| Background: Ovarian cyst is a common benign tumor in women of childbearing age in China.Laparoscopic ovarian cystectomy has become a first-line treatment in recent years,but postoperative management especially postoperative pain management,is still an important clinical problem to improve the quality of surgical recovery.Early postoperative pain is one of the most common adverse reactions,and the degree of pain varies greatly among individuals.26%-41% of day surgery patients will be hospitalized again because of pain on the night of surgery,and up to 80% of patients may need opioid relief during hospitalization.Traditional opioids mostly exert their analgesic effect by activating ? opioid receptors,and their side effects are mainly produced by ? opioid receptors too.When used in large quantities alone,it may lead to adverse reactions such as respiratory depression,nausea,vomiting,excessive sedation,skin itching and urinary retention.The ? opioid receptor stimulation can also produce analgesic effect,but does not cause mental euphoria,gastrointestinal peristalsis inhibition and respiratory inhibition,and can relieve visceral pain by acting on smooth muscle through ? opioid receptor.Nalbuphine is a newly synthesized opioid receptor agonist-antagonist in China.It activates ? opioid receptors to exert analgesic and sedative effects,and its analgesic effect is similar to that of morphine.At the same time,it antagonizes ? receptors and produces fewer ? receptor-mediated adverse reactions.It has an advantage in intra-abdominal surgery.Dexmetomidine is a ? 2-adrenergic receptor agonist,which has sedation and anti-anxiety properties,can reduce sympathetic tension and has potential analgesic effect.It has also been reported that can be used for analgesia and sedation after gynecological surgery.With the development of ultrasound-guided technology,transversus abdominis plane(TAP)block has become one of the main schemes of multimodal analgesia,which provides an effective and reliable means for perioperative analgesia in abdominal surgery.Different analgesic schemes will bring different analgesic effects.How to choose an appropriate perioperative multimode analgesia regimen for patients with laparoscopic ovarian cystectomy is still worthy of study.At present,there are no reports on the application or dose of nalbuphine in postoperative treatment for patients undergoing laparoscopic ovarian cystectomy on the basis of TAP block.Considering that different doses of Naborphine have a great influence on the analgesic effect and the incidence of side effects,the appropriate dose is still a question worth exploring.In addition,as the main cause of infection and pain,the level of inflammatory factors reflects the changes of postoperative pain to a certain extent.However,inflammatory factors are rarely reported in gynecological surgery.In order to solve the blind spots of these clinical studies and provide more reference for perioperative analgesia,this study intends to conduct patient-controlled intravenous analgesia(patient-controlled intravenous analgesia,PCIA)with different doses of nalbuphine combined with dexmetomidine on the basis of preoperative TAP block through a prospective double-blind randomized controlled study to explore its effects in laparoscopic benign ovarian cystectomy.Methods: Methods: This study included 219 patients underwent laparoscopic benign ovarian cystectomy in our hospital from September 2019 to October 2019.Bilateral TAP nerve block guided by ultrasound was performed before induction of general anesthesia.0.3% ropivacaine 30 ml was injected into each side.General anesthesia was induced with midazolam 0.04-0.1mg/kg,sufentanil 0.3 ?g / kg,etomidate 0.15-0.3mg/kg and cis-atracurium 0.1?0.2mg/kg.Propofol 4-10mg/kg/h and remifentanil 5-10 ?g / kg/h were injected intravenously,and sevoflurane was inhaled as needed to maintain BIS between 40 and 60.Stopped sevoflurane 30 min before the end of the operation and stopped propofol and remifentanil at the end of the operation,then connected the preequipped analgesia pump to the peripheral vein.When the patient is naturally awake and the spontaneous breathing is satisfied,removed the endotracheal tube and sent the patient to the anaesthesia recovery room.According to different postoperative PCIA strategies,patients were randomly divided into four groups: low(0.5mg/kg),medium(1.0mg/kg)and high(1.5mg/kg)dose of nalbuphine combined with dexmetomidine(4 ?g / kg)group(LND group,MND group,HND group).The control group was given sufentanil 2.5 ?g / kg.The total volume of PCIA was 100 ml,and