硬膜外阻滞和术后镇痛对胸壁结核患者术后T细胞亚群及血浆皮质醇的影响

The effects of epidural blockade and postoperative PCEA on T-lymphocyte subsets and plasma cortisol in patients undergoing chest wall tuberculosis surgery

目的观察全麻联合硬膜外阻滞和术后镇痛对胸壁结核患者术后T细胞亚群比例及血浆皮质醇变化的影响。方法选择60例ASAⅠ或Ⅱ级择期行胸壁结核病灶清除术的患者,随机均分为三组,A组:静脉复合全麻+术后静脉患者自控镇痛(PCIA),B组:静脉复合全麻联合硬膜外阻滞+术后PCIA,C组:静脉复合全麻联合硬膜外阻滞+术后硬膜外患者自控镇痛(PCEA),分别于麻醉前30min(T0)、术后4h(T1)、术后1d(T2)、术后2d(T3)、术后3d(T4)及7d(T5)晨抽取外周静脉血2ml,用流式细胞仪测定患者外周血T细胞亚群CD3+、CD4+和CD8+,用放免法测定各时点血浆皮质醇水平,记录T1～T4各时疼痛VAS和镇静RSS评分。结果 T1、T2时A组的VAS评分明显高于B、C组(P<0.05);C组的RSS评分明显高于A、B组(P<0.05)。在T1和T2时三组患者的CD3+、CD4+、CD8+、CD4+/CD8+均明显低于T0时(P<0.05,P<0.01);C组T4时恢复至T0水平,A组和B组T5时恢复至T0时水平。T3、T4时A、B两组血浆皮质醇水平明显高于C组(P<0.05)。结论静脉复合全麻基础上联合硬膜外阻滞和PCEA可使胸壁结核病灶清除术的患者外周血T淋巴细胞各亚群比例较早恢复到术前水平,其机制与抑制皮质醇水平上升有关。

Objective To investigate the effect of general anesthesia combined epidurat blockade and PCEA on the changes of the ratios of T-lymphocyte subsets and levels of plasma eortisol in patients undergoing chest wall tuberculosis surgery. Methods Sixty ASA classⅠ or Ⅱ patients undergoing chest wall tuberculosis surgery were randomly devided into three groups with 20 cases each. The patients in group A were used with total intravenous anesthesia （TIVA） and PCIA; in group B with TIVA combined epidural block and PCIA; and in group C with TIVA combined epidural block and PCEA. Two ml peripheral blood samples were taken at half an hour before induction of anesthesia（T0 ） ,4 hours after operation（T1 ） and on the first（T2 ）, second（T3 ）, third（T4 ）, seventh （T5） postoperative day in the morning. T-lymphocyte subsets（CD3＋,CD4＋, CD8＋, CD4＋/CD8＋） were detected by flow cytometry. The levels of plasma cortisol were measured by RIA. VAS and RSS scores were recored from T1 to T4 time points. Results VAS scores in group A at T1 and T2 were much higher than those in group B and C（P〈0. 05）. RSS scores in group C at T1 and T2 were much higher than those in group A and B （P〈0.05）, respectively. CD3＋ ,CD4＋ ,CD8＋ and CD4＋/CD8 ＋decreased significantly at T1 and T2 in three groups compared with those in To （P〈0. 05 or P〈0. 01） , respectively. The ratios of T-lymphocyte subsets in the group C at T4 recovered to the preoperative levels, while group A and B at T5. Plasma cortisol levels in group A and B at T3 and T4 were much higher than those in group C（P〈0.05）. Conclusion The ratios of the T-lymphocyte subsets in peripheral blood of the patients undergoing chest wall tuberculosis surgery under the TIVA combined epidural block and PCEA can be recovered to the perioperative levels as soon as possible, which mechanism is related to the suppression of the plasma eortisol level.