Scott N B, James K, Murphy M, Kehlet H
Dept. of Anaesthesia, HCI International Medical Centre, Glasgow, UK.
Acta Anaesthesiol Scand. 1996 Jul;40(6):691-6. doi: 10.1111/j.1399-6576.1996.tb04512.x.
The neuroendocrine response following major surgery has not been previously influenced by either regional anaesthetic techniques or opioid analgesia probably due to insufficient intraoperative afferent neural blockade. In this study we attempted to determine whether significant inhibition of these pathways could be achieved by combining preoperative high spinal anaesthesia with postoperative thoracic epidural anaesthesia. In theory too, there may be additional benefits over perioperative thoracic epidural anaesthesia on pain and pulmonary dysfunction.
20 ASA 1-3 patients undergoing elective colonic surgery were studied. Gp 1 (n = 10) received a high spinal intraoperative block to T4 using 6mls of 0.5% bupivacaine plus continuous epidural 0.125% bupivacaine/0.0025% diamorphine. Gp 2 (n = 10) patients received epidural 0.5% bupivacaine block to T4 plus continuous epidural infusion of 0.125% bupivacaine/0.0025% diamorphine. We measured a) plasma glucose and cortisol at 0, 1, 2, 3, 4, 8 and 24 h; b) forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak flow rate (PFR) preoperatively, at 8 and 24 h; c) visual analogue pain scores (VAS 0-10) at rest, cough and mobilisation at 8 and 24 h; d) block height every hour for 12 hours then 3 hourly; e) 24-hour urine volumes for dopamine, adrenaline and noradrenaline f) 24-hour PCA morphine requirements.
The two groups did not differ in age, sex, height, weight, duration of surgery, blood loss or serum albumin. Pain relief was excellent and similar in both groups. The average 24 hour morphine consumption was 10 mg in both groups with no differences in the block height. All the patients had a 30-50% reduction in FEV1, FVC and PFR (P > 0.05). Metabolically, there was no statistical difference between the 2 groups except a higher rise in glucose in Gp1 at 2 and 3 h (P = 0.0312 and 0.014). 24-hour catecholamine studies showed no differences for noradrenaline (P = 0.8), adrenaline (P = 0.47) and dopamine (P = 0.36).
Thoracic epidural bupivacaine/diamorphine infusion provided excellent postoperative analgesia following colonic surgery. An intraoperative combined spinal/epidural technique conferred no additional benefit on analgesia, pulmonary function and the neuroendocrine response.
大手术后的神经内分泌反应此前未受区域麻醉技术或阿片类镇痛的影响，这可能是由于术中传入神经阻滞不足。在本研究中，我们试图确定术前高位脊髓麻醉与术后胸段硬膜外麻醉联合应用是否能显著抑制这些通路。理论上，与围手术期单纯胸段硬膜外麻醉相比，这一联合方式在疼痛和肺功能障碍方面可能还有额外益处。
对20例美国麻醉医师协会（ASA）分级为1 - 3级、接受择期结肠手术的患者进行研究。第1组（n = 10）术中接受T4水平的高位脊髓阻滞，使用6毫升0.5%布比卡因，外加持续硬膜外输注0.125%布比卡因/0.0025%二氢吗啡酮。第2组（n = 10）患者接受T4水平的硬膜外0.5%布比卡因阻滞，外加持续硬膜外输注0.125%布比卡因/0.0025%二氢吗啡酮。我们测量了：a）0、1、2、3、4、8和24小时的血浆葡萄糖和皮质醇；b）术前、8小时和24小时的用力肺活量（FVC）、第1秒用力呼气量（FEV1）和峰值流速（PFR）；c）8小时和24小时静息、咳嗽及活动时的视觉模拟疼痛评分（VAS 0 - 10）；d）每小时测量12小时，然后每3小时测量一次阻滞平面；e）24小时尿中多巴胺、肾上腺素和去甲肾上腺素的含量；f）24小时内患者自控镇痛（PCA）吗啡需求量。
两组患者在年龄、性别、身高、体重、手术时间、失血量或血清白蛋白水平上无差异。两组的镇痛效果均极佳且相似。两组患者24小时吗啡平均消耗量均为10毫克，阻滞平面无差异。所有患者的FEV1、FVC和PFR均降低了30 - 50%（P > 0.05）。代谢方面，两组间无统计学差异，但第1组在2小时和3小时血糖升高幅度更大（P = 0.0312和0.014）。24小时儿茶酚胺研究显示，去甲肾上腺素（P = 0.8）、肾上腺素（P = 0.47）和多巴胺（P = 0.36）无差异。
胸段硬膜外输注布比卡因/二氢吗啡酮为结肠手术后提供了极佳의术后镇痛效果。术中联合脊髓/硬膜外技术在镇痛、肺功能和神经内分泌反应方面未带来额外益处。
