吸烟者胸科术后镇痛效果及干预措施的临床研究

发布时间：2017-12-27 02:06

本文关键词：吸烟者胸科术后镇痛效果及干预措施的临床研究　出处：《山东大学》2015年博士论文　论文类型：学位论文

【摘要】：研究背景烟草危害是影响全世界人民健康的最严重的公共卫生问题之一。全球约有10亿人吸烟,每年死于烟草相关疾病的有540万人。在每年约2.3亿接受手术治疗的成年人当中,有30%的手术病人在手术以前是正在吸烟的烟民。数百万的手术病人围术期会发生与吸烟相关的并发症。吸烟也是影响术后疼痛的独立危险因素,术后疼痛及其应激反应对机体呼吸、循环、内分泌等多个方面带来不良反应,增加术后并发症的发生率。良好的术后镇痛是减少病人痛苦,保证其顺利康复的条件。因此如何做好吸烟患者的术后疼痛管理是麻醉医师所关注的问题之一。而有关吸烟对术后疼痛影响的临床对照研究尚少见,且现有研究所涉及的手术类别仅限于冠脉搭桥术、妇产科手术、髋或膝关节置换术,对吸烟者的界定也仅根据每日吸烟的量和烟龄。胸科患者的吸烟率远高于其他科室,开胸手术又被认为是术后最疼痛的外科手术之一。而烟瘾的本质就是尼古丁依赖,每个烟民对尼古丁的依赖程度也不同,我们推测其对术后疼痛的影响亦不同。因此,研究吸烟者尼古丁依赖程度对胸科术后镇痛效果的影响及干预措施具有重要的临床意义,但目前国内外尚未见相关报道。我院于2011年6月成立了麻醉医师督导下以疼痛专科护士为主体的急性疼痛服务组织(acute pain service, APS)。经过团队成员共同努力取得了良好的效果,并建立了手术麻醉数据库及急性疼痛服务数据库,积累了丰富的资料。本研究第一部分拟通过回顾性研究方法,探讨尼古丁依赖程度对胸科术后病人自控静脉镇痛(patient controlled intravenous analgesia, PCIA)效果的影响；第二部分采用前瞻性、随机、双盲、安慰剂对照的研究方法,对高度尼古丁依赖吸烟患者术中应用α2受体激动剂右美托咪定进行干预,评估干预措施的效果。旨在为吸烟患者的个体化镇痛提供参考依据。第一部分尼古T依赖程度对胸科患者术后阿片类镇痛药需求量的影响目的：探讨尼古丁依赖程度对胸科患者术后自控静脉镇痛阿片类药物需求量的影响。方法：采用回顾性研究方法,纳入“聊城市人民医院术后镇痛数据库”中2012年6月～2013年12月期间,实施PCIA的胸外科手术患者215例(112例非吸烟者,103例吸烟者)。根据吸烟状况及尼古丁依赖Fagerstrom测试(Fagerstrom test of nicotine dependence, FTND)问卷评分,分为非吸烟组(NS组,n=112)、低度尼古丁依赖组(FTND评分6分,LD组,n=58)及高度尼古丁依赖组(FTND评分≥6分,HD组,n=45)。用于PCIA的药物为舒芬太尼,非阿片类辅助镇痛药物包括酮咯酸、曲马多,PCIA应用至术后48h以上。疼痛评估采用数字评分法(numerical rating scale, NRS),术后每4h评估一次。APS小组每日查房,记录患者的一般情况、尼古丁依赖程度、手术麻醉信息、及术后各时点的镇痛效果和舒芬太尼的用量等。通过“术后镇痛数据库”和"Docare手术麻醉系统”提取相关资料,进行统计分析。结果：3组患者的一般资料、手术类型、术中芬太尼用量组间比较差异无统计学意义(P0.05)；转入麻醉恢复室(postanesthesia care unit, PACU)及术后24h和48 h的疼痛评分组间比较,HD组和LD组高于NS组(P0.05),且HD组高于LD组(P0.05)；HD组术后24、48 h累积舒芬太尼用量分别为116±45μg和227±78μg,LD组术后24、48 h累积舒芬太尼用量分别为97±37μg和164±80μg,两组均明显高于NS组的术后24、48 h累积舒芬太尼用量(74±46μg和134±63μg)(P0.05)；且HD组亦高于LD组(P0.05)。FTND评分与术后24h和48 h舒芬太尼累积用量存在正相关关系(r分别为0.370、0.441,P0.001)。HD组术后恶心、呕吐的发生率分别为6.6%和2.2%,LD组分别为6.9%和3.4%,NS组分别为7.1%和3.6%,组间比较差异无统计学意义(P0.05)；3组均未发生呼吸抑制、过度镇静等不良反应。结论：吸烟患者的术后疼痛程度和累积舒芬太尼用量高于非吸烟者,且随尼古丁依赖程度的升高,术后疼痛程度和累积舒芬太尼用量亦增加。第二部分术中应用右美巧咪定对高度尼古T依赖患者胸科术后镇痛效果的影响目的:评估术中应用右美托巧定干预对高度尼古下依赖男性患者胸科术后镇痛效果的影响。方法:采用前瞻性、随机、双盲、安慰剂对照的研充方法,纳入聊城市人民医院2014年1月至2014年7月期间,择期行胸科手术且术后实施PCIA的男性高度尼古T依赖(FTND6)患者100例,随机分配至右美托咪定组(D组)和生理盐水组(C组)。D组有46例,C组有48例完成试验。D组入室后静脉给予右美托咪定l.0|-ig/kg,lOmin内输注完毕,随之W0.5腿/kg/h的速率输注至手术结束前30min。C姐入室后速率给予等容量的生理盐水。两组采用相同的支气管插管静吸复合全麻方案,术毕气管拔管后转入PACU。术后采用舒芬太尼病人自控静脉镇痛(patient controlled intravenous analg的ia,PCIA),疼痛评估采用数字评分方法(numerical rating scale,NRS,0分=无痛,10分=最痛),控制目标为静息痛NRS4分。转入PACU时,如静息痛NRS4分,给予舒芬太尼负荷量,至静息痛NRS4分时,启动PCIA。主要临床终点指标为术后Oh(入PACU即刻)、1、4、8、12、16、20、24、28、32、36、40、44、4化的静息痛和咳嗽痛NRS评分及相应时点的舒芬太尼累积用量。次要终点指标为术中血流动力学的变化及术后恶也、呕吐、呼吸抑制、过度镇静等镇痛相关副作用。并记录患者的一般特征资料及对术后镇痛服务的满意度。结果;1.两组的人口学特征和围术期一般资料,组间比较差异无统计学意义(P0.05)2.疼痛评分:入PACU即刻(术后化),D组的静息痛NRS评分2(1~3)(中位数,四分位间距,interquartile range,IQ民)和咳嗽痛N民S评分3(2~4)(中位数,IQR)显著低于C组的静息痛NRS评分4(3~5)(中位数,巧R)和咳嫩痛N艮S评分6(4~7)(中位数,IQR),组间比较差异有统计学意义(P0.001)。之后的24h,各时点的静息痛和咳嗽痛NRS评分,D姐均低于C组(P0.05)。24h之后各时点的静息痛和咳嗽痛NRS评分组间比较差异无统计学意义(P0.05)。3.舒芬太尼用量术毕转入PACU后,C组有18例(37.5%)D组有5例(10.9%),在启动PCA前需要给予舒芬太尼负荷量。术后1h内的累积舒芬太尼用量(负荷量+PCA用量),0组的为6(5-7)(中位数,IQ民)显著低于C组的12(8-16)惦(中位数,IQ民)(P0.001)。术后1~24h:随着术后镇痛时间的延长,两组舒芬太尼的用量也随之增加。但术后1~24h的累积舒芬太尼用量D组10化38μg低于C组11±48峭(P0.05)。术后24~48h:D组术后24~4化的累积舒芬太尼用量90±32μg,低于C组的102±40ng,但差异无统计学意义(P0.05)。术后镇痛期间:术后舒芬太尼累积总用量(含负荷量)D组为20化55μg,明显低于C组232±64μg,(p0.05)。4.术中D组的心率低于C组,组间比较差异有统计学意义(P0.01)。两组间收缩压和舒张压均无明显变化(P0.05)。术后恶心、、呕吐、呼吸抑制、过度镇静及镇痛服务满意度姐间比较差异无统计学意义(P0.05)。结论:术中应用右美托咪定可W降低高度尼古T依赖患者胸科术后早期(24h内)的静息痛和咳嗽痛NRS评分,减少舒芬太尼用量。
