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目的:考察老年人髋关节手术术后盐酸氢吗啡酮单用或联用右美托咪定两种方式镇痛的合理剂量探讨。方法:第一部分选择2016年1月至2016年4月在我院行择期人工髋关节置换手术的老年患者120例,随机分为6个组别:盐酸氢吗啡酮(HYD)0.020mg/ml组、盐酸氢吗啡酮0.035mg/ml组、盐酸氢吗啡酮0.050mg/ml组、盐酸氢吗啡酮0.065mg/ml组、盐酸氢吗啡酮0.080mg/ml组和盐酸氢吗啡酮0.095mg/ml组。检测不同时间的血液黏度、血清白细胞介素-1b(Interleukin-1b,IL-1b)、白细胞介素-6(Interleukin-6,IL-6)和肿瘤坏死因子-α(Tumor Necrosis Factor-alpha,TNF-α)、收缩压(Systolic Blood Pressure,SBP)、舒张压(Diastolic Blood Pressure,DBP)、心率(Heart Rate,HR)、镇痛VAS评分和镇静RSS评分、术后认知功能障碍(Postoperative Cognitive Dysfunction,POCD)、不良反应和患者镇痛满意度。第二部分选择2016年5月至2016年9月在我院行择期人工髋关节置换手术的老年患者120例,随机分为6个组别:盐酸氢吗啡酮0.020mg/ml+右美托咪定(DEX)0.50μg/kg/d、盐酸氢吗啡酮0.035mg/ml+右美托咪定(DEX)0.50μg/kg/d、盐酸氢吗啡酮0.05mg/ml+右美托咪定(DEX0.50μg/kg/d)、盐酸氢吗啡酮0.065mg/ml+右美托咪定(DEX)0.50μg/kg/d、盐酸氢吗啡酮0.080mg/ml+右美托咪定(DEX)0.50μg/kg/d和盐酸氢吗啡酮0.095mg/ml+右美托咪定(DEX)0.50μg/kg/d。检测指标同第一部分。结果:第一部分6个组别术前的血液黏度无显著差异,术后1d和3d较术前均有不同程度地升高(P<0.05),随着HYD浓度增加,术后1d和3d的血液黏度有不同程度地降低,0.020mg/ml~0.050mg/ml组的血液黏度相当(P>0.05),0.065mg/ml~0.095mg/ml组的血液黏度相当(P>0.05),与0.020mg/ml~0.050mg/ml组相比,0.065mg/ml~0.095mg/ml组的黏度较低(P<0.05)。6个组别术前的炎症因子无显著差异(P>0.05),术后1d和3d较术前均有不同程度地升高(P<0.05),随着HYD浓度增加,术后1d和3d的炎症因子有不同程度地降低(P<0.05),0.020mg/ml~0.050mg/ml组的炎症因子相当(P>0.05),0.065mg/ml~0.095mg/ml组的炎症因子相当(P>0.05),与0.020mg/ml~0.050mg/ml组相比,0.065mg/ml~0.095mg/ml组的炎症因子较低(P<0.05)。6个组别术后不同时间的SBP和DBP无显著差异(P>0.05),与0.020mg/ml组~0.035mg/ml组的HR相当(P>0.05),0.050mg/ml~0.095mg/ml组的HR相当(P>0.05),与0.020mg/ml~0.035mg/ml组比,0.050mg/ml~0.095mg/ml组的HR较低(P<0.05)。随着时间的延长,6个组别的VAS均有不同程度降低,随着HYD浓度增加,术后不同时间的VAS均有不同程度地降低(P<0.05),0.020mg/ml~0.035mg/ml组的VAS相当(P>0.05),0.050mg/ml~0.095mg/ml组的VAS相当(P>0.05),与0.020mg/ml~0.035mg/ml组相比,0.050mg/ml~0.095mg/ml组的VAS较低(P<0.05)。单次给予盐酸氢吗啡酮镇痛的ED50为0.0381mg/ml,ED95为0.0530 mg/ml。