右美托咪啶对胸腹腔镜下食管癌根治术患者围手术期应激和术后疼痛的影响

Effect of dexmedetomidine on perioperative stress and postoperative pain in patients With radical resection of esophageal cancer under combined thoracoscope and laparoscope

目的 探讨右美托咪啶对胸腹腔镜下食管癌根治术患者围手术期应激和术后疼痛的影响.方法 本研究为前瞻性研究.选取2016年1月至2017年10月在郑州大学附属肿瘤医院行胸腹腔镜下食管癌根治术患者100例,随机数字表法分为对照组(C组)、右美托咪啶组(D组).两组患者均进行静脉靶控输注丙泊酚和瑞芬太尼、静脉推注苯磺酸阿曲库铵进行麻醉诱导和维持,脑电双频指数(BIS)监测麻醉深度,术中维持BIS值45~60,术毕前30 min单次静脉注射舒芬太尼(0.3μg/kg)后接静脉镇痛泵进行术后患者自控镇痛(PCA).D组患者诱导前20 min静脉滴注右美托咪啶(1μg/kg)、术中静脉泵注右美托咪啶(0.2μg·kg-1·h-1),PCA舒芬太尼0.025μg·kg-1·h-1+右美托咪啶0.1μg·kg-1·h-1,单次按压给予舒芬太尼0.025μg/kg+右美托咪啶0.1μg/kg.C组PCA舒芬太尼0.04μg·kg-1·h-1,单次按压给予舒芬太尼0.04μg/kg.记录患者手术时间、液体出入量、术后PCA按压次数,并于术前1 d(T0)、麻醉诱导前即刻(T1)、麻醉苏醒后1 h(T2)、术后24 h(T3)、术后3 d(T4)、术后7 d(T5)、术后1个月(T6)、术后3个月(T7)、术后6个月(T8)采集静脉血检测血清去甲肾上腺素、肾上腺素、皮质酮水平;并于T2、T3、T4、T5、T6、T7、T8时间点对患者进行疼痛模拟评分.结果 2组患者年龄、性别、体质指数(BMI)、美国麻醉医师协会(ASA)分级差异均无统计学意义(均P>0.05).2组患者手术时间、术中补液量、术中出血量差异均无统计学意义(均P>0.05).D组术后24 h内舒芬太尼用量为(35.86±8.65)μg,明显少于C组的(59.53±15.26)μg,差异有统计学意义(t=7.061,P<0.05).D组术后24 h内PCA按压次数为(2.15±1.38)次,明显少于C组[(5.85±2.16)次,t=4.971,P<0.05].D组血清去甲肾上腺素水平在T1、T2、T3、T4、T5时间点均明显低于C组(t=13.276、16.027、14.319、12.771、12.296,均P<0.05);其余时间点两组差异均无统计学意义(均P>0.05).D组血清肾上腺素水平在T2、T3、T4、T5时间点均明显低于C组(t=6.153、8.774、9.127、8.409,均P<0.05);其余时间点两组差异均无统计学意义(均P>0.05).D组血清皮质酮水平在T2、T3、T4、T5时间点明显低于C组(t=16.364、15.306、12.153、12.592,均P<0.05);其余时间点两组差异均无统计学意义(均P>0.05).2组术后疼痛VAS评分在T2、T3、T4、T5时间点差异均无统计学意义(均P>0.05);D组在T6、T7、T8时间点疼痛患者(VAS评分≥4分)分别为10例(20%)、4例(8%)、3例(6%),均明显低于C组20例(40%)、12例(24%)、10例(20%),差异均有统计学意义(χ2=4.762、4.762、4.332,均P<0.05).结论 围手术期应用右美托咪啶可以有效减轻胸外科胸腹腔镜联合食管癌根治术患者围手术期应激水平,减少围手术期阿片类药物应用,并减少患者术后慢性疼痛的发生率.

Objective To investigate the effects of dexmedetomidine on perioperative stress and postoperative pain in patients with radical resection of esophageal cancer under combined thoracoscope and laparoscope.Methods In this prospective study,one hundred patients undergoing radical resection of esophageal cancer in Affiliated Cancer Hospital of Zhengzhou University from January 2016 to October 2017, were randomly divided into control group (group C)and dexmedetomidine group (group D),n =50.All patients were anaesthetized (induced and maintained)with intravenous target-controlled infusion(TC[)of propofol and remifentanil,and intermittent intravenous injection of cisatracuriumbesylate.Bispectral index (BIS)was used to monitor the depth of anesthesia and maintained between 45-60during operation.All patients received sufentanil (0.3μg/kg)30min before the end of the operation and then received intravenous analgesia pump for postoperative patient controlled analgesia (PCA).Patients in group D received intravenous infusion of dexmcdetomidine (1g,g/kg)20min before anesthesia induction,followed by intravenous pumping of dexmedetomidine (0.2μg·kg^-1·h^-1)intraoperatively.Postoperative intravenous patient-controlled analgesia(PCA)was performed in all patients,with background doses of sufentanil 0.04 μg·kg^-1·h^-1for patients in group C,and sufentanil 0.025μg·kg^-1·h^-1 plus dexmedetomidine 0.1 μg·kg^-1·h^-1 for patients in group D.The operation time,liquid input and output during operation,the number of PCA pressings after operation were recorded.At these time points:T0(the day before operation), T1(immediate before anesthesia induction),T2(1h after emergence),T3(24h after operation),T4(3d after operation),T6 (7d after operation),T6(one month after operation),T7(3months after operation)and T8(6 month after operation),venous blood samples of patients were collected for detection of epinephrine, norepinephrine and eorticosterone.The pain visual analogue scale (VSA)was used to assess pain levels in patients at T2,T3,T4,T5,T6,T7,Ts.Results The age,sex ratio,body mass index (BMI)and ASA grading ratio in two groups were not significantly different (all P >0.05).There were no Significant differences in operation time,liquid input and blood output between group C and group D (all P >0.05).Within 24h after operation,the sufentanil consumption in group D [(35.86±8.65)μg ]was significantly less than that in group C[(59.53±15.26)μg,t =7.061,P <0.05],and the number of PCA pressing in group D(2.15± 1.38)was obviously less than that in group C(5.85±2.16,t =4.971,P <0.05).Compared with group C,serum norepinephrines in group D was significantly less (t =13.276,16.027,14.319,12.771,12.296, respectively;all P <0.05)at T1,T2,T3,T4,T5.And there were no difference between these two groups at To,T6,T7,T8 (all P >0.05).Serum epinephrine in group D were siguificanfly lower than them in group C at T2,T3,T4,T5(t =6.153,8.774,9.127,8.409,respectively ;all P <0.05),but there were no difference between these two groups at T0,T1 ,T6,T7,T8 (all P >0.05).Serum corticosterone in group D were sharply less than them in group C at T2,T3,T4,T5(t =16.364,15.306,12.153,12.592,respectively;all P < 0.05),but at T0,T1,T6,T7,T8,there were no difference between these two groups (all P >0.05). Compared with group C,the number of patients with postoperative pain (VAS score >/4)in group D was obviously less at T6,T7,T8 (10vs 20,4vs 12,3vs 10;x^2=4.762,4.762,4.332,respectively ;all P < 0.05).Conclusion Perioperative application of dexmedetomidine can effectively decrease the perioperative stress response,obviously cut down the perioperative opioid consumption,and prevent the transition from postoperative acute pain to chronic pain in patients with radical resection of esophageal caneer under combined thoracoscope and laparoscope.