| BackgroundPain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Because of the complexity and diversity of pain, the classification method is different. It can be divided into acute and chronic pain according to the difference of occurrence time and transmission characteristics. Postoperative pain is one of the most common form of acute pain in clinic. As the model estimates, about 60% of patients were not treated with timely and effectively,10 to 50% of patients with acute postoperative pain may be converted into persistent pain among the 300 million surgeries per year. Postoperative acute pain can trigger a series of adverse effects:to increase cardiovascular system complication by activating the catecholamine and other endogenous neurotransmitter. to increase the early incidence of hypoxia and carbon dioxide accumulation by limiting the recovery of pulmonary function, to lead to high blood glucose and negative nitrogen balance by breaking the metabolic balance of patients, delay the recovery of patients with early recovery by inhibiting the recovery of gastrointestinal function, to make the body in a high state of coagulation and easy to lead to cardiovascular adverse events by destroying the blood coagulation system balance.Pain following thoracoabdominal surgery can occur in> 70% of patients and is considered to be one of the most severe types of postoperative pain. As the influencing factors are complex, the mechanisms haven’t been fully understood so far. It will increase the probability of developing chronic pain, affect the long-term postoperative quality of life and even reduce the survival time of patients if poorly controlled. Therefore, it is of great significance to study the ideal analgesic methods for patients undergoing thoracoabdominal surgery. The postoperative analgesia methods of these patients are widely used at present mainly including systemic approach (oral, intravenous, intramuscular injection, rectum, etc.) and local analgesia (wound infiltration, epidural analgesia, transversus abdominis plane block, intercostal nerve block, paravertebral block, etc.) and multimodal analgesia. Patient-controlled analgesia (PCA) is a new way to treat the postoperative pain proposed by sechzer during the early 1970s. The medical personnel set up the dose of analgesic drugs, then hand over to patients by "self management" of pain according to the individual differences so as to achieve the needs of patients with pain by the minimum effective blood concentration and the purpose of pain treatment for the individual.According to the different ways of administration of PCA, it can be divided into patient controlled epidural analgesia, patient controlled intravenous analgesia, patient controlled nerve analgesia and patient controlled subcutaneous analgesia, etc. The patient controlled intravenous analgesia, because of more convenient operation, easier management and less complications, is currently the most widely used both at home and abroad. Although dexmedetomidine combined with opioids have been widely used in perioperative analgesia for 24 h after surgery, no human studies are available on their combination for analgesia prolonged for 72 h after thoracoabdominal surgery.The first part of this prospective, randomized, double-blind, placebo-controlled study is to investigate the effect of combining dexmedetomidine and sufentanil on postoperative analgesia in patients undergoing hysterectomy. The second part of this prospective, randomized, double-blind, placebo-controlled study is to investigate the effect of combining dexmedetomidine and sufentanil on the quality of postoperative analgesia in highly-nicotine dependent patients after thoracic surgery. The aim of this study is to provide a new reference postoperative analgesia model for patients undergoing thoracoabdominal surgery.PART I Effect of combining dexmedetomidine and sufentanil on postoperative analgesia in patients undergoing hysterectomy: A CONSORT-Prospective, Randomized, Controlled TrialObjective:This CONSORT-prospective, randomized, double-blinded, controlled trial sought to evaluate the safety and efficacy of the combination of dexmedetomidine and sufentanil in intravenous (iv) patient-controlled analgesia (PCA) for 72 h after abdominal hysterectomy.Methods:Ninety women undergoing total abdominal hysterectomy were divided into three equal groups that received sufentanil (Group C; 0.02μg·kg-1h·h-1), sufentanil plus dexmedetomidine (Group D1; 0.02μg·kg-1h·h-1,each), or sufentanil (0.02μg·kg-1h·h-1) plus dexmedetomidine (0.05μg·kg-1h·h-1) (Group D2) for 72 h after surgery in this double-blind, randomized study. The primary outcome measure was the postoperative sufentanil consumption, while the secondary outcome measures were baseline characteristics, heart rate and mean blood pressure of patients during perioperative period, requirement