Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy
Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy
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DOI：
10.1016/s0039-6060(96)80018-3
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发表时间：
1996-10-01
期刊：
影响因子：
3.8
通讯作者：
Harms, BA
中科院分区：
文献类型：
--
作者：
Scott, AM;Starling, JR;Harms, BA
背景硬膜外麻醉作为围手术期辅助手段，已被证明可提供上级疼痛控制，并可能通过交感神经阻滞机制，在腹部大手术后更快地解决肠梗阻。研究表明，硬膜外给药的脊椎水平影响这些参数。1989年至1995年间，179例患者（120例男性，59例女性;平均年龄36岁）因溃疡性结肠炎或家族性息肉病接受了恢复性直肠结肠切除术。根据麻醉类型对患者进行分组。THO组（n = 53）接受胸（T6-T10）假体。LUM组（n = 51）采用腰（L2 ~ L4）骶管镇痛，PCA组（n = 75）采用静脉自控镇痛。比较两组患者的并发症、围手术期危险因素、术后疼痛和肠梗阻缓解情况。硬膜外麻醉剂，单独或与局部麻醉剂联合使用，平均给药2（LUM）至4（THO）天，无明显并发症。与硬膜外导管相关的罕见问题包括自限性头痛或背痛（4例）和部位感染（2例）。通过因疼痛控制不充分而转换为PCA来测量硬膜外失败，LUM（25%）的硬膜外失败率也不显著高于THO（23%）。术后第1天至第5天，PCA患者（4.2分）的平均疼痛评分（每日视觉模拟评分）显著高于LUM（3.5分）（p < 0.05）和THO（2.4分）（p < 0.05）。通过大便排出量和肠鸣音恢复确定的肠梗阻消退，THO组明显快于LUM或PCA组（p < 0.05）。PCA和LUM的肠梗阻缓解率无显著差异（p > 0.5）。胸段硬膜外镇痛在缩短术后肠梗阻测量参数和减少手术疼痛方面比腰段硬膜外或传统的患者自控镇痛具有明显的优势。该手术是安全的，发病率低。胸段硬膜外麻醉在经济上也是合理的，并可能通过减少住院时间而对未来的术后管理产生重大影响。我们的数据和其他数据在这些方面对胸导管患者最为引人注目，表明椎体水平在硬膜外给药中的重要性。
Background. Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters.Methods. One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4 epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain and ileus resolution.Results. Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was nor significantly greater for LUM (25 %) than THO (23 %). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.5).Conclusions. Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.