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人工耳蜗植入术是让重度感音性耳聋病人获得听力的重要方法,术后疼痛对人工耳蜗植入术成败较为关键,因常致病人术后谵妄、烦躁,有导致耳蜗移位等严重不良后果。传统的静脉镇痛药物因剂量依耐性不良反应制约了其在术后镇痛中的使用,而超声引导颈浅丛阻滞是较为有效的多模式镇痛方法之一[1],现已广泛应用于围手术期镇痛,但仍存在镇痛时间短等缺点。右美托咪定是具有较强协同镇痛作用的α2受体激动剂,硫酸镁也具有外周镇痛作用[2],现已有临床研究[3-4]证实这两种药物作为辅剂可有效延长局麻药神经阻滞的镇痛时间,但在人工耳蜗植入术病人中的研究较少。本研究拟评价超声引导下硫酸镁或右美托咪定复合罗哌卡因行颈浅丛阻滞用于人工耳蜗植入术病人术后镇痛效果,为临床应用提供参考。
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本研究初始纳入研究90例病人,每组各30例。R组和RD组各有1例病人中途拒绝参与研究退出,最终完成研究88例,其中男59例,女29例。3组病人一般资料、手术时间、麻醉时间和PACU恢复时间比较差异均无统计学意义(P < 0.05)(见表 1)。
分组 n 年龄/岁 男 女 体质量指数/(kg/m2) ASA分级 手术时间/min 麻醉时间/min PACU恢复时间/min Ⅰ Ⅱ R组 29 37.5±11.2 20 9 20.2±2.3 18 11 120.1±15.3 146.6±12.8 27.8±7.8 RD组 29 37.7±9.2 22 7 21.0±2.5 16 13 120.7±14.8 149.1±12.1 29.0±7.6 RM组 30 34.9±7.0 20 10 21.2±2.8 17 13 122.9±16.3 148.8±15.5 28.3±8.1 F — 0.82 0.65* 1.13 0.31* 0.29 0.30 0.19 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 MS组内 — 85.921 — 6.476 — 239.913 184.168 61.452 *示χ2值 表 1 3组病人一般资料及手术、麻醉、PACU恢复时间的比较(x±s)
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VAS评分方面,3组病人术后1 h、6 h和24 h各组间差异无统计学意义(P>0.05);术后12 h RM组和RD组较R组低,术后18 h RD组较RM组和R组低,差异均有统计学意义(P < 0.05)(见表 2)。
分组 n 1 h 6 h 12 h 18 h 24 h R组 29 2(1.5~3) 3(1.5~3) 4(3~5) 4(3~5) 6(3~5) RD组 29 2(2~3) 3(2~3)* 3(2~3)* 5(2~4)* 6(3~4) RM组 30 3(2~3) 3(2~3)* 3(2~3)* 3(3~5)△ 3(3~5) Hc — 2.12 0.97 18.27 17.22 2.95 P — >0.05 >0.05 < 0.01 < 0.01 >0.05 与R组比较*P < 0.05;与RD组比较△P < 0.05 表 2 3组病人术后各时间VAS评分比较[M(ISQ);分]
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拔管时Ricker躁动评分,R组>RD组>RM组;首次镇痛所需时间,RD组和RM组均较R组延长;补充镇痛药量,R组>RD组>RM组;病人满意度评分,R组低于RD组和RM组,差异均有统计学意义(P < 0.05~P < 0.01)(见表 3)。
分组 n Ricker评分/分 首次镇痛所需时间/min 补充镇痛药量/mg 病人满意度评分/分 R组 29 5.0±1.5 508.6±68.9 39.8±9.9 2.7±1.2 RD组 29 4.1±1.4* 720.0±95.2** 22.0±11.1** 3.5±1.2* RM组 30 3.3±1.3**△ 687.8±60.7** 28.1±10.1**△ 3.6±1.2* F — 10.86 65.05 21.79 4.17 P — < 0.01 < 0.01 < 0.01 < 0.05 MS组内 — 1.963 5 806.320 107.675 1.440 q检验:与R组比较*P < 0.05,**P < 0.01;与RD组比较△P < 0.05,△△P < 0.01 表 3 3组病人躁动评分、首次镇痛时间、补镇痛药量及满意度评分比较(x±s)
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3组病人术后均无低血压、穿刺部位血肿、呼吸抑制等相关并发症发生;呕吐,RM组有2例,R组和RD组各1例,差异无统计学意义(P>0.05);心动过缓,RD组有6例,R组和RM组各1例,RD组心动过缓发生率高于R组和RM组,差异有统计学意义(P < 0.05)(见表 4)。
分组 n 呕吐 心动过缓 R组 29 2(6.7) 1(3.4) RD组 29 1(3.4) 6(20.7)* RM组 30 1(3.3) 1(3.3)△ χ2 — 0.55 7.04 P — >0.05 < 0.05 与R组比较*P < 0.05;与RD组比较△P < 0.05 表 4 3组病人并发症发生率的比较[n;百分率(%)]
硫酸镁或右美托咪定复合罗哌卡因颈浅丛阻滞对人工耳蜗植入术后镇痛效果的比较