of drugs during the operation, pain intensity (visual analogue scale, VAS), level of sedation (LOS), Bruggrmann comfort scale (BCS) and concerning adverse effects.Results:The postoperative sufentanil consumption was significantly lower in Groups D1 and D2 than in Group C during the observation period (P<.05), but lower in Group D2 than in the Group D1 at 24 h.48 h.72 h after surgery (P<.05). All the three groups were similar in terms of patient characteristics. The heart rate after intubation and incision were lower in Groups D1 and D2 than in Group C (P<.05). On arrival at the recovery room, Groups D1 and D2 had lower mean blood pressure than Group C (P<.05). The intraoperative requirement of sevoflurane was 30% lesser in Groups D1 and D2 than in Group C. The severity of pain, in terms of the VASr and VASm, was lower in Groups D1 and D2 than in Group C throughout the first three postoperative days (P<.05). Compared with Group D1, Group D2 had lower VASr during the first two hours of surgery (P<.05) and lower VASm during the first three postoperative days (P<.05). The sedation levels were greater in Groups D1 and D2 during the first hour (P<.05). Group D2 had higher BCS score than Group C until the third postoperative day (P<.05). whereas it had higher BCS scores than Group D1 only on the first day after surgery (P<.05). Further, the BCS score in Group D1 was higher than that in Group C on the first day after surgery (P<.05). Compared with Group C and D1, Group D2 showed lower levels of the overall incidence of nausea and vomiting (P<.05).Conclusions:Among the tested PCIA options, the addition of sufentanil (0.02μg-kg-1·h-1) and dexmedetomidine (0.05μg·kg-1·-h-1) showed better analgesic effect and greater patient satisfaction without other clinically relevant side effects for patients undergoing hysterectomy during the first 72 h after abdominal hysterectomy.PART II Effect of combining dexmedetomidine and sufentanil on the quality of postoperative analgesia in highly-nicotine dependent patients after thoracic surgery: A CONSORT-Prospective, Randomized, Controlled TrialObjective:This CONSORT-prospective, randomized, double-blinded, controlled trial investigated the efficacy of combination of dexmedetomidine and sufentanil in patient-controlled intravenous analgesia (PCIA) of highly-nicotine (Fagerstrom Test of Nicotine Dependence (FTND)≥6) dependent patients for 72 h after thoracic surgery.Methods:One hundred and thirty-two highly-nicotine dependent male patients who underwent thoracic surgery were divided into three groups after surgery in this double-blind, randomized study:sufentanil (Group S; 0.02μgkg-1·h-1), sufentanil plus dexmedetomidine (Group D1; 0.02μg·kg-1h·h-1 each), or sufentanil (0.02μg·kg-1·h-1) plus dexmedetomidine (0.04μg·kg-1h·h-1) (Group D2). The primary outcome measure was the cumulative amount of self-administered sufentanil, the secondary outcome measures were the clinical characteristics of patients, pain intensity (numerical rating scale, NRS), level of sedation (LOS), bruggrmann comfort scale (BCS). functional activity score (FAS) and concerning adverse effects.Results:The amount of self-administered sufentanil was lower in group D2 compared with groups S and D1 during the 72 h after surgery (P<.05). While the amount of self-administered sufentanil was significantly lower in group Dl than that of group S only at 4 h,8 h, and 16 h after surgery (P<.05). All the three groups were similar in terms of patient characteristics. Compared with group S, the NRS scores at rest at 1 h,4 h.8 h after surgery and with coughing at 4h,8 h,16 h, and 24 h after surgery were significantly lower in group D2 (P<.05). While compared with group D1, the NRS scores both at rest and with coughing at 4 h. 8 h after surgery were significantly lower in group D2 (P<.05). The NRS scores both at rest and with coughing showed that there was no significant difference between groups D1 and S at each time point after surgery (P>.05). LOS of group D2 was higher than groups S and D1 at 1 h after surgery (P<.05), BCS of group D2 was higher than groups S and D1 at 4 h,8 h,16 h after surgery (P<.05), and FAS of group D2 was higher than groups S and D1 at 48 h,72 h after surgery (P<.05). The number of rescue analgesia during 72 h after surgery in group D2 was lower than groups S and D1 (P<.05). Compared with Group S and D1, Group D2 showed lower levels of the overall incidence of itching (P<.05).Conclusions:Among the tested patient controlled intravenous analgesia (PCIA) options, the addition of sufentanil (0.02μg·kg-1h·h-1) and dexmedetomidine (0.04μg·kg-1h·h-1) showed better analgesic effect and greater patient satisfaction without other clinically relevant side effects for highly-nicotine dependent patients during the initial 72 h after thoracic surgery. |
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