[Abstract]:The study of the hazards of tobacco is one of the most serious public health problems that affect the health of the people of the world. About 1 billion people all over the world are smoking, and 5 million 400 thousand people die from tobacco related diseases every year. Of the 230 million adults who receive surgical treatment every year, 30% of the patients are smokers who are smoking before the operation. Millions of surgical patients have complications associated with smoking during the perioperative period. Smoking is also an independent risk factor for postoperative pain. Postoperative pain and stress reaction bring adverse reactions to respiratory, circulatory, endocrine and other aspects, and increase the incidence of postoperative complications. Good postoperative analgesia is a condition to reduce the pain of the patients and ensure the smooth recovery of the patients. So how to do the smoking patients postoperative pain management is one of the issues of concern to anesthesiologists. However, the clinical control study on the effect of smoking on postoperative pain is rare. The operative categories involved in the current studies are limited to coronary artery bypass grafting, gynecologic surgery, hip or knee replacement, and the definition of smokers is based on daily smoking volume and smoking duration. The smoking rate of patients in the chest is much higher than that of other departments, and thoracotomy is considered to be one of the most painful surgical operations after the operation. The essence of smoking addiction is nicotine dependence, and each smoker's dependence on nicotine is different, and we speculate that it has a different effect on postoperative pain. Therefore, it is of great clinical significance to study the effects of nicotine dependence on postoperative analgesia and interventions on smokers. The hospital established acute pain service organization to pain nurse specialist as the main body under the supervision of the anesthesiologist in June 2011 (acute pain service, APS). Good results have been achieved through the joint efforts of the team members, and a database of surgical anesthesia and acute pain service has been established, and rich data have been accumulated. The first part of this study intends to review research methods, the study of nicotine dependence on patient-controlled intravenous analgesia after thoracic surgery (patient controlled, intravenous analgesia, PCIA) effect; the second part of the prospective, randomized, double-blind, placebo-controlled study, 2 receptor agonist dexmedetomidine intervention using alpha smoking in patients with high dependence on nicotine, evaluating the effectiveness of the intervention measures. The purpose of this study is to provide a reference for the individualized analgesia of smoking patients. The first part T the influence of nicotine dependence on opioid analgesic requirement of post thoracic surgery patients: To investigate the effect of nicotine dependence on thoracic surgery patients controlled intravenous analgesia after opioid demand. Methods: a retrospective study was carried out in 215 patients (112 non-smokers and 103 smokers) in Department of thoracic surgery during the period from June 2012 to December 2013 in the postoperative analgesia database of Liaocheng People's Hospital, which was carried out in PCIA. According to the status of smoking and nicotine dependence test (Fagerstrom test of nicotine