Comparison of the analgesia effects between magnesium sulfate or dexmedetomidine combined with ropivacaine in superficial cervical plexus block after cochlear implantation
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摘要:
目的评价硫酸镁或右美托咪定复合罗哌卡因颈浅丛神经阻滞对人工耳蜗植入术术后镇痛效果。 方法择期行人工耳蜗植入术病人88例,根据数字表法随机分为3组,R组(29例):0.25%罗哌卡因13 mL+2 mL 0.9%氯化钠溶液行颈浅丛阻滞;RD组(29例):0.25%罗哌卡因13 mL+0.75 μg/kg右美托咪定稀释至2 mL颈浅丛阻滞;RM组(30例):0.25%罗哌卡因13 mL+4 mg/kg硫酸镁稀释至2 mL颈浅丛阻滞。3组均采用静吸复合全麻。记录3组病人术后1、6、12、18及24 h病人疼痛评分(VAS评分);拔管时苏醒期Ricker镇静-躁动评分;首次补救镇痛时间和补救镇痛药物用量;围术期相关不良反应发生情况及病人满意度评价。 结果VAS评分方面,3组病人术后1 h、6 h和24 h各组间无差异;术后12 h RM组和RD组较R组低,术后18 h RD组较RM组和R组低,差异均有统计学意义(P < 0.05)。拔管时Ricker躁动评分,R组>RD组>RM组;首次镇痛所需时间,RD组和RM组均较R组延长;补充镇痛药量,R组>RD组>RM组;病人满意度评分,R组低于RD组和RM组,差异均有统计学意义(P < 0.05~P < 0.01)。术后3组呕吐率差异无统计学意义(P>0.05);心动过缓率RD组发生率高于R组和RM组,差异有统计学意义(P < 0.05)。 结论硫酸镁和右美托咪定作为辅剂复合罗哌卡因超声引导下颈浅丛阻滞用于人工耳蜗手术病人都可延长术后镇痛时间,减少静脉镇痛药物使用,降低麻醉苏醒期躁动发生率,提高病人满意度,右美托咪定可能作用时间更久,但麻醉苏醒期躁动和术后心动过缓发生率较硫酸镁高。 Abstract:ObjectiveTo evaluate the analgesia effects between magnesium sulfate or dexmedetomidine combined with ropivacaine in superficial cervical plexus block after cochlear implantation. MethodsEighty-eight patients scheduled by cochlear implantation were randomly divided into the group R(29 cases), group RD(29 cases) and group RM(30 cases) according to digital table method.The superficial cervical plexus block in group R was implemented using 13 mL of 0.25% ropivacaine combined with 2 mL of 0.9% sodium chloride solution, the superficial cervical plexus block in group RD was implemented using 13 mL of 0.25% ropivacaine combined with 0.75 mg/kg dexmedetomidine diluted to 2 mL, and the superficial cervical plexus block in group RM was implemented using 13 mL of 0.25% ropivacaine combined with 4 mg/kg magnesium sulfate diluted to 2 mL.Three groups were treated with static aspiration combined general anesthesia.The VAS scores in three groups after 1, 6, 12, 18 and 24 h of operation were recorded.The Ricker sedation-agitation score in the wake period during extubation, time of the first remedial analgesia, dosage of the remedial analgesia drugs, incidence rate of perioperative adverse reactions and satisfaction scores of patients among three groups were compared. ResultsThe differences of the VAS scores among three groups after 1, 6 and 24 h of operation were not statistically significant(P>0.05), the VAS scores in group RM and group RD after 12 h of operation were lower than those in group R, and the VAS score in group RD after 12 h of operation was lower than that in group RM and group R(P < 0.05).The Ricker