全身麻醉复合椎旁阻滞对食管手术围术期循环及术后镇痛的影响

Effects of general anesthesia combined with paravertebral block technique on perioperative circulatory system and postoperative analgesia in patients undergoing thoracic esophagus surgery

目的观察全身麻醉复合椎旁阻滞、全身麻醉复合硬脊膜外腔阻滞及单纯全身麻醉3种麻醉方法,在开胸手术平卧位、侧卧位、单肺通气时对血流动力学及术后镇痛的影响。方法选择60例美国麻醉医师学会分级Ⅰ～Ⅱ级择期行开胸手术的患者,手术切口在第4、5肋间,胸腔引流管在第7、8肋间。随机分为全身麻醉组(组Ⅰ)、全身麻醉复合硬脊膜外腔阻滞组(组Ⅱ)及全身麻醉复合椎旁阻滞组(组Ⅲ),每组20例。分别于入手术室静息状态(T0)、全身麻醉诱导气管插管后(T1)、侧卧位后(T2)、硬脊膜外腔加药后或胸椎旁阻滞后5min(T3)、开胸单肺通气后20min(T4)及术毕气管拔管前(T5)5个时间点,应用多功能监测仪连续监测心电图、心率(HR)、平均动脉压(MAP)、中心静脉压(CVP),采用Vigileo持续心排出量监测仪持续监测心排血量(CO)和每搏量变异度(SVV)。3组患者均于术毕缝皮时开启患者静脉自控镇痛(PCIA)泵。记录术后2、24、48h的静息状态和咳嗽状态的疼痛视觉模拟评分(VAS评分),术后0～2h、2～24h、24～48h的PCIA泵按压次数,以及不良反应情况。结果①血流动力学:3组在T1、T2时间点的SVV值均高于正常参考值10%。与T0时间点比较,组Ⅰ、组Ⅱ在各时间点及组Ⅲ在T1～T4时间点的MAP值均显著降低(P值均<0.05);组Ⅰ在T1、T2时间点,组Ⅱ在T1～T5时间点,组Ⅲ在T1～T4时间点的CO值均显著降低(P值均<0.05);组Ⅰ及组Ⅱ在T4时间点的CVP显著升高(P值均<0.05)。组Ⅲ在T3、T4时间点的MAP值显著低于组Ⅰ及组Ⅱ(P值均<0.05);SVV值显著低于组Ⅱ(P值均<0.05),与组Ⅰ的差异无统计学意义(P值均>0.05);组Ⅱ在T4时间点的SVV值显著高于组Ⅰ及组Ⅲ(P值均<0.05)。3组间同一时间点CO值的差异均无统计学意义(P值均>0.05)。②镇痛评分:组Ⅱ、组Ⅲ在术后2、24、48h的静息状态和咳嗽状态的疼痛VAS评分<4分的构成比均显著高于组Ⅰ(P值均<0.05),组Ⅲ在术后24h的静息状态的疼痛VAS评分<4分的构成比显著高于组Ⅱ(P<0.05)。组Ⅲ在术后0～2h、24～48h的PCIA按压次数显著少于组Ⅰ、组Ⅱ(P值均<0.05)。结论全身麻醉复合椎旁阻滞麻醉联合术后PCIA用于开胸手术患者术后镇痛的效果最好。全身麻醉复合硬脊膜外腔阻滞引起的循环波动表现为SVV升高,不伴MAP下降;全身麻醉复合椎旁阻滞对循环的抑制表现为MAP下降,不伴SVV升高。

Objective To investigate the effects of general anesthesia combined with paravertebral block,general anesthesia combined with epidural block as well as general anesthesia alone on hemodynamic parameters and postoperative analgesia in patients undergoing thoracic surgery at supine position,lateral position,and with one-lung ventilation.Methods Sixty American Society of Anesthesiologists（ASA）Ⅰ-Ⅱ patients undergoing elective thoracic surgery were randomly divided into groupⅠ（general anesthesia）,group Ⅱ（general anesthesia combined with epidural block） and group Ⅲ（general anesthesia combined with paravertebral block）.There were 20 patients in each group.Operative incision was chosen in the 4th to 5th intercostal space and chest drainage tube was put in the 7th to 8th intercostal space.Electrocardiogram（ECG）,heart rate（HR）,mean arterial pressure（MAP）,central venous pressure（CVP）,cardiac output（CO） and stroke volume variability（SVV） were continuously recorded by Vigileo monitor before general anesthesia（T0）,immediately after intubation（T1）,after lateral position（T2）,5 min after nerve block（T3）,20 min after one-lung ventilation（T4） and before extubation（T5）.Patient-controlled intravenous analgesia（PCIA） was started at the time of suture in all patients.Static and dynamic visual analogue scale（VAS） scores were measured 2 h,24 h and 48 h after surgery.The pressing times of PCIA during 0-2 h,2~24 h and 24-48 h apostoperatively and adverse reactions were recorded.Results SVV in the 3 groups were higher than the normal reference value of 10%.Compared with T0,MAP in the 3 groups were significantly decreased at all time points（P0.05）,except for group Ⅲ at T5;CO were also significantly decreased at T1 and T2 in groupⅠ,at T1-T5 in groupⅡ and at T1-T4 in group Ⅲ（P0.05）;CVP in groupⅠand Ⅱ at T4 were significantly increased（P0.05）.At T3 and T4,MAP in group Ⅲ was lower than that in groupⅠand Ⅱ（P0.05）;SVV in group Ⅲ was lower than that in group Ⅱ（P0.05）,but the difference of SVV between group Ⅲ and groupⅠhad no statistical significance（P0.05）.SVV in groupⅡwas significantly higher than that in group Ⅰ and Ⅲ at T4（P0.05）.The difference of CO between the 3 groups had no statistical significance at T0-T5（P0.05）.The patients with postoperative VAS4 in group Ⅱ and Ⅲ were much more than in group Ⅰ at each time point（P0.05）.The patients with static VAS4 in group Ⅲ was much more than in group Ⅱ at 24 h after surgery（P0.05）.The pressing times of PCIA in group Ⅲ were less than those in group Ⅰand Ⅱ during 0-2 h,24-48 h of postoperation（P0.05）.Conclusion Paravertebral block combined with PCIA can provide adequate postoperative analgesia after thoracotomy.Hemodynamic changes induced by general anesthesia combined with epidural anesthesia is characterized by SVV increase without MAP drop,while hemodynamic changes induced by general anesthesia combined with paravertebral block is characterized by MAP decrease without SVV increase.