自控式止痛藥物在老年人的使用經驗──醫學中心之回溯性研究

Patient Controlled Analgesia (PCA) in the elderly - A retrospective study in the medical center

背景及目的：目前＂病患自控式止痛＂將其使用在老人族群時，仍需考慮到它的併發症與效果。 在老年人中，止痛藥給予的途徑，手術本身對止痛需求的影響，以及性別的不同對止痛 劑給予的影響，仍是需要被澄清的重要課題。研究設計：利用回朔性的方式將7176位手術後使用病患自控式止痛機器的病人納入研究範圍， 並依據他們的年齡將病患分成族群A（小於60歲）與族群B（大於60歲）。針對術後的病患在病床上使用自控式止痛相關併發症（暈眩、噁心嘔吐、皮膚癢、尿滯留、運動或感覺恢復不良以及呼吸抑制等）以及在床上休息、活動或咳喇時的疼痛指數，收集至少手術後前三天的資訊。性別手術部位以及止痛藥給予途徑是預測止痛需求與止痛效果的重要獨立性變數。統計結果：在此兩族群（族群A vs.族群B）中的併發症發生率都是可以接受的範圍（呼吸抑制：0.0% vs. 0.2%，p=0.134，暈眩： 23.6% vs. 19.7，p=0.022，噁心： 13.0% vs. 11.4%，p=0.231，嘔吐： 10.5% vs. 16.6%，p=0.000，皮膚癢： 1.8% vs. 1.9%，p=0.935，尿滯留：0.8% vs. 0.2%，p=0.034，不當的運動神經阻斷：0.8% vs. 1.3%，p=0.194，不當的感覺神經阻斷：0.4% vs. 1.0%，p=0.082），而止痛效果則兩組沒有明顯差異（第一天VAS，在病床上休息：22.7±15.0 vs. 21.7±12.5，p=0.146，活動時：51.5±17.4 vs. 52.6±15.5，p=0.177，咳嗽時：62.3±19.2 vs. 60.1±18.5，p=.128）。止痛藥的需求在年輕族群明顯比老年族群止痛藥需求高。若根據手術部位，上腹部手術所需止痛藥劑量最多（morphine：2.0±1.1 mg/kg），其次是胸腔手術（morphine：1.4±1. 1），下腹部手術（morphine：1.3±1. 2），下肢手術（morphine：1. 1±1. 2），其他部位（morphine：0.4±0.6），背部手術（morphine：0.3±0.2）以及上肢手術（morphine：0.2±0.1）。從硬脊膜給予止痛藥物比靜脈給予止痛藥物的止痛效果好（術後第一天的VAS：病床上休息時：22.3±14.0 vs. 13.0±15.0，p=0.000，活動時： 51.9±16.7 vs. 35.3±19.9，p=0.000，咳喇時：61.7±19.0 vs. 45.2.1±21.6，p=0.000）。性別差異部分（術後第一天VAS：病床休息時：17.4±13.6 vs. 19.2±13.9，p=0.043，活動時：45.2±19.2 vs. 47.9±18.6 p=0.030）.研究結論：病患自控式止痛對老年人傷口疼痛是安全有效的止痛方式，而在這些病患使用病患自控式止痛機器時，應該根據手術的部位、藥物給予的途徑、年齡和性別等條件來設定使用止痛藥物的給予。

Although Patient-Controlled Analgesia (PCA) was a popular device for postoperative pain management, concerns about the potential complications and effectiveness of PCA utilities still exist in the old-age population. In the elderly, the analgesics delivery routes, surgical influences on the requirement of analgesics, and gender disparities in pain management are still important issues to clarify. Methods: 7176 patients receiving surgical treatment and PCA for postoperative pain were enrolled in this retrospective study. The patients were grouped according to their ages (<60 years old for group A, others for group B). The postoperative complications related to PCA (vertigo, nausea, vomiting, skin itching, urine retention, improper motor or sensory blockage, and respiratory depression) and pain scores (visual analog scale VAS) in bed resting, moving and coughing were registered for at least three days postoperatively. Gender, surgical sites, and analgesics delivery route were also regarded as independent variables to predict analgesic requirement and effectiveness of pain relief. Results : The complication rates in both groups were acceptable (respiratory depression: 0.0% vs. 0.2%, p=0.134, vertigo: 23.6% vs. 19.7, p=0.022, nausea; 13.0% vs. 11.4%, p=0.231, vomiting: 10.5% vs. 16.6%, p=0.000, skin-itching: 1.8% vs. 1.9%, p=0.935, urine retention: 0.8% vs. 0.2%, p=0.034, improper sensory block: 0.8% vs. 1.3%, p=0.194, improper sensory block: 0.4% vs. 1.0%, p=0.082), and the pain relief effectiveness of PCA makes no significant difference in both groups (VAS in 1st day, bed resting: 22.7±15.0 vs. 21.7±12.5, p=0.146, moving: 51.5±17.4 vs. 52.6±15.5, p=0.177, coughing 62.3±19.2 vs. 60.1±18.5, p=.128). The analgesic requirements were significant higher in the young than in the elderly (morphine in mg/kg, 0.35±0.22 vs. 0.31±0.22, p=0.000). The surgeries involved upper abdomen demanded most analgesic, followed by surgeries on chest(1.4±1.1), lower abdomen (1.3±1.2), lower extremities (1.1±1.2), others (0.4±0.6), back (0.3±0.2) and upper extremities (0.2±0.1). The analgesics delivered through an epidural catheter produced far more effectiveness of pain relief than through an intravenous route (VAS in 1st postoperative day: bed resting: 22.3±14.0 vs. 13.0±15.0 p-=0.000, moving: 51.9±16.7 vs. 35.3±19.9, p=0.000, coughing: 61.7±19.0 vs. 45.2.1±21.6, p=0.000). The gender disparities of pain perception in the elderly were also noted in this study (VAS in 1st postoperative day: bed resting: 17.4±13.6 vs. 19.2±13.9 p=0.043, moving: 45.2±19.2 vs. 47.9±18.6 p=0.030). Conclusions: PCA was a safe and effective maneuver for wound pain in the elderly. The PCA setting in these patients should consider the surgical sites, drugs delivery routes, age and gender.