【作者】 王佳；

【导师】 邱晓东；

【作者基本信息】 东南大学 ， 临床医学（麻醉学）， 2017， 硕士

【摘要】 目的:以阿片药物为基础的术后持续静脉自控镇痛是乙型肝炎病毒携带产妇剖腹产术后镇痛的主要方式。当前临床常用的阿片类镇痛药μ受体激动剂会带来免疫抑制作用,尤其对合并有乙型肝炎病毒携带的产妇可能带来不利的影响。羟考酮是μ和K双受体激活剂,镇痛效价与吗啡相当,其镇痛作用主要是通过兴奋K阿片受体发挥镇痛作用。我们比较羟考酮与吗啡用于肝功能在正常范围内的乙型肝炎病毒携带产妇的术后镇痛,观察其对产妇免疫功能的影响。方法:选择60例肝功能指标正常范围内的足月乙型肝炎病毒携带产妇,择期腰-硬联合麻醉下进行剖宫产术;随机分成两组:羟考酮组(O组,n=30)和吗啡组(M组,n =30),术后静脉自控镇痛的用药配方,O组为0.8mg/kg的羟考酮用生理盐水稀释到总量为100ml,M组为0.8mg/kg的吗啡用生理盐水稀释至总量为100ml。两组背景剂量均为2ml/h,追加剂量均为2ml/15min,均于关腹前开启电子镇痛泵。抽取实施镇痛后不同时间点(术后即刻、术后24、48、72小时)的外周血测定Th1、Th2细胞及Th1/Th2的值以及生化指标(TP、Alb、Glu、UN、Crea、ALT、AST、TB、LDH)的情况。记录实施镇痛后 1、2,6,12,24,48小时各不同时间点的产妇宫缩痛NRS评分以及24h内镇痛泵的总按压次数,产妇累积镇痛药用量。记录剖宫产后恶心、呕吐、头晕、头痛、嗜睡、瘙痒副反应的发生率。结果:两组产妇术前一般资料之间统计学无显著差异。两组产妇术后实施镇痛后宫缩痛NRS评分差异无统计学意义。羟考酮组产妇实施镇痛后24h内PCA自控总按压次数和镇痛药累计用量显著低于吗啡组。术后48h内,两组间恶心、呕吐等不良反应发生率比较无统计学差异。羟考酮组Th1在手术结束后的24h、48h比吗啡组高(P<0.05),Th2在手术结束后的24h、48h、72h比吗啡组高(P<0.05),Th1/Th2在手术结束48h、72h比吗啡组低(P<0.05);羟考酮组ALT在手术结束后24h比吗啡组低、手术结束后72h比吗啡组高(P<0.05),AST在手术结束后24h比吗啡组低、手术结束后72h比吗啡组高(P<0.05),TB在手术结束后24h、48h、72h比吗啡组高(P<0.05)。TP、Alb、Glu、UN、Crea两组之间无显著性差异,各时间点之间也无显著性差异。结论:1.吗啡和羟考酮对慢性乙型肝炎病毒携带产妇均具有良好的术后镇痛效果,羟考酮用量较吗啡减少,但不良反应的发生率无明显差异。2.羟考酮能提高慢性乙型肝炎病毒携带产妇外周血Th1和Th2免疫细胞的百分比,以及Th1/Th2的水平,而吗啡降低外周血Th1免疫细胞的百分比。3.羟考酮在慢性乙型肝炎病毒携带产妇术后镇痛中对肝功能的影响较吗啡大,但未造成肝功异常。更多还原

【Abstract】 Objective:The continuous intravenous controlled analgesia based on opioid medicine is the main way of postoperative analgesia in hepatitis B virus carrying pregnant women.In the present,opioid analgesics used in clinic are mainly MOR agonists,however,μ receptor agonists will bring immune inhibition,especially for patients with chronic hepatitis B.Oxycodone is a semi-synthetic drug of opioid alkaloids,it is a μ and κ double receptor activator and the analgesic potency of oxycodone is equivalent to morphine,but it’s pharmacological analgesic effect is mainly through the κ opioid receptor while the effect on μ receptor is weaker.Therefore,We observed the immune function of hepatitis B virus carrying maternal to compare the effect of oxycodone and morphine for postoperative analgesia on immune function.Methods:60 hepatitis B virus carrying cesarean section maternal undergoing CS were randomly divided into two groups:oxycodone group(group O,n = 30)and morphine group(group M,n = 30).For postoperative intravenous analgesia,oxycodone 0.8mg/kg was given in group O and morphine 0.8mg/kg was given in group M,which were all diluted with saline to a total of 100ml.The analgesic pump were opened before abdomen closure with the background dose of 2ml/h and the additional dose of 2ml/15min.The changes of immune cells(Thl,Th2 and Thl/Th2)and blood biochemical indexes(P,Alb,Glu,UN,Crea,ALT,AST,TB,LDH)were recorded after the analgesia(immediate,24h,48h,72h).At lh,2h,6h,12h,24h,48 the contraction pain NRS score was recorded.Results:There was no significant difference in general information of pregnant patients between two groups.There was no significant difference in NRS score between the two groups after cesarean section analgesia.Total number of times of self-control and cumulative amount of oxycodone group was significantly lower than morphine group.There was no significant difference in incidence of adverse reactions such as nausea and vomiting among two groups.The Thl of group O was higher than that of group M at 24h,48h after operation,while Th2 was higher than group M at 24h,48h and 72h after operation;.ALT of group O was significantly lower than that in the morphine group at 24 h after the end of the surgery.The end of the surgery was shorter than that in the morphine group at 72 h.The TB group was higher than that in the morphine group at 24 h,48 h and 72 h after operation.TP,Alb,Glu,UN,Crea have no significant difference between the two groups.Conclusion:1.Both oxycodone and morphine have a good postoperative analgesic effect.The dosage of oxycodone is lower than morphine as the same analgesic effect.but the incidence of adverse reactions was not significantly different between the two groups.2.Oxycodone can increase Thl and Th2 immune cells and the percentage of Th1/Th2 in peripheral blood of hepatitis B virus carrying cesarean section maternal,while morphine reduces the percentage of Thl immune cells in peripheral blood.3.Oxycodone has greater impact on liver function in patients with chronic hepatitis B for postoperative analgesia and morphine has little effect.But all the liver function of hepatitis B virus carrying cesarean section maternal the two groups were in the normal range.更多还原