超声引导下肋间与胸椎旁神经阻滞对胸腔镜肺楔形切除术后急性疼痛及麻醉药用量的影响

Effects of ultrasound-guided intercostal and thoracic paravertebral nerve blocks on acute pain and anesthetic dosage after radical sleeve resection of lung cancer

目的探讨超声引导下肋间与胸椎旁神经阻滞对胸腔镜肺楔形切除术后急性疼痛及麻醉药用量的影响。方法选取2019年1月至2021年12月于新疆医科大学第一附属医院昌吉分院拟行胸腔镜下肺楔形切除术患者76例,采用随机数字表法分为肋间组与胸椎旁组,各38例。肋间组采用全麻联合肋间神经阻滞,胸椎旁组采用全麻联合胸椎旁神经阻滞。比较2组手术相关情况、术后24 h内不同时间点疼痛视觉模拟(VAS)评分、麻醉药用量、手术前后血清疼痛应激指标[前列腺素E2(PGE2)、去甲肾上腺素(NE)、皮质醇(Cor)]、不良反应。结果胸椎旁组下床时间早于肋间组(P<0.05);在术后不同时间点(2、4、8、12、24 h),胸椎旁组患者在静息和咳嗽状态下的VAS评分均低于肋间组(P<0.05);术后2 h、24 h胸椎旁组血清PGE2、NE及Cor水平均低于肋间组(P<0.05);与术前比较,术后2 h、24 h 2组血清PGE2、NE均升高(P<0.05),术后24 h胸椎旁组Cor水平与术前无差异(P>0.05)。2组术中丙泊酚用量、术后48 h舒芬太尼用量及镇痛泵按压次数比较,差异均无统计学意义(P>0.05);胸椎旁组术中瑞芬太尼用量及术后24 h舒芬太尼用量均低于肋间组(P<0.05)。肋间组与胸椎旁组恶心(28.95%vs.34.21%)、呕吐(7.89%vs.5.26%)、嗜睡(2.63%vs.7.89%)、咳痰无力(2.63%vs.5.26%)及肺部感染(2.63%vs.0.00%)发生率比较均无差异(P>0.05)。结论超声引导下胸椎旁神经阻滞在缓解肺楔形切除术后急性疼痛及减少术后24 h麻醉药用量方面效果较好,两种神经阻滞方案在术后总麻醉药用量方面相当,且均有较好的安全性,临床可依据具体情况选择镇痛方案。

Objective To investigate the effect of ultrasound-guided intercostal and thoracic paravertebral nerve blocks on acute pain and anesthetic dosage after thoracoscopic pulmonary wedge resection.Methods Seventy-six patients who were scheduled to undergo thoracoscopic pulmonary wedge resection in our hospital from January 2019 to December 2021 were selected and divided into an intercostal group and a thoracic paravertebral group by random number table method,with 38 cases in each group.The intercostal group received general anesthesia combined with intercostal nerve block,and the thoracic paravertebral group received general anesthesia combined with thoracic paravertebral nerve block.Surgery-related conditions,pain visual analogue(VAS)scores at different time points within 24hours after surgery,anesthetic dosage,serum pain stress indexes before and after surgery[prostaglandin E2(PGE2),norepinephrine(NE),Cortisol(Cor)],adverse reactions were compared.Results The time of getting out of bed in the thoracic paravertebral group was earlier than that in the intercostal group(P<0.05).At different time points after operation(2,4,8,12,and 24hours),the VAS scores of patients in the thoracic paravertebral group at rest and in cough state were lower than those in the intercostal group(P<0.05).The levels of serum PGE2,NE and Cor in the thoracic paravertebral group were lower than those in the intercostal group at 2hours and 24hours after operation(P<0.05).Compared with preoperative,serum PGE2 and NE in both groups increased at 2 hours and 24 hours after operation(P<0.05),and there was no difference in Cor level in thoracic paravertebral group at 24 hours after operation(P>0.05).There were no differences in intraoperative propofol dosage,sufentanil dosage at 48hours after operation and the number of analgesic pump pressings between the two groups(P>0.05).The intraoperative remifentanil dosage and 24 hours postoperative sufentanil dosage in the thoracic paravertebral group were lower than those in the intercostal group(P<0.05).There was no difference in the incidence of nausea(28.95%vs.34.21%),vomiting(7.89%vs.5.26%),somnolence(2.63%vs.7.89%),asthenia(2.63%vs.5.26%)and pulmonary infection(2.63%vs.0.00%)between the intercostal group and the thoracic paravertebral group(P>0.05).Conclusion Ultrasound-guided thoracic paravertebral nerve block is effective in relieving acute postoperative pain and reducing the dosage of anesthetics within 24 hours after pulmonary wedge resection.The two kinds of nerve block programs are equivalent in terms of total postoperative anesthetic dosage,and both have good safety.The clinical analgesic program can be selected according to the specific situation.