随着时间的延长,0.020mg/ml~0.035mg/ml组的Ramsay有不同程度升高(P<0.05),0.065mg/ml~0.095mg/ml组有不同程度降低(P<0.05),至36h除了0.020mg/ml组个别患者评分较低,其余组别均恢复正常状态,0.050mg/ml组无显著变化(P>0.05)。与术前比,6个组别的POCD均有不同程度地降低(P<0.05),与0.020mg/ml组比,0.035mg/ml组~0.095mg/ml组的POCD均有不同程度地降低(P<0.05),0.035mg/ml-0.050mg/ml组的POCD均处于正常水平。0.020mg/ml~0.035mg/ml组的恶性呕吐发生例数较多,0.065mg/ml~0.095mg/ml组的嗜睡、恶心呕吐、皮肤瘙痒和呼吸抑制发生例数较多,0.050mg/ml组的不良反应例数最低(P<0.05)。0.020mg/ml~0.035mg/ml组术后镇痛满意度评分最低(P<0.05),0.050mg/ml~0.095mg/ml组的满意度评分较高(P<0.05),且组间比较无统计学差异(P>0.05)。第二部分6个组别术前的血液黏度无显著差异,术后1d和3d较术前均有不同程度地升高(P<0.05),随着HYD浓度增加,术后1d和3d的血液黏度有不同程度地降低(P<0.05),与0.020mg/ml+DEX组比,0.035mg/ml+DEX~0.095mg/ml+DEX组的血液黏度明显降低(P<0.05),组间有降低趋势,但无统计意义(P>0.05)。6个组别术前的炎症因子无显著差异,术后1d均有不同程度地升高(P<0.05),术后3d有不同程度地降低,随着HYD浓度增加,术后1d有不同程度地降低(P<0.05),与0.020mg/ml+DEX组比,0.035mg/ml+DEX~0.095mg/ml+DEX组的炎症因子明显降低(P<0.05),术后3d,0.035mg/ml+DEX~0.095mg/ml+DEX组的炎症因子降至术前水平。6个组别术后不同时间的SBP和DBP无显著差异(P>0.05),与0.020mg/ml+DEX组比,0.035mg/ml+DEX-0.095mg/ml+DEX组的HR降低明显(P<0.05),但组间无显著差异(P>0.05)。随着时间的延长,6个组别的VAS均有不同程度降低,随着HYD浓度增加,术后不同时间的VAS均有不同程度地降低(P<0.05),与0.020mg/ml+DEX组比,0.035mg/ml+DEX~0.095mg/ml+DEX组的VAS明显降低,组间无显著差异(P>0.05)。未检出ED50 ED95为0.038 mg/ml。随着时间的延长,0.020mg/ml+DEX~0.095mg/ml+DEX组的Ramsay有不同程度升高,与0.020mg/ml+DEX组比,0.035mg/ml+DEX~0.095mg/ml+DEX组的Ramsay均明显升高,所有组别9h均降至正常状态。与术前比,6个组别的POCD均有不同程度地降低(P<0.05),与0.020mg/ml+DEX组比,0.035mg/ml+DEX组~0.095mg/ml+DEX组的POCD均有不同程度地降低(P<0.05),0.035mg/ml-0.065mg/ml组的POCD均处于正常水平。0.020mg/ml+DEX组的恶性呕吐发生例数较多,0.050mg/ml+DEX~0.095mg/ml+DEX组的嗜睡、恶心呕吐和皮肤瘙痒例数较多,0.035mg/ml组的不良反应例数最低。0.020mg/ml+DEX组术后镇痛满意度评分最低(P<0.05);0.035mg/ml~0.095mg/ml组的满意度评分较高(P<0.05),组间比较无统计学差异(P>0.05)。结论:老年人髋关节手术术后盐酸氢吗啡酮单用的合理剂量为0.050mg/ml,给药体积100ml,镇痛的ED50为0.0381mg/ml,ED95为0.0530 mg/ml。采用0.50μg/kg/d右美托咪定联用盐酸氢吗啡酮,盐酸氢吗啡酮的合理剂量为0.035 mg/ml,给药体积100ml。老年人髋关节手术术后盐酸氢吗啡酮联用右美托咪定可明显降低盐酸氢吗啡酮的用量。