Effects Of PCIA And PCEA On Gastrointestinal Function Restoration In Patients After Lower Limb Orthopedic Operating

Abstract:Objective:Postoperative pain is one of the greatest concerns of patients who receive surgery. Improved postoperative analgesia can reduce the patient's pain and fear, promote their physical function recovery, effectively prevent occurrence of chronic pain and complications after surgery, thus help reducing medical costs. Many surgeons reported that postoperative analgesia greatly hampers the recovery of gastrointestinal function, such as abdominal distension, nausea and vomiting. Currently, it is still controversial whether postoperative analgesia will affect postoperative gastrointestinal function. Two commonly used methods for postoperative analgesia:PCIA and PCEA, and their effects on the gastrointestinal function of patients who receive lower limb orthopedic surgery will be compared, the mechanism of their effects will be explored with prospective study. Methods:This project conducts clinical research with randomly selected samples and corresponding controls.80 patients who received elective lower limb orthopedic surgery under general anesthesia were selected on a random base, from patient groups that meet the following criteria:ASA gradeⅠ～Ⅱ,18 to 45 years old, body weight within the standard body weight±10%, developed normally, heart, lung, liver, kidney and other organs function was normally and no gastrointestinal disease, no neurology and psychiatry, no endocrine disease, no long-term sedation and analgesia drug use history, no history of heavy drinking, Hb>80g/L, and normal blood clotting function. Only cases meet the above conditions were observation. Cases were excluded if they have received other anesthesia and epidural puncture not to be done due to various reasons in observation time. Cases were excluded also if they were injected analgetika after surgery or epidural catheter was lost. The 80 cases of patients were divided into four groups,20 cases per group. Group I received patient-controlled intravenous analgesia (PCIA) after surgery, and further divided into two sub-groups:GroupⅠ1(tramadol hydrochloride+fentanyl citrate); GroupⅠ2 (tramadol hydrochloride+fentanyl citrate+granisetron hydrochloride). Group E received epidural analgesia (PCEA) after surgery. Group C is blank control group which did not receive any analgesics. It have been observed and recorded that general situation of patients, the analgesic effect, sleep state, the recovery of gastrointestinal function (first exhaust time, the incidence of nausea and vomiting, bowel movement recovery time) and other projects, in the period of postoperative analgesia. The implementation of Anesthesia and Analgesia:All patients were injected with 100mg sodium phenobarbital and 0.5mg atropine in 30min before surgery. Eating were prohibited 10 hours, drinking were prohibited 8 hours before entering the operating room. Compound lactate Ringer's solution was injected into the patient body in with 20～30ml·Kg-1·h-1 after entering the operating room. Patients were monitored for ECG, noninvasive blood pressure, pulse oxygen saturation and respiratory rate with Dash-4000 Monitor. Epidural analgesia group of patients, have been used the lateral decubitus position on the left and select the appropriate spinal space to puncture, after the success of the puncture and placed catheter in 3.5cm in the direction of the head. Firstly, the patient were injected with 2% lidocaine hydrochloride 3ml. Observed in 5 minutes:starting general anesthesia if there is no phenomenon of spinal anesthesia and no local anesthetic poisoning early response and after appearing spinal anesthetic block height. Then induction of anesthesia:midazolam 0.04mg/kg, fentanyl 2μg/kg, propofol 2mg/kg, atracurium 0.5mg/kg followed by intravenous injection of rapid induction. And do tracheal intubation to controll breathing with OHMEDA-7100 type anesthesia machine. Maintenance of anesthesia:continuous infusion of propofol 50-150μg·kg-1·min-1, remifentanil 0.05-0.2μg·kg-1·min-1, atracurium 6μg·kg-1·min-1 to maintain anesthesia, and adjust the dose according to blood pressure and heart rate. About another two groups of general anesthesia according to the above steps. Surgery was