开胸食管癌手术后病人自控硬膜外镇痛对内分泌和呼吸功能的影响

Changes of endocrine and respiratory function following patient-controlled epidural analgesia after thoracic surgery: a comparison with intramuscular analgesia

目的 研究开胸食管癌手术后病人自控硬膜外镇痛（ＰＣＥＡ）对机体内分泌和呼吸功能的影响。方法 比较ＰＣＥＡ 组和肌注镇痛（ＭＩ）组病人的镇痛效果，监测围麻醉期病人血清皮质醇、胰岛素和血糖以及呼吸频率（ＲＲ）、分钟通气量（ＭＶ）和脉搏血氧饱和度（ＳｐＯ２ ）的变化。结果 （１）ＰＣＥＡ镇痛效果优于肌注镇痛，病人感觉良好（ＶＡＳ：１．４５±０．４３和３．８０±１．６１ Ｐ＜ ０．０１）；（２）镇痛期血清皮质醇和血糖浓度ＰＣＥＡ组明显低于ＭＩ组，ＰＣＥＡ组胰岛素和血糖相对恒定，ＭＩ组胰岛素镇痛期分泌增加（Ｐ＜ ０．０１）；（３）ＰＣＥＡ期病人呼吸平稳，ＭＶ 和ＳｐＯ２ 变化不明显，病人能及早咳嗽、排痰、深呼吸和转动体位，而肌注镇痛病人呼吸频率较ＰＣＥＡ 病人明显快（Ｐ＜ ０．０５），ＭＶ 和ＳｐＯ２ 下降显著，氧疗后恢复正常水平。结论 开胸食管癌手术后应用ＰＣＥＡ能较好地调控内分泌功能，抑制机体应激反应，改善呼吸功能和提高术后康复质量。

Objective To evaluate the feasibility of patient controlled epidural analgesia (PCEA) for the patients after thoracic surgery. Methods Thirty two patients suffering from esophageal cancer,ASA class I II,scheduled for thoracic surgery under general anesthesia, were randomly allocated to one of both groups respectively: PCEA group(n=16) and intramuscular analgesia (IM) group (n=16).Before anesthesia induction,the epidural catheter was iserted between T 7 and T 8 with the epidural block level between T 4 and T 10 .The mixture of 0.2% bupivacaine and 0.0002% fentanyl was administered posteroperatively for PCEA by a computer driven infusion system with loading dose of 3.5 ml ,PCA dose of 3ml and lockout time of 30min in group PCEA, and in group IM intramuscular pethidine 1 mg.kg -1 was given intermittently for postoperative analgesia. Results In PCEA group the score of visual analog scale was significantly lower than that in group IM (P<0.01). Serum insulin and blood sugar concentrations were kept stable (P<0.05) and serum cortisol level decresed markedly in PCEA group (P<0.05) during whole procedures.The levels of serum cortisol and insulin,and blood sugar were obviously lower during analgesia in PCEA group than those in IM group (P<0.05 or 0.01). Respiratory rate(RR), minute volume of ventilation(MV) and SpO 2 remained unchanged in PCEA group (P>0.05), but in IM group RR increased and MV and SpO 2 decreased dramatically (P<0.05 or 0.01).Conclusion After thoracic surgery PCEA can effectively applied to inhibiting postoperative stress and improving respiratory function.