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경막외 morphine, bupivacaine 및 고장성용액 혼주시 진통지속효과에 미치는 영향

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 Effect of epidural morphine and bupivacaine with hypertonic solution on the duration of analgesia 
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[한글] 국소마취제에 dextran을 첨가해서 마취를 하면 국소마취제의 흡수를 물리적으로 지연시켜 국소마취제의 마취작용시간을 연장시킨다는 보고가 있으나 확실한 작용기전은 불명하다. 그러나 morphine과 bupivacaine을 고장성용액에 혼합하여 단회흉추경막외차단을 시행 할 시에 진통에 대한 환자의 주관적평가에 있어서 morphine 및 bupivacaine의 진통효과가 연장된다는 보고는 찾아보기 어렵다. 본 연구는 다발성늑골골 및 흉부좌상으로 급성 혹은 만성흉통을 호소하는 환자 50명을 대상으로 단회흉추경막외차단을 시행할시에 morphine, bupivacaine 그리고 0.9%식염수를 혼주하였던 제1군(대조군)과 식염수 대신에 dextran 70 또는 50% 포도당용액을 각각 혼주하였던 제2 및 제3군을 실험군으로 정하고 차단후 진통효과를 관찰하였으며 각군에서 약물의 tonicity가 진통 지속효과에 미치는 영향을 비교하였다. 그리고 차단전 및 후 폐 기능예비력의 변화와 차단후 발생한 후유증도 관찰하였다. 혼주한 약물의 용량은 다음과 같다. 제 1 군 (n = 15) : morphine (2.13±1.64mg) 0.5% bupivacaine (3.10±1.04ml) 0.9% saline (3.64±1.11ml) 제 2 군 (n = 16) : morphine (2.13±0.72mg) 0.5% bupivacaine (3.06±0.77ml) dextran 70 (3.75±1.29ml) 제 3 군 (n = 19) : morphine (2.42±0.51mg) 0.5% bupivacaine (3.21±0.71ml) 50% dextrose in water (3.68±1.11ml) 관찰결과는 다음과 같다. 1. 경막외차단후의 진통효과는 제2군에서 우수 또는 양호한 예가 93.8 %로서 제1 및 제3군에 비해서 많았다. 2. 진통지속기간은 제2군에서 2일이상인 예가 81.2%로서 제1 및 제3군에 비하여 장시간 진통효과가 지속한 예가 많았다. 3. 흉외상병력일이 1내지 31일에 속한 27명은 통증차단후 폐기능예비력 (FVC%+FEV^^1.0 %)이 약 13% 증가하였고, 32내지 82일에 속한 13명은 통증차단후 약 4% 감소하였다. 4. 경막외차단후의 후유증은 오심이 5명 (10%),구토가 4명 (8%), 소양증이 10명 (20%), 체뇨증 (urinary retention)이 17명 (34%), 두통이 3명 (6%) 그리고 경막외천자가 2명 (41%) 이었다. 이상의 관찰결과를 미루어 보면 흉추경막외강에 morphine과 bupivacaine을 주입할 때에 고장성용액을 혼주하면 진통효과가 더 오래 지속되는 것으로 사료된다.
[영문] Recent studies have shown that narcotic drugs produce an unusually intense, prolonged and segmental analgesic action when injected into the spinal subarachnoid or epidural space of man (Wang et al, 1979; Behar et al, 1979; Cousins et at, 1979; Magora et al, 1980; Johnston and McCaughey, 1980). Since 1960, many investigators claimed that low molecular weight (IMW) dextran increased the clinical duration of lido-caine (Loder, 1960; Loder, 1962), tetracaine (Chinn and Wir-joatmadja,1967) and bupivacaine (Kaplan et al,1975) in man but the mechanism of the action of dextran was unclear. But Curtiss and Scurlock (1979), and Buckley and Fink (1979) claimed that LMW dextran has no effect on the duration of action of bupivacaine In animal studies. The present study was performed to evaluate the clinical efficacy of analgesia by the thoracic epidural injection of morphine and bupivacaine mixture for the relief of pain due to fractured or contused ribs, to evaluate the duration of analgesic effect by the use of above mixture in the hypertonic solution (dextran 70 or 50% dextrose in water), and to observe the possibility of improvement in the lung function after the pain block. The complications following the pain block were also observed. The 50 single thoracic epidural injections of the mixture were divided into three groups: Group 1 (n=15) served as a control group and drugs used for the relief of pain were as follows (Mean±S.D.): morphine (2.13±1.64 mg), 0.5% bupivacaine (3.10±1.04 ml) and 0.9% saline (3.64±1.11 ml). Group 2 (n=16) served as a experimental group and drugs were as follows (Mean±S.D.): morphine (2.13±0.72 mg), 0.5% bupivacaine (3.06±0.77 ml) and dextran 70 (3.75±1.29 ml). Group 3 (n=19) served as a experimental group and drugs were as follows (Mean ±S.D.): morphine (2.42±0.51 mg). 0.5% bupivacaine (3.21±0.71 ml) and 50% dextrose in water (3.68±1.11 ml). The results are as follows : 1. The number of patient who obtained excellent and good analgesic effect following the block were greater in Group 2 (93.8%) than those of Group 1 or Group 3. 2. The duration of pain relief which lasted more than 2 days after the epidural block was longer in Group 2 (81.2%) than those of Group 1 or Group 3. 3. The pulmonary reserve (FVC + FEV^^1.0 %) of 27 cases who were treated by the pain block between 1 to 31 days following the chest injury was increased to about 13% than those before the block, and that of 13 eases between 32 to 82 days following the chest injury was decreased to about 4% than those before the block. 4. Of the complications following the pain block, there were 5 cases (10%) of nausea within 2 hours following the block, 4 cases (8%) of vomiting after 2 hours following the block, 10 cases (20%) of pruritus after 3-4 hours following the block, 17 cases (34%) of transient urinary retention which lasted 8 to 19 hours, 3 cases (6%) of headache within 2 hours following the block and 2 cases (4%) of dural puncture. In conclusion, it is suggested that the clinical duration of analgesic effect produced by morphine and bupivacaine mixture can be prolonged by addition of the hypertonic solution to the mixture.
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