多模式鎮痛方式在胸腔鏡圍手術期的應用研究

□ 陳雅 CHEN Ya 孔敏 KONG Min 施瑛 SHI Ying

Objective To investigate the effect of multimodal analgesia in the perioperative period of fast track thoracoscopic surgery. Methods A total of 130 patients with lung cancer who underwent thoracoscopic surgery from January 2017 to May 2018 were randomly divided into the experimental group (n=65)and the control group (n=65). The control group was given routine postoperative analgesia and the experimental group was given multimodal analgesia. The degree of pain after surgery in both groups was assessed and compared. The total number of analgesia pump compressions and the cumulative amount of morphine use after surgery were recorded. Adverse reactions such as nausea and vomiting, lethargy, decreased blood pressure and respiratory depression were observed in the two groups. Results The resting pain and exercise pain were significantly lighter in the experimental group at each time point after operation than in the control group (p＜0.05). The total number of analgesia pump compressions and the cumulative amount of morphine use in the experimental group were significantly lower than those in the control group (p＜0.05). The incidence of hypotension, lethargy, nausea and vomiting and total adverse reactions were lower in the experimental group than in the control group (p＜0.05). Conclusion Multimodal analgesia can effectively control postoperative pain in patients undergoing thoracoscopic surgery and promote rapid recovery.

肺癌是威脅人類健康和生命的惡性腫瘤之一，其發病率和死亡率逐年增加[1]。胸腔鏡手術(Video-Assisted Thoracic Surgery，VATS)是二十世紀末期胸外科的重大技術革新，是治療肺癌的有效方法。雖然，胸腔鏡手術(VATS)對患者的創傷比較小，但是，術后疼痛仍是VATS最常見的臨床問題之一，是阻礙患者術后快速恢復的主要因素[2-4]。VATS術后患者因疼痛不敢用力咳嗽排痰、深呼吸及翻身，極易發生肺不張和肺部感染等并發癥[4-5]。嚴重的術后疼痛使患者產生恐懼、焦慮，導致機體產生應激反應、免疫力下降，手術切口感染等并發癥增加[4]。而VATS 術后疼痛發生的機制是多源的，常規鎮痛方法效果不理想，需要不斷探索鎮痛方法[6]。快速康復外科(Fast Track Surgery，FTS)是指在術前、術中及術后綜合優化應用各種已證實有效的方法，最終達到降低患者應激反應、減少并發癥，促進早期康復[7]，在許多外科領域的應用取得了巨大成功。VATS手術快速康復外科中多模式鎮痛方式的研究在國內外鮮見相關的報道。本研究旨在針對VATS術后疼痛發生的機制，采用多模式鎮痛方式減輕術后疼痛，促進患者快速康復。

資料與方法

1.臨床資料。選擇2017年1月至2018年5月在我院胸外科住院行胸腔鏡手術的肺癌患者共130例。納入標準：(1)美國麻醉醫師協會(ASA)分級Ⅰ～Ⅲ級；(2)年齡30～80歲；(3)電視胸腔鏡下擇期行胸部手術的肺癌患者，TNM分期為Ⅰ～ⅢA級；(4)手術時間預計在1～6小時范圍內；(5)胸腔鏡孔數設計3孔；(6)患者愿意參加本研究，并簽署知情同意書者。排除標準：(1)術前有慢性阻塞性肺疾病、2型糖尿病、慢性疼痛的患者；……