开胸手术后患者肋间神经冷冻镇痛与硬膜外镇痛对凝血功能的影响

Effect of postoperative intercostal cryoanalgesia and epidural analgesia on blood coagulation in patients undergoing thoracic surgery

目的 比较肋间神经冷冻镇痛和硬膜外术后镇痛对开胸手术患者凝血功能的影响。方 法46例I～Ⅲ级择期行开胸手术的患者,随机分为硬膜外镇痛组(E组,24例)和肋间神经冷冻镇 痛组(C组,22例)。分别于麻醉诱导前(T0)、术毕(T1)、术后1d(T3)、3 d(T3)、5 d(T4)抽取静脉血进行 血栓弹性描记图检测[包括R—time(反应时间)、K—time(凝血时间)、α角、MA(血栓最大幅度)、CI(凝血 指数)]和凝血功能筛选检测[包括凝血酶原时间(PT)、部分凝血酶原时间(APTT)、纤维蛋白原(FIB)], 并于术后4、24、48、72 h采用数字评分法(NRS)进行疼痛评分。术后7～10 d行双下肢B超检查,检测 深静脉血栓形成情况。结果两组间NRS评分差异无统计学意义(P>0．05)。与术前相比,两组T3,4 时K—time缩短,MA、α角增大,FIB升高,T2～4时R—time缩短,CI增大;与E组比较,C组T2-4时CI升高, T3,4时FIB升高(P<0．05),术后各时点PT、APTT差异无统计学意义。两组深静脉血栓形成率[C组 (3／20)、E组(1／20)]比较差异无统计学意义。结论 肋间神经冷冻镇痛和硬膜外镇痛对开胸手术患 者均能产生良好的术后镇痛效果,但与肋间神经冷冻镇痛相比,硬膜外镇痛能降低术后高凝状态。

Objective To compare the influence of postoperative intercostal nerve freezing and epldural analgesia on blood coagulation in patients undergoing thoracic surgery. Methods Forty-six ASA Ⅰ-Ⅲ patients of both sexes （31 male, 15 female） aged 36-83 yr weighing 50-84 kg undergoing thoracic surgery （esophagus cancer resection and lung resection） under general anesthesia were randomly divided into group E - epidural analgesia （ n = 24） and group C - intercostal nerve cryoanalgesia （ n = 22）. In group E, epidural catheter was placed at T7.8 . PCEA solution contained bupivacaine 30 mg ＋ morphine 12.5 mg ＋ dropefidol 2.5 mg in 250 ml of normal saline. PCEA was commenced with a loading dose of 5-7 ml. The PCA pump was set up with a background infusion of 3 ml · h^-1 , 3 ml bolus dose and a 30-minutes lockout interval. In group C, three intercostal nerves （the nerve in the thoracotomy incision and one nerve each above and below incision） were freezed （ - 70℃ ） for 90 seconds. Pain intensity was measured using NRS scores （0～10,0 = no pain, 10 = worst pain）. Blood samples were taken before operation （T0） （baseline）, at the end of operation （T1）, on the 1st, 3rd and 5th day after operation （T2 , T3 , T4） for thrombelastogrophy （TEG） analysis and determination of prothrombin time （PT）, activated partial thromboplastin time （APTT） and plasma fibrinogen concentration （FIB）. Uhrasonography was used for detection of deep vein thrombus on the 7th-10 th day after operation. Results Analgesia was satisfactory in both groups. There was no significant difference in NRS scores between the two groups （P 〉 0.05）. Hypereoagulation state was found in both groups as shown by shorter R-time and K-time, higher coagulation index （CI） and plasma fibrinogen concentration and widerα-angle as compared to the baseline （TO ） before operation. R-time was significantly shorter and CI and FIB concentration were significantly higher in group C than in group E at T2.4 . There was no significant difference in the incidence of deep vein thrombosis between the two groups （ P 〉 0.05 ）. Conclusion Intercostal nerve cryoanalgesia and epidural analgesia both provide satisfactory analgesia after thoracic surgery. Epidural analgesia can attenuate postoperative hypercoagulation state as compared with intercostals nerve cryoanalgesia.