术中保温对食管癌根治术患者应激的影响

Efficacy of perioperative temperature protection during radical resection of esophagus carcinoma and its effect on stress responses

目的比较围术期体温保护对食管癌根治术患者的保温效果及其对患者应激的影响。方法选取择期行食管癌根治术患者36例,美国麻醉医师学会(ASA)Ⅰ～Ⅱ级,根据术中温度处理措施将患者随机分为常规体温管理组(C组)、充气加温毯保温组(T组),每组各18例。T组患者在麻醉诱导前以充气毯43℃预加热20min,并保温直至术毕。观察两组患者在麻醉诱导即刻(T1),诱导后30min(T2)、60min(T3)、120min(T4)、180min(T5)和(或)240min(T6),术毕(T7)时间点的鼻咽温度。采用酶联免疫吸附试验(ELISA)测定麻醉诱导前及术毕时间点的血浆去甲肾上腺素、肾上腺素质量浓度,分析麻醉诱导后及术毕患者的桡动脉血气。结果两组在不同时间点的鼻咽温度的差异均有统计学意义(P值均<0.05),从变化趋势来看,T组在各时间点的鼻咽温度变化较平稳,而C组的鼻咽温度下降较快,在T2～T4时间段下降最快,C组在T3以后各时间点的平均鼻咽温度低于36℃,T组在各时间点的鼻咽温度均在36℃以上,且两组在T2时间点后鼻咽温度差值进一步增大。C组在T1、T2时间点的鼻咽温度均显著高于其他时间点(P值均<0.05),在T1时间点的鼻咽温度显著高于T2时间点(P<0.05),在T3以后各时间点的差异均无统计学意义(P值均>0.05)。C组在术毕的血浆去甲肾上腺素质量浓度为(660.33±89.83)mg/L,显著高于麻醉前的(598.28±86.87)mg/L(P<0.01)。T组在术毕的血浆去甲肾上腺素质量浓度为(736.46±152.48)mg/L,显著高于麻醉前的(721.69±143.72)mg/L(P<0.01)。C组去甲肾上腺素增加幅度显著高于T组(P<0.05)。C组在术毕的肾上腺素质量浓度为(25.14±2.63)mg/L,显著高于麻醉前的(22.18±3.43)mg/L(P<0.01);T组在术毕的肾上腺素质量浓度为(25.92±2.95)mg/L,显著高于麻醉前的(24.79±3.41)mg/L(P<0.01);C组肾上腺素增加幅度显著高于T组(P<0.05)。T组术毕剩余碱(BE)的降低值显著小于C组(P<0.05),两组间乳酸值(Lac)的增加值或降低值的差异均无统计学意义(P值均>0.05)。T组在术毕有3例患者(3/17)发生代谢性酸中毒,显著低于C组的10例(10/18,P<0.05)。结论术中采用充气毯加温可以给患者提供良好的体温保护,减少围术期低体温的发生,且可以降低血浆去甲肾上腺素、肾上腺素升高幅度,减轻围术期的应激反应。术中保温还可以降低代谢性酸中毒的发生率及严重程度,改善围术期患者内环境紊乱。

Objective To investigate the efficacy of perioperative temperature protection during radical resection of esophagus carcinoma and its effect on stress responses.Methods Thirty-six patients undergoing radical resection for esophagus carcinoma were randomly assigned to two groups：routine temperature care group（Group C,patients were not warmed intraoperatively,n=18）and perioperative temperature protection group（Group T,patients were pre-warmed for 20 min before anesthesia induction using forced-air warming system and were kept warm until the end of operation,n=17）.The nasopharyngeal temperatures at anesthesia induction（T1）,30 min（T2）,60 min（T3）,120 min（T4）,180 min（T5）,and 240 min（T6）after induction and the end of operation（T7）were recorded.The plasma concentrations of noradrenaline and adrenaline were determined by enzyme-linked immunosorbent assay（ELISA）before anesthesia and at the end of operation.The blood gas analysis was performed after anesthesia induction and at the end of operation.Results There were significant differences in nasopharyngeal temperatures between two groups at different time points.The temperature change was comparatively stable in Group T at different time points.The temperature in Group C decreased rapidly,especially during T2-T4;after T3,the mean temperature in Group C at different time points were lower than at 36 ℃.The temperature in Group T was above 36 ℃ at all time points.The temperature difference between the two groups was increased after T2.The temperatures at T1 and T2 were significantly higher than those at other time points in both groups（P〈0.05）.At the end of operation,the plasma level of noradrenaline increased from（598.28±86.87）mg/L to（660.33±89.83）mg/L in Group C,and an increase of noradrenaline from（721.69±143.72）mg/L to（736.46±152.48）mg/L was found in Group T.The increased level of noradrenaline in Group T was less than that in Group C.The plasma level of adrenaline rose sharply from（22.18±3.43）to（25.14±2.63）mg/L in Group C,and an increase of adrenaline from（24.79±3.41）mg/L to（25.92±2.95）mg/L was found in Group T（P〈0.01）.The incidence of metabolic acidosis in Group T was significantly lower than that in Group C（3/17 vs.10/18,P〈0.05）.Conclusion Forced-air warming system can effectively maintain normothermia during operation and reduces the incidence of mild hypothermia.Temperature protection can reduce the increase of noradrenaline and adrenaline during operation and the stress response.Good temperature control can also reduce the incidence and severity of disturbance of acid-base equilibrium.（Shanghai Med J,2010,33：720-723）