Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain J L
Department of Anesthesiology, Institut Gustave-Roussy, Villejuif, France.
Anesthesiology. 1993 Apr;78(4):666-76; discussion 22A. doi: 10.1097/00000542-199304000-00009.
Different types of analgesia have been proposed for the prevention of postoperative respiratory complications. The aim of this prospective, double-blind randomized study was to compare the impact of epidural bupivacaine and opioids versus parenteral opioids on respiratory complications in patients who had undergone major abdominal surgery.
One hundred fifty-three patients undergoing abdominal surgery for cancer were randomly allocated to receive either general anesthesia with intravenous fentanyl and postoperative analgesia with subcutaneous morphine (SC group) or general anesthesia combined with epidural bupivacaine and epidural bupivacaine plus morphine for postoperative pain relief (EP group). Analgesia was tested on a visual analog pain scale. Pulmonary complications were evaluated according to clinical complications, chest radiographs, arterial blood gas analysis, and pulmonary function tests. The evaluation was carried out on the day before the operation and on the first 5 postoperative days. Particular attention also was paid to the episodes of arterial hypotension and hemoglobin oxygen desaturation during the 1st postoperative night.
Pain relief was significantly better in the EP group than in the SC group (P < 0.05) especially during recovery and on the 1st and 2nd postoperative days. In the EP group, vital capacity decreased less on the 1st postoperative day (P < 0.05) and arterial oxygen tension was greater in the recovery room (P < 0.05). However, no statistically significant difference was observed between the SC and EP groups in the incidence of clinical pulmonary complications (31% and 27%, respectively) and radiographic chest abnormalities (52% and 46%, respectively). The EP group recovered intestinal function earlier (P < 0.05), but significantly more patients in this group had episodes of systolic hypotension (21% vs. 8%; P < 0.05) during the 1st postoperative night. The length of the hospital stay was similar in both groups of treatment.
Epidural analgesia with a combination of local anesthetic and opioid improves patient comfort. However, this type of analgesia does not decrease the incidence of postoperative pulmonary complications, does not reduce the length of the hospital stay, and carries the risk of complications from episodic systemic hypotension.
已提出不同类型的镇痛方法用于预防术后呼吸并发症。这项前瞻性、双盲随机研究的目的是比较硬膜外布比卡因和阿片类药物与胃肠外阿片类药物对接受腹部大手术患者呼吸并发症的影响。
153例接受癌症腹部手术的患者被随机分配，分别接受静脉注射芬太尼全身麻醉和皮下注射吗啡术后镇痛（皮下组），或全身麻醉联合硬膜外布比卡因及硬膜外布比卡因加吗啡用于术后疼痛缓解（硬膜外组）。采用视觉模拟疼痛量表测试镇痛效果。根据临床并发症、胸部X线片、动脉血气分析和肺功能测试评估肺部并发症。在手术前一天和术后的前5天进行评估。还特别关注术后第1个晚上的动脉低血压和血红蛋白氧饱和度下降情况。
硬膜外组的疼痛缓解明显优于皮下组（P<0.05），尤其是在恢复期间以及术后第1天和第2天。在硬膜外组，术后第1天肺活量下降较少（P<0.05），恢复室中的动脉血氧分压较高（P<0.05）。然而，皮下组和硬膜外组在临床肺部并发症发生率（分别为31%和27%）和胸部X线异常发生率（分别为52%和46%）方面未观察到统计学上的显著差异。硬膜外组肠道功能恢复较早（P<0.05），但该组在术后第1个晚上有更多患者出现收缩期低血压（21%对8%；P<0.05）。两组治疗的住院时间相似。
局部麻醉药和阿片类药物联合硬膜外镇痛可提高患者舒适度。然而，这种类型的镇痛并不能降低术后肺部并发症的发生率，不能缩短住院时间，并且存在间歇性全身性低血压并发症的风险。
