皮下与静脉术后自控镇痛对乳腺癌患者T淋巴细胞亚群及NK细胞的影响

Subcutaneous vs intravenous postoperative patient-controlled analgesia on T-lymphocyte subtypes and natural killer cells in patients after breast cancer surgery

目的比较皮下与静脉术后自控镇痛对乳腺癌根治手术患者的镇痛效果及其对T淋巴细胞亚群、自然杀伤（natural killer,NK）细胞的影响。方法按美国麻醉医师协会制定的患者体格情况分级为Ⅰ-Ⅱ级、拟在我院住院行乳腺癌根治手术的女性患者40例,年龄（45±10）岁,按信封法随机分为皮下自控镇痛组（patient controlled subcutaneous analgesia,PCSA组）和静脉自控镇痛组（patient controlled intravenous analgesia,PCIA组）,每组各20例。术毕以电子镇痛泵分别行皮下、静脉自控镇痛,采用视觉模拟评分（visual analogue scale,VAS）比较2组术后6、12、18、24、48h的镇痛效果。并在麻醉前（基础值T1）,术毕（T2）、术后第1天（T3）、术后第2天（T4）、术后第5天（T5）采集外周静脉血2ml,采用流式细胞仪检测T淋巴细胞亚群（CD3^＋、CD4^＋、CD8^＋、CD45^＋）及NK细胞的水平。结果 2组患者VAS评分均在3分以内,且无统计学差异（P〉0.05）。术后各时点与基础值比较：2组患者的CD3^＋、CD4^＋、CD8^＋在T3、T4、T5时间点均下降（P〈0.01）;NK细胞,PCSA组在T4时间点下降（P〈0.05）,PCIA组在T3、T4时间点下降（P〈0.01）;CD4^＋/CD8^＋比值,PCIA组在T2时间点下降（P〈0.05）,在T3时间点上升（P〈0.05）,PCSA组在T4、T5时间点上升（P〈0.05）。PCSA组的CD4^＋和PCIA组的CD4^＋/CD8^＋比值在T2时间点下降（P〈0.05）。2组各时间点CD3^＋、CD4^＋、CD8^＋、CD4^＋/CD8^＋、CD45^＋及NK细胞组间差异无显著性（P〉0.05）。结论PCSA和PCIA应用于乳腺癌患者术后均可达到满意的镇痛效果,2种术后自控镇痛方式对免疫功能的影响相同。

Objective To investigate the effect of subcutaneous or intravenous postoperative patient- controlled analgesia on T-lymphocyte subtypes and natural killer cells in patients after breast cancer surgery. Methods Forty female patients in our hospital, mean age 45 ±10, with American Society of Anesthesiologists （ASA） classification Ⅰ to Ⅱ undergoing elective breast cancer surgery were randomly divided into 2 groups by the envelope method,patient-controlled subcutaneous analgesia group （PCSA, n = 20）, and patient-controlled intravenous analgesia group （PCIA, n = 20）. Visual analogue scaling （VAS） were evaluated at 6, 12, 18, 24 and 48 h after operation respectively. Blood samples were collected before anesthesia （T1） , at the end of surgery （T2） and 1 （T3）, 2 （T4）, and 5 d （T5） after surgery to measure T-lymphocyte subsets （CD3 ^＋, CD4^＋ , CD8 ^＋ , CD4 ^＋/CD8 ^＋ and CD45^＋ ） and NK cells by flow cytometry. Results VAS scores was lower than 3 in both groups, and there was no any difference between them （P 〉 0.05 ）. Compared with baseline, the levels of CD3^ ＋ , CD4 ^＋ and CD8^ ＋ were decreased significantly at T3, T4 and T5 in both groups. （P 〈 0. 01 ）. The level of NK cells was decreased significantly at T4 in PCSA group （P 〈 0. 05） and at T3 and T4 in PCIA group （P 〈 0.01 ）. CD4 ^＋/CD8 ^＋ ratio was decreased significantly at T2 and increased significantly at T3 in PCIA group （ P 〈 0. 05 ）, but the ratio was increased significantly at T4 and T5 in PCSA group （ P 〈 0. 05 ）. The level of CD4 ^＋ in PCSA group and the CD4 ^＋/CD8 ^＋ ratio in PCIA group were decreased significantly at T2 （ P 〈 0. 05）. There was no significant difference in CD3 ^＋ , CD4^ ＋ , CD8 ^＋ , CD4^ ＋/CD8 ^＋ , CD45 ^＋ and NK cells in both groups at anytime points after operation （P 〉 0.05）. Conclusion PCSA and PCIA are excellent methods for analgesia in patients after breast cancer surgery, and they have the same effects on the immune system.