sedation-agitation scores in group R, group RD and group RM during extubation gradually decreased, the time of the first remedial analgesia in group RD and group RM prolonged compared with group R, the dosage of the remedial analgesia drugs in group R, group RD and group RM gradually decreased, and the satisfaction score in group R was lower than that in group RD and group RM(P < 0.05 to P < 0.01).There was no statistical significance in the vomiting rate among three groups(P>0.05).The incidence rate of bradycardia in group RD was higher than that in group R and group RM(P < 0.05). ConclusionsBoth magnesium sulfate and dexmedetomidine combined with ropivacaine ultrasonic-guided superficial cervical plexus block can prolong the duration of postoperative analgesia, reduce the use of intravenous analgesia drugs and incidence rate of agitation during anaesthesia recovery, and improve satisfaction in patients treated with cochlear implantion.Compared with magnesium sulfate, the duration of postoperative analgesia is relatively long, and the agitationnd postoperative bradycardia rate are high in patients treated with dexmedetomidine. -
表 1 3组病人一般资料及手术、麻醉、PACU恢复时间的比较(x±s)
分组 n 年龄/岁 男 女 体质量指数/(kg/m2) ASA分级 手术时间/min 麻醉时间/min PACU恢复时间/min Ⅰ Ⅱ R组 29 37.5±11.2 20 9 20.2±2.3 18 11 120.1±15.3 146.6±12.8 27.8±7.8 RD组 29 37.7±9.2 22 7 21.0±2.5 16 13 120.7±14.8 149.1±12.1 29.0±7.6 RM组 30 34.9±7.0 20 10 21.2±2.8 17 13 122.9±16.3 148.8±15.5 28.3±8.1 F — 0.82 0.65* 1.13 0.31* 0.29 0.30 0.19 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 MS组内 — 85.921 — 6.476 — 239.913 184.168 61.452 *示χ2值 表 2 3组病人术后各时间VAS评分比较[M(ISQ);分]
分组 n 1 h 6 h 12 h 18 h 24 h R组 29 2(1.5~3) 3(1.5~3) 4(3~5) 4(3~5) 6(3~5) RD组 29 2(2~3) 3(2~3)* 3(2~3)* 5(2~4)* 6(3~4) RM组 30 3(2~3) 3(2~3)* 3(2~3)* 3(3~5)△ 3(3~5) Hc — 2.12 0.97 18.27 17.22 2.95 P — >0.05 >0.05 < 0.01 < 0.01 >0.05 与R组比较*P < 0.05;与RD组比较△P < 0.05 表 3 3组病人躁动评分、首次镇痛时间、补镇痛药量及满意度评分比较(x±s)
分组 n Ricker评分/分 首次镇痛所需时间/min 补充镇痛药量/mg 病人满意度评分/分 R组 29 5.0±1.5 508.6±68.9 39.8±9.9 2.7±1.2 RD组 29 4.1±1.4* 720.0±95.2** 22.0±11.1** 3.5±1.2* RM组 30 3.3±1.3**△ 687.8±60.7** 28.1±10.1**△ 3.6±1.2* F — 10.86 65.05 21.79 4.17 P — < 0.01 < 0.01 < 0.01 < 0.05 MS组内 — 1.963 5 806.320 107.675 1.440 q检验:与R组比较*P < 0.05,**P < 0.01;与RD组比较△P < 0.05,△△P < 0.01 表 4 3组病人并发症发生率的比较[n;百分率(%)]
分组 n 呕吐 心动过缓 R组 29 2(6.7) 1(3.4) RD组 29 1(3.4) 6(20.7)* RM组 30 1(3.3) 1(3.3)△ χ2 — 0.55 7.04 P — >0.05 < 0.05 与R组比较*P < 0.05;与RD组比较△P < 0.05 -
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