done after the completion of the intubation. During the anesthesia we give them atropine 0.3mg if patients' HR<55/minute, we give them ephedrine as 0.2mg/kg if patients' SBP<90mmHg or decreasing exceed 20% of baseline. Lactate Ringer's solution and 6% hydroxyethyl starch was injected into the patient body with 10～15ml·Kg-1·h-1 speed (the ratio of Colloid liquid to crystal liquid is 2:1) to maintain an adequate and effective blood volume. Analgesia:analgesic liquids of groupⅠwas prepared as follows:GroupⅠ1: tramadol hydrochloride 20mg/kg+fentanyl citrate 10μg/kg, GroupⅠ2:tramadol hydrochloride 20mg/kg+fentanyl citrate 10μg/kg+Granisetron Hydrochloride 6mg, it was diluted to 150ml with saline and done patient-controlled intravenous analgesia (PCIA), background dose:2ml/h, lockout time:15min, bolus:0.5ml/times. Loading dose of tramadol 1.0mg/kg+granisetron hydrochloride 3mg was intravenously 30min before the end of surgery. Analgesic liquids of group E was prepared as follows:0.125% ropivacaine+ fentanyl citrate Concentration of 1μg/ml, it was diluted to the 150ml with saline and done patient-controlled epidural analgesia (PCEA), continuous dose:2ml/ h, lockout time:15min, a single dose:0.5ml/times. Loading dose of 0.125% ropivacaine 4ml was intravenously 30min before the end of surgery. Group C was the control group, do not give analgesia. Results:The visual analogue scale (VAS) of four groups of patients:at the first and second days after surgery, The VAS of the analgesia group was significantly lower than the control group. The difference is statistically significant, analgesic effect of group E is significantly better than groupⅠ1 and groupⅠ2, The VAS were significantly different (P<0.01). While the VAS between the GroupⅠ1 and GroupⅠ2 was no significant difference (P> 0.05). At the third day after surgery, the VAS between the GroupⅠ1 GroupⅠ2 and the control group was not significantly different (P> 0.05). The VAS between the group E and the control group or groupⅠ1, groupⅠ2 were significant different, analgesic effect of group E was superior those three groups(P<0.01), while the VAS between groupⅠ1 and groupⅠ2 was not significantly different(P>0.05). The rate of four groups patients'sleep state were compared with X2 segmentation method. Result of which was on the first days the rate of patients with good sleep at night of groupⅠ1 after surgery was significantly lower than the other three groups (P＜0.01). There was no significant difference among the remaining three groups (P>0.05). On the second and third day, patients slept better at night, there was no significant difference among four groups of patients (P＞0.05). Comparison of postoperative gastrointestinal function of four groups patients:the first exhaust time of group E was significantly earlier than that of other groups (P＜0.01). The first exhaust time of groupⅠ2 was longer than both groupⅠ1 and group C, with a significant difference (P＜0.01). The first exhaust time between groupⅠ1 and group C was not significantly different (P>0.05). The gastrointestinal motility recovery time of group E was significantly earlier than the others (P＜0.01). There was no significant difference among the remaining three groups (P>0.05). The nausea and vomiting rate of four groups were compared with X2 segmentation method, result of which was the nausea and vomiting rate of groupⅠ1 of the first and second days after surgery was significantly higher than the other three groups (P<0.01). There were no significant difference among the remaining three groups (P＞0.05). On the third day, there were not occurred with nausea and vomiting in each group patients. Conclusion:1. For lower limb orthopedic surgery patients, epidural analgesia was better than intravenous analgesia.2. Epidural analgesia can significantly enhance gastrointestinal functional recovery of patients after lower limb orthopedic operating.3.Granisetron could significantly reduce the incidence of postoperative nausea and vomiting (PONV), but to extend onset time of postoperative exhaust, there were likely to be a slow down peristalsis.4. Epidural analgesia and intravenous analgesia (granisetron) did not increase the incidence of postoperative nausea and vomiting (PONV) of patients after lower limb orthopedic operation.