比较硬膜外与静脉镇痛对开胸手术患者红细胞糖代谢限速酶和血浆葡萄糖及皮质醇的影响

Comparison of different analgesia on the effects of glycometabolism rate-limiting enzymes in erythrocytes and the plasma levels of glucose and cortisol in patients undergoing esophagectomy surgery

目的:比较硬膜外与静脉镇痛对开胸手术患者红细胞磷酸果糖激酶(PFK)、葡萄糖-6-磷酸脱氢酶(G-6PD)和醛糖还原酶(AR)的活性,以及血浆葡萄糖和皮质醇水平的影响。方法:42例食道癌手术患者随机分为Ⅰ、Ⅱ两组,每组21例。两组患者术中均行静脉全麻复合硬膜外阻滞,Ⅰ组术后行静脉芬太尼镇痛(15μg/kg),Ⅱ组术后行硬膜外镇痛(0.1250%罗哌卡因混合0.0002%芬太尼)。分别于麻醉前(T0)、手术60min(T1)、术后60min(T2)、术后1天晨(T3)和术后2天晨(T4)抽取肘静脉血,测定红细胞PFK、G-6PD和AR的活性及血浆葡萄糖和皮质醇的水平,采用视觉模拟评分(VAS)判定术后4、12、24、48h镇痛效果,比较术后镇痛(PCA)泵内芬太尼用量和按压次数。结果:①与T0相比,T3时Ⅰ组患者PFK活性显著降低(P<0.01),G-6PD和AR活性显著升高(P<0.01),Ⅱ组患者三个酶的活性无明显变化(P>0.05);此时两组之间相比较有显著性差异(P<0.05)。②两组患者血糖和皮质醇水平均自T1开始明显升高(P<0.05或P<0.01),至T3时达峰值(均P<0.01),T4时点Ⅱ组患者的血糖值恢复至术前水平(P>0.05);T3、T4时Ⅰ组血糖和皮质醇值均明显高于Ⅱ组(P<0.05或P<0.01)。③两组患者术后镇痛效果均良好,VAS镇痛评分<3分,但Ⅰ组患者术后12、24hVAS评分明显高于Ⅱ组(P<0.05),PCA的芬太尼用量和按压次数也明显高于Ⅱ组(P<0.01)。结论:食管癌手术患者采用硬膜外镇痛,可抑制血糖与皮质醇水平升高,减轻术后的应激反应,改善红细胞内糖代谢状况,其镇痛效果优于静脉镇痛。

Objectlve：To compare the effects of epidural and intravenous analgesia on the activities of phosphofructokinase（PFK）, glucose-6-phasphate dehydrogenase （G-6PD）, aldose reductase （AR） in erythrocytes and the plasma levels of glucose and cortisol in patients undergoing thoracic surgery. Methods：Forty-two patients scheduled for esophagectomy were randomly allocated to receive either intravenous analgesia group with fentanyl 15 μg/kg （group I , n = 21） or epidural analgesia group with 0.125 0% ropicaine and 0.000 2% fentanyl （group ]I , n = 21 ） after operation. Venous blood samples were collected for the measurement of PFK, G-6PD and AR activities in erythrocytes and the plasma levels of glucose and cortisol before induction （T0）,60 min following the incision（T1） and 60 min（T2） after operation, I^st（T3）, 2^nd（T4） postoperative day. Results： ①The activity of PFK was decreased significantly, and the activities of G-6PD and AR were increased markedly on T3 in group I , comparing with those activities on T0 （P 〈 0.01 ）. But these enzymes activities slightly changed in group II on T3 （P 〉 0.05）. There were significant differences between two groups on T3 （P 〈 0.05）. ②The levels of plasma glucose and cortisol concentration in both groups elevated significantly on T1 （P 〈 0.01 ）,reached high peak values on T3 （P 〈 0,01 ） and revived on the T4 in both groups. The values of plasma glucose and cortisol concentration in group I were higher than group II on T3 and T4 （P 〈 0.05 or P 〈 0.01 ）. ③The patients of two groups obtained satisfied pain relief, both VAS 〈 3, but total fentanyl consumption （P 〈 0.01）, bolus times （P 〈 0.01 ） and VAS values at 12 h and 24h postopertation were lower in group II than in group I. Conclusion： Compared with intravenous analgesia, epidural analgesia could have better pain relief effect and allevate stress response more markedly. And it should improve those erythrocyte glucose metabolism changes after esophageal surgery.