Fagerstrom dependence, FTND) questionnaire, divided into non smoking group (group NS, n=112), low nicotine dependence group (FTND score 6 points, LD group, n=58) and high nicotine dependence group (FTND score more than 6 points, HD group, n=45). For the treatment of PCIA sufentanil, non opioid analgesic drugs including auxiliary ketorolac, tramadol, PCIA application to 48h after operation above. The pain assessment was evaluated by numerical rating scale (NRS), and each 4H was evaluated once after the operation. The APS group rounds the ward daily to record the general condition, nicotine dependence, operative anesthesia information, analgesic effect and the dosage of sufentanil. The relevant data were collected through the "postoperative analgesia database" and "Docare operation anesthesia system", and the statistical analysis was carried out. Results: no fentanyl group was statistically significant between the general information, operation type, operation in 3 groups (P0.05); to anesthesia recovery room (postanesthesia care, unit, PACU) and 24h after operation and 48 h pain scores between the two groups, HD group and LD group than in NS group (P0.05). And the HD group than in LD group (P0.05); HD group after 24 and 48 h cumulative dosage of sufentanil were 116 + 45 and 227 + G 78 g, LD group after 24 and 48 h cumulative dosage of sufentanil were 97 + 37 and 164 + G 80 g, the two groups were significantly than that of the NS group after 24 and 48 h cumulative dosage of sufentanil (74 + 134 + 46 g and 63 g) (P0.05); and HD group was also higher than that of group LD (P0.05). There was a positive correlation between the FTND score and the amount of 24h and 48 h sufentanil after the operation (r was 0.370, 0.441, P0.001, respectively). The incidence of postoperative nausea and vomiting in group HD was 6.6% and 2.2%, respectively, in group LD, 6.9% and 3.4%, respectively, and NS group was 7.1% and 3.6%, respectively. There was no significant difference between groups (P0.05). No adverse reactions such as respiratory depression and excessive sedation were found in 3 groups. Conclusion: postoperative pain and cumulative sufentanil consumption in smokers are higher than those in non-smokers. With the increase of nicotine dependence, postoperative pain and cumulative dosage of sufentanil increase. The second part of the right beauty Qiao Mi effect on analgesia in patients after thoracic surgery on the height of Nikolaos T Objective: To evaluate the application of intraoperative dexmedetomidine intervention on the analgesic effect of clever set of male patients on postoperative chest height under nicholas. Methods: a prospective, randomized, double-blind, placebo-controlled study of the method, in Liaocheng People's Hospital from January 2014 to July 2014 period, PCIA male height nicotine dependent T implementation undergoing selective thoracic surgery and postoperative (FTND6) patients 100 cases, randomly assigned to the right holder MI group (D group) and saline group (Group C). There were 46 cases in group D, and 48 in group C completed the test. In group D, right metodetonidine l.0|-ig/kg was given after admission, and lOmin infusion was completed, and the rate of /kg/h of W0.5 leg was then injected to 30min before the end of the operation. C sister
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R614.1

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