小儿开颅术后镇痛的随机对照研究
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Postoperative analgesia for pediatric craniotomy patients: a randomized controlled trial
背景与目的
小儿开颅术后疼痛多见并可能导致一些严重的术后并发症。然而，小儿神经外科术后镇痛的最佳方案尚未确定。本研究旨在探讨小儿神经外科术后镇痛的最佳选择及方案。
方 法
将320例1～12岁开颅手术患者按不同的病人自控镇痛方案随机分为4组。方案如下：对照组为生理盐水100 ml，背景剂量为2ml/h，单次追加剂量为0.5 ml；芬太尼组背景输注剂量为0.1～0.2μg/kg·h，单次追加剂量为0.1～0.2μg/kg；吗啡组背景输注剂量为10～20μg/kg·h，单次追加剂量为10～20μg/kg；曲马多组背景输注剂量为100～400μg/kg·h，单次追加剂量为100～200μg/kg。分别记录术后疼痛评分和镇痛相关并发症。四组之间进行比较分析。
结 果
与曲马多组、芬太尼组和对照组比较，吗啡组术后1 h和8 h疼痛评分较低（P < 0.05）。曲马多组和芬太尼组的疼痛评分均低于对照组（P < 0.05）。术后48小时PCIA使用期间，曲马多组发生恶心呕吐较其他组明显增多（P = 0.020）。对照组使用的紧急镇痛药物（布洛芬和吗啡）较多（CI = 0.000–0.019）。各组均未观察到意识改变和呼吸抑制。研究人群中共有56人（17.5%）出现中度至重度疼痛。对发生中重度疼痛的危险因素的多元回归分析表明，年龄较小的儿童(OR = 1.161, 1.027–1.312, P = 0.017)、枕部开颅术(OR = 0.374, 0.155–0.905, P = 0.029)和吗啡治疗(OR = 0.077, 0.021–0.281, P < 0.001)是相关因素。
结 论
其他镇痛方案相比，PCIA或NCIA吗啡镇痛可能是接受神经外科手术的患儿术后最安全、最有效的镇痛方案。
原始文献摘要
Xing F, An LX, Xue FS, et al. Postoperative analgesia for pediatric craniotomy patients: a randomized controlled trial.[J].BMC Anesthesiol 2019 ,19(1):53. DOI：10.1186/s12871-019-0722-x.
Background: Pain is often observed in pediatric patients after craniotomy procedures, which could lead to some serious postoperative complications. However, the optimal formula for postoperative analgesia for pediatric neurosurgery has not been well established. This study aimed to explore the optimal options and formulas for postoperative analgesia in pediatric neurosurgery.
Methods: Three hundred and twenty patients aged 1 to 12-years old who underwent craniotomy were randomly assigned to receive 4 different regimens of patient-controlled analgesia. The formulas used were as follows: Control group included normal saline 100 ml, with a background infusion of 2 ml/h, bolus 0.5 ml; Fentanyl group was used with a background infusion of 0.1–0.2 μg/kg·h, bolus 0.1–0.2 μg/kg; Morphine group was used with a background infusion of 10–20 μg/kg·h, bolus 10–20 μg/kg; while Tramadol group was used with a background infusion of 100–400 μg/kg·h, bolus 100–200 μg/kg. Postoperative pain scores and analgesia-related complication were recorded respectively. Comparative analysis was performed between the four groups.
Results: In comparison of all groups with each other, lower pain scores were shown at 1 h and 8 h after surgery in Morphine group versus Tramadol, Fentanyl and Control groups (P < 0.05). Both Tramadol and Fentanyl groups showed lower pain scores in comparison to Control group (P < 0.05). Nausea and vomiting were observed more in Tramadol group in comparison to all other groups during the 48 h of PCIA usage after operation (P = 0.020). Much more rescue medicines including ibuprofen and morphine were used in Control group (CI = 0.000–0.019). Changes in consciousness and respiratory depression were not observed in study groups. Moderate-to-severe pain was observed in a total of 56 (17.5%) of the study population. Multiple regression analysis for identifying risk factors for moderate-to-severe pain revealed that, younger children (OR = 1.161, 1.027–1.312, P = 0.017), occipital craniotomy (OR = 0.374, 0.155–0.905, P = 0.029), and morphine treatment (OR = 0.077, 0.021–0.281, P < 0.001) are the relevant factors.
Conclusions: Compared with other analgesic projects, PCIA or NCIA analgesia with morphine appears to be the safest and most effective postoperative analgesia program for pediatric patients who underwent neurosurgical operations.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：何幼芹 审校：王贵龙