本文關鍵詞：吸煙者胸科術后鎮(zhèn)痛效果及干預措施的臨床研究　出處：《山東大學》2015年博士論文　論文類型：學位論文

  更多相關文章： 尼古丁依賴 吸煙 術后鎮(zhèn)痛 病人自控靜脈鎮(zhèn)痛 舒芬太尼 尼古丁依賴 胸科手術 右美托咪定 術后鎮(zhèn)痛

【摘要】：研究背景煙草危害是影響全世界人民健康的最嚴重的公共衛(wèi)生問題之一。全球約有10億人吸煙,每年死于煙草相關疾病的有540萬人。在每年約2.3億接受手術治療的成年人當中,有30%的手術病人在手術以前是正在吸煙的煙民。數百萬的手術病人圍術期會發(fā)生與吸煙相關的并發(fā)癥。吸煙也是影響術后疼痛的獨立危險因素,術后疼痛及其應激反應對機體呼吸、循環(huán)、內分泌等多個方面帶來不良反應,增加術后并發(fā)癥的發(fā)生率。良好的術后鎮(zhèn)痛是減少病人痛苦,保證其順利康復的條件。因此如何做好吸煙患者的術后疼痛管理是麻醉醫(yī)師所關注的問題之一。而有關吸煙對術后疼痛影響的臨床對照研究尚少見,且現有研究所涉及的手術類別僅限于冠脈搭橋術、婦產科手術、髖或膝關節(jié)置換術,對吸煙者的界定也僅根據每日吸煙的量和煙齡。胸科患者的吸煙率遠高于其他科室,開胸手術又被認為是術后最疼痛的外科手術之一。而煙癮的本質就是尼古丁依賴,每個煙民對尼古丁的依賴程度也不同,我們推測其對術后疼痛的影響亦不同。因此,研究吸煙者尼古丁依賴程度對胸科術后鎮(zhèn)痛效果的影響及干預措施具有重要的臨床意義,但目前國內外尚未見相關報道。我院于2011年6月成立了麻醉醫(yī)師督導下以疼痛�？谱o士為主體的急性疼痛服務組織(acute pain service, APS)。經過團隊成員共同努力取得了良好的效果,并建立了手術麻醉數據庫及急性疼痛服務數據庫,積累了豐富的資料。本研究第一部分擬通過回顧性研究方法,探討尼古丁依賴程度對胸科術后病人自控靜脈鎮(zhèn)痛(patient controlled intravenous analgesia, PCIA)效果的影響；第二部分采用前瞻性、隨機、雙盲、安慰劑對照的研究方法,對高度尼古丁依賴吸煙患者術中應用α2受體激動劑右美托咪定進行干預,評估干預措施的效果。旨在為吸煙患者的個體化鎮(zhèn)痛提供參考依據。第一部分尼古T依賴程度對胸科患者術后阿片類鎮(zhèn)痛藥需求量的影響目的：探討尼古丁依賴程度對胸科患者術后自控靜脈鎮(zhèn)痛阿片類藥物需求量的影響。方法：采用回顧性研究方法,納入“聊城市人民醫(yī)院術后鎮(zhèn)痛數據庫”中2012年6月～2013年12月期間,實施PCIA的胸外科手術患者215例(112例非吸煙者,103例吸煙者)。根據吸煙狀況及尼古丁依賴Fagerstrom測試(Fagerstrom test of nicotine dependence, FTND)問卷評分,分為非吸煙組(NS組,n=112)、低度尼古丁依賴組(FTND評分6分,LD組,n=58)及高度尼古丁依賴組(FTND評分≥6分,HD組,n=45)。用于PCIA的藥物為舒芬太尼,非阿片類輔助鎮(zhèn)痛藥物包括酮咯酸、曲馬多,PCIA應用至術后48h以上。疼痛評估采用數字評分法(numerical rating scale, NRS),術后每4h評估一次。APS小組每日查房,記錄患者的一般情況、尼古丁依賴程度、手術麻醉信息、及術后各時點的鎮(zhèn)痛效果和舒芬太尼的用量等。通過“術后鎮(zhèn)痛數據庫”和"Docare手術麻醉系統(tǒng)”提取相關資料,進行統(tǒng)計分析。結果：3組患者的一般資料、手術類型、術中芬太尼用量組間比較差異無統(tǒng)計學意義(P0.05)；轉入麻醉恢復室(postanesthesia care unit, PACU)及術后24h和48 h的疼痛評分組間比較,HD組和LD組高于NS組(P0.05),且HD組高于LD組(P0.05)；HD組術后24、48 h累積舒芬太尼用量分別為116±45μg和227±78μg,LD組術后24、48 h累積舒芬太尼用量分別為97±37μg和164±80μg,兩組均明顯高于NS組的術后24、48 h累積舒芬太尼用量(74±46μg和134±63μg)(P0.05)；且HD組亦高于LD組(P0.05)。FTND評分與術后24h和48 h舒芬太尼累積用量存在正相關關系(r分別為0.370、0.441,P0.001)。HD組術后惡心、嘔吐的發(fā)生率分別為6.6%和2.2%,LD組分別為6.9%和3.4%,NS組分別為7.1%和3.6%,組間比較差異無統(tǒng)計學意義(P0.05)；3組均未發(fā)生呼吸抑制、過度鎮(zhèn)靜等不良反應。