metoclopramide 20 mg was added to prevent nausea and vomiting.The parameters were background infusion dose 2ml/h,patient-controlled analgesia dose 2ml/ times and locking time 15 min.If the patient's VAS pain score is more than 4,it is recommended to press the analgesic pump first.If there is no significant pain relief after 5 minutes,tramadol can be injected intravenously to relieve analgesia.The observation indexes included the VAS score of resting and active(cough or deep breathing)at 2,8,12,24,48 hours after operation;the Ramsay score at 2,8,24,48 hours after operation;the effective pressing times of PCIA within 48 hours;the dose and times of supplemental analgesia;the serum levels of interleukin-1 ?(IL-1 ?)and interleukin-6(IL-6)before and 1 day after operation.Postoperative hospital stay,nausea,vomiting,respiratory depression,skin itching,drowsiness and other adverse reactions occurred were also be recorded.Results: There was no significant difference in basic information of patients,including age,body mass index(BMI),pathological type,cyst diameter,intraoperative sufentanil dosage,operation time and blood loss among the four groups.In the resting state,the VAS scores at 2 hours after operation were lowest in the HND group,and there was no significant difference between the LND group and the MND group,but they were significantly lower than those in the control group(P < 0.001).The VAS scores at 8hours after operation were lowest in HND group,the second in MND group,higher in LND group than in HND group and MND group,and the highest in control group(P <0.001).The VAS scores at 12 hours after operation were lowest in the HND group,and there was no significant difference between the LND group and the MND group,but both were significantly lower than those in the control group(P < 0.001).The VAS scores at 24 hours after operation were lowest in HND group,followed by MND group,higher in LND group than in HND group and MND group,and the highest in control group(P < 0.001).At 48 hours after operation,the VAS scores decreased significantly among the four groups,but there was no significant difference between groups(P =0.849).When coughing or breathing deeply,the VAS scores were higher than that at rest.The VAS scores at 2 hours after operation were lowest in HND group,the second in MND group,higher in LND group than in HND group and MND group,and the highest in control group(P < 0.001).At 8 h,12 h and 24 h after operation,the trend of VAS scores between groups was the same as that at 2 h after operation.The VAS scores of all groups decreased significantly at 48 hours after operation,and there was no significant difference between groups(P = 0.799).The number of effective PCIA pression within 48 hours after operation was the lowest in the HND group,there was no significant difference between the LND group and the MND group,and the control group was the highest(P < 0.001).None of the patients in the four groups asked for additional analgesia.The Ramsay sedation scores at 2 hours after operation were highest in the HND group,followed by the MND group,and there was no significant difference between the LND group and the control group(P < 0.001).The Ramsay sedation scores at 8h and 24 h after operation were highest in the HND group,and no significant difference among the other three groups(P < 0.001).The Ramsay sedation scores at 48 hours after operation were highest in the HND group too,followed by the MND group,and lower in the LND group and the control group(P < 0.001).In terms of inflammatory indexes,the levels of IL-1 ? and IL-6 in the four groups had no difference before operation,but increased significantly after operation and decreased with the increase of the dose of nalbuorphine,which was the lowest in the HND group,no difference between the LND group and the MND group,and the highest in the control group(P < 0.001).The postoperative hospital stay was the shortest in the HND group,no difference between the LND group and the MND group,and the longest in the control group(P < 0.05).There was no significant difference in the incidence of postoperative adverse reactions among the groups(P = 0.650).Conclusion: For patients undergoing laparoscopic ovarian cystectomy,the multimode analgesia regimen of ultrasound-guided bilateral TAP nerve block(0.3% ropivacaine bilateral 30ml)combined with postoperative nalbuphine(1.5mg/kg)and dexmetomidine(4 ?g / kg)PCIA can significantly reduce postoperative pain level and inflammation index,which is beneficial to the early rehabilitation of patients. |
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