硬膜外阻滞对胸科手术患者血液流变学及凝血功能的影响

Effect of thoracic epidural anesthesia and PCEA on blood coagulation and hemorheology in patients undergoing major thoracic surgery

目的 观察硬膜外阻滞及硬膜外镇痛对胸科手术患者血液流变学和凝血功能的影响。方法胸科手术(肺叶切除或食管中下段切除)患者22例,随机分全麻复合硬膜外阻滞组(GEA组)和全麻组(GA组),每组11例。分别测定全麻诱导前(基础值)、术中1、3 h、术后1、3 d的血栓弹性描记图(TEG)、血液粘度、红细胞变形聚集指数、血小板计数(PLT)、血小板聚集指数(PAG)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、纤维蛋白原(FIB)、组织纤溶酶原激活物(t-PA)、组织纤溶酶原抑制物(PAI-A)的水平。结果GEA组PT、APTT显著性高于GA组(P<0.01);GEA组红细胞聚集指数较GA组显著性降低(P<0.05);GEA组血液粘度较GA组显著性降低(P<0.05);GEA组血小板聚集功能显著性增强(P<0.05),GA组无改变;GEA组t-PA无显著性变化,而GA组术后1 d显著性升高(P<0.05);两组PAI-A均无显著性变化;TEG参数:R、K在GA组显著性缩短(P<0.05),而GEA组无显著性变化;两组ANG均在术后3 d时显著性增大(P<0.05);GEA组MA术后3 d显著性高于GA组(P<0.01);GA组CL30、CL60术后1 d升高,并显著性高于GEA组(P<0.05)。GEA组TPI术后3 d显著性高于GA组(P<0.05)。结论胸段硬膜外阻滞及术后镇痛能够抑制胸科手术应激反应引起的凝血功能增强,可降低红细胞的聚集、降低血液粘度、改?

Objective To evaluate the influence of epidural block on blood coagulation and rhedogy in patients undergoing esophagectomy or lobectomy. Methods Twenty-two ASA Ⅰ-Ⅱ patients (14 male, 8 female) aged 40-65 yr undergoing esophagectomy or lobectomy were randomized to receive either combined general-epidural anesthesia (GEA group , n = 11) or general anesthesia (GA group, n = 11). The patients were premedicated with intramuscular pethidine 50 mg, promethazine 25 mg and scopolamine 0.3 mg. In GEA group epidural catheter was placed at T9-10 interspace before general anesthesia. A test dose of 4 ml 2% lidocaine was given. When correct positioning of the epidural catheter was confirmed, general anesthesia was induced with propofol 1.5-2.0 mg· kg-1 , fentanyl 2μg·kg-1 and rocuronium 0.6 mg· kg-1 , after placement of double- lumen endobronchial tube the patients were mechanically ventilated (VT 10 ml·kg-1 , RR 12 bpm, I: E = 1:2). Anesthesia was maintained with isoflurane inhalation and intermittent i. v. boluses of vecuronium. A mixture of 2 % lidocaine and 0.33% dicaine (1:1) was continuously infused at a rate of 4-6 ml·h-1 during operation. After operation PCEA was commenced with 0.12% ropivacaine and morphine 80 μg·ml-1 (background infusion 4 ml·h-1 , bolus dose 2 ml, lockout interval 6 min) . In GA group the patients received the same general anesthesia technique. Postoperatively the patients were placed on PCIA with morphine 0.5 mg·ml-1 (background infusion 1 ml·h-1 , bolus dose 2 ml, lockout interval 6 min) Pain intensity was measured using VAS (0-10). Blood samples were taken before induction of anesthesia (T0, baseline), 1 and 3 h after skin incision (T1 , T2 ) and on the morning of 1st and 3rd postoperative day (T3 , T4 ) . Blood samples were tested immediately in a thromboelastograph (TEG) coagulation analyzer. Usual clotting tests (PT, APTT, platelet count, Hb, Hct), fibrinolysis tests (t-PA, PAI-A) and rheology tests were performed at the same time. Results PT and APTT were significantly prolonged during and after operation (T2,T3 ) as compared with the baseline values in both groups (P < 0.05 or 0.01) . RBC aggregation and plasma viscosity were significantly decreased during operation (T1 , T2) compared with baseline values (T0) in GEA group (P < 0.05) , while there was no significant change in the two variables in GA group. Blood viscosity was significantly decreased in both groups and was significantly lower in GEA group than that in GA group (P < 0.05) . Platelet count was significantly decreased while platelet aggregation was significantly increased in GEA group but there was no significant change in platelet count and aggregation in GA group. There were no significant changes in PAI-A in both groups. t-PA increased significantly on the 1st postoperative day in GA group. , The TEG variables : there was no significant change in R- and K time in GEA group while R- and K-time were significantly shortened during and after operation (T2 , T3 , T4) in GA group ( P < 0.05) . Alpha angle was significantly increased on the 3rd postoperative day (T4) in both groups (P < 0.05). Maximum amplitude (MA) was significantly increased on the 3rd postoperative day (T4 ) in both groups, and the increase was significantly larger in GEA group than that in GA group ( P < 0.01) . CL30 and CL60 were significantly increased on the 1 st postoperative day in GEA group as compared with those in GA group ( P < 0.05). Conclusion Thoracic epidural anesthesia and PCEA can inhibit increase in coagulation induced by stress, reduce RBC aggregation and blood viscosity and prevent postoperative inhibition of fibrinolysis. However it can improve platelet aggregation.