帕瑞昔布钠论文：帕瑞昔布钠在不同时点应用对乳腺癌术后镇痛效果及不良反应对比

帕瑞昔布钠论文：帕瑞昔布钠在不同时点应用对乳腺癌术后镇痛效果及不良反应对比【中文摘要】乳腺癌手术由于手术范围广、创伤大、术后疼痛中等,术后需要镇痛。

良好的术后镇痛能明显抑制疼痛引起的应激反应,有利于咳嗽、排痰和术后早期下床活动,能减少肺部并发症和下肢深静脉血栓的形成。

目前临床常用哌替啶、吗啡、曲马多、芬太尼等进行术后镇痛,虽然效果确切,但副作用明显,如恶心、呕吐、瘙痒等,给患者及其家属带来困扰。

帕瑞昔布钠是一种新型的特异性环氧化酶2(COX-2)抑制剂,无抗血小板作用,不会增加出血危险,临床上主要用于与创伤和手术有关的急性疼痛的短期治疗,现已知帕瑞昔布钠可作用于中枢神经系统产生超前镇痛作用,其用药时机与其镇痛效果有关,如何使用该药才能充分发挥它的优势还需要进一步的临床探讨。

研究观察不同时点应用帕瑞昔布钠对于全身麻醉下乳腺癌改良根治术患者术后镇痛的临床效果及其对机体应激反应的影响、不良反应等,从而探求一种更加合理、安全、有效的解决乳腺癌改良根治术术后疼痛的方法。

研究方法选择ASAⅠ—Ⅱ级、年龄25—70岁择期行乳腺癌改良根治术患者90例,所有入选病例均采用静吸复合全麻。

以咪唑安定、芬太尼、丙泊酚、顺式阿曲库铵静脉诱导行气管内插管,术中以丙泊酚、瑞芬太尼、顺式阿曲库铵持续输注,七氟烷吸入维持麻醉,术中切皮开始给予芬太尼静注入选病例随机分为三组：A组(术前给药组)、B组(术后给药组)、N组(对照组)。

A组于手术开始前30min静脉注射帕瑞昔布钠(特耐)40mg,于术中乳房组织切除、腋窝淋巴结清扫完成后静注生理盐水5ml；B组于手术开始前30min静注生理盐水5ml,术中乳房组织切除及腋窝淋巴结清扫完成后静注帕瑞昔布钠40mg；N组于术前30min及术中乳房组织切除、腋窝淋巴结清扫完成后分别静注生理盐水5ml。

所有病人于缝皮时给予托烷司琼5mg静脉注射预防恶心、呕吐。

术后拔除气管导管,送返乳腺外科病房,根据病人疼痛主诉,追加哌替啶75mg肌注。

观察记录三组术后30min (T2)、2h (T3)、4h (T4)、8h (T5)、12h (T6) 16h (T7)、24h (T8)、36h (T9)、48h (T10)的疼痛评分(VAS)、镇静评分(Ramsay);术前(T0)、术后拔管时(T1)、术后30min(T2)、2h(T3)、4h(T4)的心率(HR)、平均动脉压(MAP)；48h内哌替啶的使用情况,同时观察术后有无呼吸、循环抑制及恶心、呕吐、出血、外周水肿等不良反应,记录病人满意度评分。

采用SPSS17.0统计软件分析,计量资料以均数±标准差(x±s)表示,组间比较采用单因素方差分析,两两比较采用Dunnett’t双侧检验,组内各时点比较采用重复测量方差分析,计数资料采用卡方检验,P0.05)2、静息状态下VAS评分：T2(术后30min)时,B组、N组均高于A组,差异有统计学意义(P0.05)；T3(术后2h)、T4(术后4h)时,N 组高于A、B两组,差异有显著性(P0.05)。

