模拟量表术后疼痛评分以及术后 48 小时内静脉注射吗啡的用量。
两个研究组的人口统计学资料相似。麻醉后护理单元以及术后第 1 天和第 3 天，Wong - Baker 视觉模拟量表疼痛评分无差异。术后第 2 天，瑞芬太尼组的疼痛评分更高（分别为 2.9 分和 3.8 分）。两组术后吗啡需求量相似（对照组和研究组分别为 0.029 与 0.017 mg/kg/48 h）。
在脊柱手术中接受术前 ITM 的患者，术中使用瑞芬太尼不会增加术后镇痛需求。
