小剂量氯胺酮静脉自控镇痛对严重烧伤休克期患者细胞因子平衡的影响

目的 探讨严重烧伤休克期患者静脉注射小剂量氯胺酮或联合芬太尼静脉自控镇痛（PCIA）对细胞因子平衡的影响。方法 45例严重烧伤患者于伤后24h内入院，随机分为传统镇痛（CAT）、静脉注射氯胺酮自控镇痛（PCIKA）和静脉注射芬太尼加氯胺酮自控镇痛（PCIKFA）3组，每组15例。在积极抗休克的同时，CAT组患者根据需要肌肉注射哌替啶50mg和异丙嗪25mg，PCIKA组给予氯胺酮20g／L＋氟哌利多50mg／L，PCIKFA组给予氯胺酮10g／L＋芬太尼5mg／L＋氟哌利多50mg／L，PCIA负荷量均为1ml，PCIA用量为1ml，锁定时间30min，持续输入量1．5ml／h。检测镇痛前和镇痛后1、8、24和48h血清中白细胞介素-1（IL-1）、IL-6、肿瘤坏北因子-α（TNF-α）的浓度。结果 PCIKA、PCIKFA两组患者镇痛效果明显优于CAT组（P均〈0．01）。镇痛评分较镇痛前及CAT组明显降低（P均〈0．01）各组患者无恶心、呕吐、幻觉及呼吸抑制等不良反应。两组PCIA患者镇痛开始后IL-1、TNF-α与镇痛前比较无明显变化（P均〉0．05），而TL-6镇痛开始后24h与镇痛前比较明显降低（P〈0．01），两组PCIA患者IL-1、IL-6及TNF-α均明显低于CAT组（P均〈0．01）。结论 严重烧伤休克期患者静脉注射小剂量氯胺酮或联合芬太尼进行自控镇痛安全、有效，并有助于维持此类患者休克期细胞因子的平衡状态。

Effect of intravenous patient-controlled intravenous analgesia with small dose of ketamine during shock stage on cytokine balance in patients with severe burn

OBJECTIVE: To investigate the influences of patient-controlled intravenous analgesia (PCIA) with small dose of ketamine solely or combined with fentanyl during shock stage on cytokine balance in patients with severe burn. METHODS: Forty-five patients with severe burn and hospitalized within 24 hours after injury were randomly divided into three groups (n=15 in each group): conventional analgesia therapy group (group CAT), patient controlled intravenous ketamine analgesia group (group PCIKA, intravenous small dose ketamine), and patient controlled intravenous ketamine and fentanyl analgesia group (group PCIKFA, intravenous small dose ketamine combined with fentanyl). In group CAT, patients received intramuscular injection of dolantin 50 mg and phenergan 25 mg when patients complained of pain. In group PCIKA, patients received intravenous infusion with a mixture of ketamine 20 g/L + droperidol 50 mg/L, and in group PCIKFA with a mixture of ketamine 10 g/L + fentanyl 5 mg/L + droperidol 50 mg/L. In two groups of PCIA, patients received loading dose of 1 ml, with background infusion of 1.5 ml/h. Pain scores and side effects of analgesics were determined or observed at the time points of before analgesia and 1, 8, 24, 48 hours after analgesia, and serum cytokines including interlukin-1 (IL-1), IL-6, tumor necrosis factor-alpha (TNF-alpha)] were measured at the same time points. RESULTS: Pain scores in PCIFA and PCIKFA groups were significantly lower than that of before analgesia and group CAT (all P<0.01). There were no significant differences in heart rate (HR) and mean artery pressure (MAP) in three groups. No significant difference in side effects was found in three groups. The serum levels of cytokines were significantly lower in two PCIA groups than those of group CAT (all P<0.01). CONCLUSION: Patient-controlled intravenous analgesia with small doses of ketamine or combined with fentanyl during shock stage in patients with severe burn give efficient and safe pain relief, and cytokine balance.