满意度：A组(98.10±1.32)、B组(95.85±2.23),均高于N组(89.27±2.3)(P0.05)。

三组均未观察到头晕、头痛、静脉疼痛、皮肤瘙痒等不良反应。

结论1、帕瑞昔布钠40mg静注对乳腺癌改良根治术患者的术后疼痛有较好的镇痛效果,能明显减轻手术创伤激活的过度应激反应,不增加不良反应的发生。

2、相对于手术结束前给药,手术开始前给予帕瑞昔布钠在术后镇痛效果上有明显的优势,且能减少术后镇痛药物的用量。

【英文摘要】Research BackgroundRadical mastectomy and modified radical mastectomy can cause moderate postoperative pain. So postoperative analgesic is required.Excellent postoperative analgesia can inhibit the stress responses caused by pain and help the patients cough, expectoration, and early postoperative ambulation, can reduce pulmonary complications and deep vein thrombosis. Pethidine, morphine, tramadol and fentanyl, etc. are commonly used in clinical for postoperative pain relief, although the effects are exact, apparent side effects such as nausea, vomiting, itching, etc., brought trouble to the patients and their families.Parecoxib sodium is a new inhibitor of cyclooxygenase 2 (COX-2). It has no anti-platelet effect and does not increase the risk of bleeding, it is used for trauma and surgery-related short-term acute pain treatment in clinic, and achieved very satisfactory results.It has preemptive analgesia-But we do not know how to use this drug and get the better pain relief. So we used Parecoxib sodium at different time to find a reasonable method of medication.Research PurposesTo observe the clinical effect of postoperative analgesic and its influence on stressresponses and adverse reactions of parecoxib sodium at different time points for modified radical mastectomy patients under general anesthesia, and evaluate safe and effective in postoperative pain relief of modified radicalmastectomy.Research MethodsNinety patients with ASA gradeⅠtoⅡ, aged from 25 to 70 yeas old and undergoing modified radical mastectomy were selected. All the patients were given intravenous combined inhalation anesthesia. Tracheal intubation was performed after inducing with midazolam, fentanyl, propofol, cis-atracurium intravenous injection., Anesthesia was maintained with continuous infusion of propofol, remifentanil, and sevoflurane inhalation.Patients were randomly divided into three groups:group A (preoperative treatment group), group B (postoperative treatment group),and group N (control group). For group A, intravenous injection of 40 mg parecoxib sodium was conducted 30 min preoperatively 5ml of saline was given intravenously after breast tissue was removed. For Group B, intravenous injection of 5ml of saline was conducted 30 min preoperatively,40mg of parecoxib sodium was given intravenously after breast tissue was excised.For group N, intravenous injection of 5ml of saline was conducted at 30 min preoperatively and after breast tissue was excisedrespectively.5mg of tropisetron was given intravenously for all patients during skin closure to prevent nausea and vomiting. After tracheal extubation, transfer the patients to breast surgery wards, additional intramuscular injection of 75mg of pethidine was conducted according to the patient self-reports of pain.We recorded the pain scores (VAS) and sedation scores (Ramsay) at the different time after extubation:30min (T2),2h (T3),4h (T4),8h (T5),12h (T6),16h (T7),24h (T8),36h (T9) and 48h (T10).. Heart rates (HR) and MAP were recorded at 30min (T2),2h (T3),4h (T4) postoperatively. Pethidine dose used were recorded in 48h. Meanwhile, respiratory rate and circulatory depression and nausea, vomiting, bleeding, peripheral edema and other adverse reactions was conducted, patient’s satisfaction scores were recorded.Analysis was conducted with statistical software SPSS17.0, All data was showed as mean±standard deviation (x±s), single factor analysis of variance was applied for the comparison between groups, Dunnett’t 2-sided test was applied for pairwise comparisons, repeated measures analysis of variance was for comparisons of each time points within the group, chi-square test was for count data, P 0.05) among three groups in age, weight, operation time and intraoperative fentanyl dosage.2. Resting VAS score: At T2(30min postoperatively), the scores in group B and group N were higher than that in group A, the difference was statistically significant (P 0.05); at T3 (2h postoperatively) and T4 (4h postoperatively), the scores in group N is higher than that in group A and B, the difference was significant (P 0.05). Degree of satisfaction:group A (98.10±1.32), group B (95.85±2.23), both higher than the group N (89.27±2.3) (P 0.05). Dizziness, headache, intravenous pain, pruritus and other adverse reactions were not observed in the three groups.Conclusions 1. Intravenous injection of 40mg of parecoxib sodium have better postoperative pain analgesia in modified radical mastectomy for breast cancer patients, can significantly reduce the excessive stress responses activated by surgical trauma, without increasing side effect.2. Compared with the treatment before the end of surgery, parecoxib sodium given preoperatively has obvious advantages in pain relief, and can reduce postoperative opioid dosage.【关键词】帕瑞昔布钠乳腺癌改良根治术超前镇痛【英文关键词】parecoxib sodium modified radical mastectomy preemptive analgesia【目录】帕瑞昔布钠在不同时点应用对乳腺癌术后镇痛效果及不良反应对比中文摘要6-9Abstract9-12符号说明13-14前言14-19材料方法19-23结果23-27讨论27-32结论32-33参考文献33-36综述36-44参考文献41-44致谢44-45学位论文评阅及答辩情况表45。