結論：吸煙患者的術后疼痛程度和累積舒芬太尼用量高于非吸煙者,且隨尼古丁依賴程度的升高,術后疼痛程度和累積舒芬太尼用量亦增加。第二部分術中應用右美巧咪定對高度尼古T依賴患者胸科術后鎮(zhèn)痛效果的影響目的:評估術中應用右美托巧定干預對高度尼古下依賴男性患者胸科術后鎮(zhèn)痛效果的影響。方法:采用前瞻性、隨機、雙盲、安慰劑對照的研充方法,納入聊城市人民醫(yī)院2014年1月至2014年7月期間,擇期行胸科手術且術后實施PCIA的男性高度尼古T依賴(FTND6)患者100例,隨機分配至右美托咪定組(D組)和生理鹽水組(C組)。D組有46例,C組有48例完成試驗。D組入室后靜脈給予右美托咪定l.0|-ig/kg,lOmin內輸注完畢,隨之W0.5腿/kg/h的速率輸注至手術結束前30min。C姐入室后速率給予等容量的生理鹽水。兩組采用相同的支氣管插管靜吸復合全麻方案,術畢氣管拔管后轉入PACU。術后采用舒芬太尼病人自控靜脈鎮(zhèn)痛(patient controlled intravenous analg的ia,PCIA),疼痛評估采用數字評分方法(numerical rating scale,NRS,0分=無痛,10分=最痛),控制目標為靜息痛NRS4分。轉入PACU時,如靜息痛NRS4分,給予舒芬太尼負荷量,至靜息痛NRS4分時,啟動PCIA。主要臨床終點指標為術后Oh(入PACU即刻)、1、4、8、12、16、20、24、28、32、36、40、44、4化的靜息痛和咳嗽痛NRS評分及相應時點的舒芬太尼累積用量。次要終點指標為術中血流動力學的變化及術后惡也、嘔吐、呼吸抑制、過度鎮(zhèn)靜等鎮(zhèn)痛相關副作用。并記錄患者的一般特征資料及對術后鎮(zhèn)痛服務的滿意度。結果;1.兩組的人口學特征和圍術期一般資料,組間比較差異無統(tǒng)計學意義(P0.05)2.疼痛評分:入PACU即刻(術后化),D組的靜息痛NRS評分2(1~3)(中位數,四分位間距,interquartile range,IQ民)和咳嗽痛N民S評分3(2~4)(中位數,IQR)顯著低于C組的靜息痛NRS評分4(3~5)(中位數,巧R)和咳嫩痛N艮S評分6(4~7)(中位數,IQR),組間比較差異有統(tǒng)計學意義(P0.001)。之后的24h,各時點的靜息痛和咳嗽痛NRS評分,D姐均低于C組(P0.05)。24h之后各時點的靜息痛和咳嗽痛NRS評分組間比較差異無統(tǒng)計學意義(P0.05)。3.舒芬太尼用量術畢轉入PACU后,C組有18例(37.5%)D組有5例(10.9%),在啟動PCA前需要給予舒芬太尼負荷量。術后1h內的累積舒芬太尼用量(負荷量+PCA用量),0組的為6(5-7)(中位數,IQ民)顯著低于C組的12(8-16)惦(中位數,IQ民)(P0.001)。術后1~24h:隨著術后鎮(zhèn)痛時間的延長,兩組舒芬太尼的用量也隨之增加。但術后1~24h的累積舒芬太尼用量D組10化38μg低于C組11±48峭(P0.05)。術后24~48h:D組術后24~4化的累積舒芬太尼用量90±32μg,低于C組的102±40ng,但差異無統(tǒng)計學意義(P0.05)。術后鎮(zhèn)痛期間:術后舒芬太尼累積總用量(含負荷量)D組為20化55μg,明顯低于C組232±64μg,(p0.05)。4.術中D組的心率低于C組,組間比較差異有統(tǒng)計學意義(P0.01)。兩組間收縮壓和舒張壓均無明顯變化(P0.05)。術后惡心、、嘔吐、呼吸抑制、過度鎮(zhèn)靜及鎮(zhèn)痛服務滿意度姐間比較差異無統(tǒng)計學意義(P0.05)。結論:術中應用右美托咪定可W降低高度尼古T依賴患者胸科術后早期(24h內)的靜息痛和咳嗽痛NRS評分,減少舒芬太尼用量。
[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
【學位授予單位】：山東大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R614.1

【參考文獻】

相關期刊論文 前1條

1 刀俊峰;章錦才;宋光保;信琪;;牙列缺損患者種植術前的焦慮水平對術后疼痛感受的影響[J];南方醫(yī)科大學學報;2014年04期

，

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