无痛治疗模式管理脊柱椎体骨折术后疼痛的临床观察

发布时间：2018-08-18 20:37

【摘要】：背景：近年来,随着经济的蓬勃发展以及人民生活水平的不断提高,老百姓对自身健康的关注日渐增加,疼痛作为“第五生命体征”已经日渐成为诊疗过程中患者越来越关注的问题。在外科领域,患者术后最直接关切的则是术后疼痛带来的痛苦与折磨。脊柱外科学是近年来的一门新兴尖端学科,多数疾病需要经历手术治疗过程。脊柱手术创伤大、失血多、手术持续时间长,术后易较早期产生术区疼痛,若处理不当则往往会演变成慢性疼痛,随之而来的而是一系列不良并发症的产生,延缓患者术后康复进程,影响总体手术预期。由此看来,及时处理术后疼痛十分关键且必要。临床上经验性镇痛方法效果差,疗效欠佳,然而目前业内尚缺乏针对性、模式化的疼痛治疗方案和更加高效、有序、成熟的术后疼痛管理经验。研究、探讨无痛治疗模式下的脊柱术后镇痛疗效为脊柱外科医师提供了术后疼痛管理新选择。目的：运用随机对照的方法研究在由本科室创建的无痛治疗模式(PTM, Pain-free Therapy Mode)管理下自行配置复合镇痛方剂(罗哌卡因+吗啡+肾上腺素)治疗脊柱胸腰椎体骨折后路切开复位钉棒系统内固定术术后疼痛的临床综合镇痛效果。方法：随机选择80位病人预备行经后路胸、腰椎切开复位内固定植入手术治疗,胸椎27例(T11、T12),腰椎42例(L1-L4),胸腰椎复合(11例),压缩性、爆裂性诊断为主。采用双盲法随机将患者分为研究组和对照组各40例,两组患者术前VAS疼痛评分无统计学差异(P0.05)。研究组采用由我科创建的无痛治疗模式镇痛方案,所有病人术前均给予西乐葆口服实施预先镇痛,术毕缝皮前给予自配复合镇痛方剂(吗啡+罗哌卡因+肾上腺素)稀释于生理盐水中注射于椎旁肌。手术结束患者麻醉清醒后给予及通安口服,痛时给药,必要时皮下注射吗啡补救镇痛。对照组术前给予西乐葆口服,术毕椎旁肌肌注生理盐水作为对照,术后同样给予及通安口服镇痛,必要时吗啡补救加强。记录补救镇痛吗啡用量、次数。记录术后4、8、12、24、36和48h病人切口疼痛VAS评分,评分标准结合视觉模拟评分法(VAS)与NRS数字量表,与此同时,记录镇静评分和不良反应(皮肤瘙瘁、头晕、恶心、呕吐、呼吸抑制)发生情况,调查患者总体手术满意率。结果：共有71例患者进入最后统计学分析,其中研究组37例,对照组34例。研究组与对照组病人术后4、8、12、24、36小时刀口疼痛VAS评分均有所降低,镇静评分有所升高,但研究组各时点疼痛评分显著低于对照组,下降趋势更明显,两组间疼痛评分差异有高度统计学意义(P0.01)。48小时以后两组间差异开始减小。另外,统计显示两组病人术后有关不良副反应没有统计学差异(P0.05),并且,研究组患者整体镇痛满意度和信心指数明显高于对照组患者(P0.05)。此外,我们还观察到了研究组与对照组相比有着较少的术后吗啡补救镇痛次数、用量以及多学科会诊次数。结论：在无痛治疗模式管理下罗哌卡因、肾上腺素、吗啡组成复合镇痛方剂用于脊柱后路胸腰椎压缩、爆裂骨折开放手术术后疼痛的控制治疗取得了良好的术后镇痛、镇静效果,副作用少,安全性高,有效减轻了术后疼痛给患者带来的痛苦,使患者得到了较满意的睡眠质量,提高了患者的整体手术满意度,极大促进了患者的术后早期功能锻炼与全面康复。无痛治疗模式为脊柱外科临床医师提供了全新的、可靠的镇痛选择。
[Abstract]:BACKGROUND: In recent years, with the vigorous development of economy and the continuous improvement of people's living standards, people pay more and more attention to their own health. Pain as the "fifth vital sign" has increasingly become a problem of concern to patients in the process of diagnosis and treatment. In the field of surgery, postoperative pain zone is the most direct concern of patients after surgery. Spinal surgery is a new and cutting-edge subject in recent years. Most diseases need to undergo surgical treatment. Spinal surgery is characterized by severe trauma, excessive blood loss, long duration of surgery, and early postoperative pain. If not handled properly, it often evolves into chronic pain, followed by a series of adverse reactions. From this point of view, it is very important and necessary to deal with postoperative pain promptly. Clinical experience analgesia method is ineffective and ineffective. However, there is still a lack of pertinence in the industry, the model of pain treatment program and more efficient, orderly, mature postoperative pain tube. To explore the analgesic effect of painless spinal surgery provides spinal surgeons with a new choice for postoperative pain management.
Objective: To study the clinical analgesic effect of ropivacaine + morphine + epinephrine self-administered compound analgesic prescription (Ropivacaine + morphine + epinephrine) in the treatment of pain after posterior open reduction and screw rod system internal fixation for thoracolumbar spine fractures by randomized controlled study.
Methods: 80 patients were randomly selected for posterior thoracotomy, lumbar open reduction and internal fixation, including 27 cases of thoracic vertebrae (T11, T12), 42 cases of lumbar vertebrae (L1-L4), thoracolumbar vertebrae complex (11 cases), compression and burst diagnosis. All patients were given Celebrex orally before operation for preemptive analgesia, and self-made compound analgesic prescription (morphine + ropivacaine + adrenaline) was given to dilute paravertebral muscle in normal saline before operation. The control group was given Celebrex orally before operation, paravertebral muscles were injected with normal saline as control, and the same was given Hetong'an orally after operation. Morphine remedy was strengthened when necessary. The amount and times of morphine remedial analgesia were recorded. Visual analogue scale (VAS) and NRS digital scale were used to evaluate the VAS score of incision pain in H patients. Meanwhile, sedation score and adverse reactions (skin distemper, dizziness, nausea, vomiting, respiratory depression) were recorded to investigate the overall satisfaction rate of the patients.
Results: A total of 71 patients entered the final statistical analysis, including 37 cases in the study group and 34 cases in the control group. The VAS scores of knife-edge pain in the study group and the control group were decreased at 4,8,12,24,36 hours after operation, and the sedation scores were increased, but the pain scores in the study group were significantly lower than those in the control group at each time point, and the downward trend was more obvious. The difference between the two groups was statistically significant (P 0.01). After 48 hours, the difference between the two groups began to decrease. In addition, statistics showed that there was no statistical difference in postoperative adverse reactions between the two groups (P 0.05), and the overall satisfaction and confidence index of the study group were significantly higher than those of the control group (P 0.05). Compared with the control group, there were fewer times of postoperative morphine remedial analgesia, dosage and multidisciplinary consultation.
Conclusion: Ropivacaine, epinephrine and morphine combined analgesic prescriptions under painless management can be used to control the pain after open surgery for burst fractures and thoracolumbar vertebral compression through posterior approach. The painless treatment mode provides a new and reliable analgesic option for spinal surgery clinicians.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3

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