Schulte-Steinberg H, Weninger E, Jokisch D, Hofstetter B, Misera A, Lange V, Stein C
Department of Anesthesiology, Ludwig-Maximilians Universität, Klinikum Grosshadern, München, Germany.
Anesthesiology. 1995 Mar;82(3):634-40. doi: 10.1097/00000542-199503000-00004.
Opioids can produce peripheral analgesic effects by activation of opioid receptors on sensory nerves. This study was designed (1) to examine a novel route of opioid administration, the intraperitoneal injection; (2) to compare this to interpleural application, and (3) to compare opioid with local anesthetic effects under both conditions.
At the end of laparoscopic cholecystectomy, 110 patients received the following injections in a double-blind, randomized manner: Group 1 (n = 18) was given intraperitoneal morphine (1 mg in 20 ml saline) and 20 ml intravenous saline. Group 2 (n = 17) received intraperitoneal saline and 1 mg intravenous morphine. Group 3 (n = 15) received 20 ml 0.25% intraperitoneal bupivacaine and intravenous saline. Group 4 (n = 20) received interpleural morphine (1.5 mg in 30 ml saline) and 30 ml intravenous saline. Group 5 (n = 20) received interpleural saline and 1.5 mg intravenous morphine. Group 6 (n = 20) received 30 ml 0.25% interpleural bupivacaine and intravenous saline. Postoperative pain was assessed using a visual analog scale, a numeric rating scale, and the McGill pain questionnaire. Pain localization, supplemental analgesic consumption, vital signs, and side effects were recorded for 24 h.
Neither intraperitoneal nor interpleural morphine produced significant analgesia after laparoscopic cholecystectomy (P > 0.05, Kruskal-Wallis test), whereas interpleural bupivacaine was effective (P < 0.05, Kruskal-Wallis test, up to 6 h postoperatively) but not intraperitoneal bupivacaine (P > 0.05, Kruskal-Wallis test). Shoulder pain was not prevalent in the majority of patients during the first 6 h. By 24 h, about half of the patients complained of shoulder pain, which was rated "low" by about one-third of all patients. No significant side effects occurred.
Interpleural bupivacaine (0.25%) produces analgesia after laparoscopic cholecystectomy. We attribute the lack of effect of intraperitoneal injections to the small dose and to a rapid dilution within the peritoneal cavity. The fact that interpleural morphine (0.005%) is ineffective may be due to an intact perineurial barrier in the noninflamed pleural cavity, which restricts the transperineurial passage of morphine to opioid receptors on intercostal nerves.
阿片类药物可通过激活感觉神经上的阿片受体产生外周镇痛作用。本研究旨在：（1）检验一种新的阿片类药物给药途径——腹腔注射；（2）将其与胸膜内给药进行比较；（3）比较两种给药条件下阿片类药物与局部麻醉药的效果。
在腹腔镜胆囊切除术结束时，110例患者以双盲、随机方式接受以下注射：第1组（n = 18）腹腔注射吗啡（1 mg溶于20 ml生理盐水中）和20 ml静脉注射生理盐水。第2组（n = 17）腹腔注射生理盐水和1 mg静脉注射吗啡。第3组（n = 15）腹腔注射20 ml 0.25%布比卡因和静脉注射生理盐水。第4组（n = 20）胸膜内注射吗啡（1.5 mg溶于30 ml生理盐水中）和30 ml静脉注射生理盐水。第5组（n = 20）胸膜内注射生理盐水和1.5 mg静脉注射吗啡。第6组（n = 20）胸膜内注射30 ml 0.25%布比卡因和静脉注射生理盐水。术后疼痛采用视觉模拟评分法、数字评分法和麦吉尔疼痛问卷进行评估。记录24小时内的疼痛部位、辅助镇痛药用量、生命体征及副作用。
腹腔镜胆囊切除术后，腹腔注射和胸膜内注射吗啡均未产生显著镇痛效果（P > 0.05，Kruskal - Wallis检验），而胸膜内注射布比卡因有效（P < 0.05，Kruskal - Wallis检验，术后6小时内），腹腔注射布比卡因则无效（P > 0.05，Kruskal - Wallis检验）。大多数患者在最初6小时内未出现肩部疼痛。至24小时时，约一半患者主诉肩部疼痛，约三分之一的患者将其评为“轻度”。未出现明显副作用。
胸膜内注射0.25%布比卡因在腹腔镜胆囊切除术后可产生镇痛作用。我们认为腹腔注射无效是由于剂量小以及在腹腔内迅速稀释。胸膜内注射0.005%吗啡无效可能是因为非炎症性胸膜腔内的神经束膜屏障完整，限制了吗啡经神经束膜通道作用于肋间神经上的阿片受体。
