内关穴对术后恶心呕吐(PONV)的防治作用上海中医药大学附属曙光医院麻醉科 唐炜PONV发生率呕吐的总发病率约为30%，恶心的发生率约为50%，而在高风险人群，其发生率可高达80%。Apfel CC, Lr E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting:conclusions from cross-validations between two centers.Anesthesiology 1999;91:693700Koivuranta M, Lr E, Snre L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997;52:4439Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:10918危险因素Evidence Risk factorsFemale sex History of PONV or motion sickness Nonsmoking Younger age General versus regional anesthesia Use of volatile anesthetics and nitrous oxide Postoperative opioids Duration of anesthesia Type of surgery (cholecystectomy, laparoscopic,gynecological) Conflicting ASA physical status Menstrual cycle Level of anesthetists experience Muscle relaxant antagonists Disproven or of limited clinical relevanceBMI Anxiety Nasogastric tube Supplemental oxygen Perioperative fasting Migraine PONV = postoperative nausea and vomiting; BMI = body mass index; MS =motion sickness.危险因素危害PONV伤口裂开出血延长住院天数增加费用电解质紊乱误吸肠内环境变化肠内环境变化抗菌素抗菌素, ,内毒素内毒素机械感受器机械感受器化学感受器化学感受器内脏感受器内脏感受器胃肠扩张胃肠扩张炎症损伤炎症损伤脑干内化学感受器催吐区脑干内化学感受器催吐区( (CRTZCRTZ) )血液或脑脊液内的毒素变化血液或脑脊液内的毒素变化麻醉性镇痛药麻醉性镇痛药, ,强心甙强心甙, ,麦角制剂麦角制剂, ,电解质紊乱电解质紊乱, ,酸中毒酸中毒, ,尿毒症尿毒症运动性恶心运动性恶心前庭迷路系统前庭迷路系统小脑小脑高级中枢如边缘系高级中枢如边缘系统和视觉皮层等统和视觉皮层等视觉视觉, ,味觉味觉, ,嗅觉嗅觉, ,疼痛疼痛, ,低低血压血压, ,缺氧缺氧, ,颅内压增高颅内压增高呕吐中枢呕吐中枢位于延髓位于延髓发生机制治疗DexamethasonePerphenazineScopolamineNonPharmacological:Acupuncture5-HT3antagonistPropofol subhypnoticdose infusion orPropofol in PACU(rescue only)PropofolAnesthesiaDimenhydrinateRegionalAnesthesiaDroperidolHaloperidolNK-1 receptorantagonistsPortfolio ofprophylaxisand treatmentstrategies替代治疗米勒麻醉学有独立章节专门阐述了中医药在麻醉相关领域所起的作用，特别提到了针灸的应用。1998年，美国国家健康学会共同小组报道，针灸在减轻手术后及化疗后的恶心，以及牙疼等方面很有疗效。针刺防治PONV的机理Streitberger等根据实验研究发现，针刺内关对PONV的作用可能和改善胃动力,调节迷走神经活性，小脑前庭功能在MRI上的变化有关。Streitberger K, Ezzo J, Schneider A. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Auton Neurosci. 2006 Oct 30;129(1-2):107-17.穴位选择目前国内外最常采用的是双侧内关穴（P6）。如果因为某些原因只能作单侧内关的针刺，绝大多数学者都推荐优势手。刺激频率Arnberger等对全身麻醉患者术中给予单刺激（1HZ，间隔0.2ms,50mA电流的连续刺激）干预，发现可明显减少术后早期（0-6小时）PONV的发生率1。Kim等研究发现利用神经刺激仪中的强直刺激模式可有效降低腹腔镜下子宫切除患者PONV的发生率，而其它几种刺激模式如单刺激、四个成串刺激、双短强直刺激等均对术后恶心呕吐也有效，但相对强直刺激而言效果较差2。我们的研究：2/100Hz电针能显著减少腹腔镜手术患者PONV的发生率，降低该手术患者PONV的严重程度31Arnberger M, Stadelmann K, Alischer P.Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthesiology. 2007 Dec;107(6):903-8.2Kim YH, Kim KS, Lee HJ el. The efficacy of several neuromuscular monitoring modes at the P6 acupuncture point in preventing postoperative nausea and vomiting. Anesth Analg. 2011 Apr;112(4):819-23.3唐炜，袁岚，傅国强等.不同频率电针对腹腔镜手术病人术后恶心呕吐的影响.中国针灸，2013,33（2）:159-62临床具体操作方法出于临床使用效果和使用方便性的考虑，目前多采用针刺或经皮穴位电刺激。术前30min开始刺激电针频率2/100Hz、疏密波，刺激强度以患者耐受程度为准，治疗时间持续至手术结束时。临床疗效EI-Deeb AM等通过对450例腰麻下行剖宫产的患者术前30分钟给予双侧内关电针刺激和术前30分钟静脉给予5-HT受体阻滞剂恩丹西酮4mg比较，发现电针可更有效减少此类患者术中及术后的恶心呕吐发生率,并能提高患者满意度1。Ezzo等对26个实验中的3000名患者做了分析后认为，针灸P6点对PONV的效果是确切的，无论是成人还是儿童，可以降低止吐药的使用量，对P6不同的刺激方法（针刺或经皮）有同样的效果2。1Allen TK, Habib AS. P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials. Anesth Analg. 2008 Oct;107(4):1308-12.2Ezzo J, Streitberger K, Schneider A.Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. J Altern Complement Med. 2006 Jun;12(5):489-95今后研究方向优化穴位选择中医辨证角度个体化选择病人大样本、多中心、对照试验