硬膜外阻滞对全麻下肺癌根治术患者术后远期生活质量的影响

Effect of epidural block on postoperative long-term quality of life in patients undergoing radical op- eration for lung cancer under general anesthesia

目的评价硬膜外阻滞对全麻下肺癌根治术患者术后远期生活质量的影响。方法择期全麻下行肺癌根治术的原发性非小细胞肺癌患者348例,性别不限,年龄18~80岁,ASA分级Ⅰ-Ⅲ级,BMI 18~30kg/m^2,IASLC肺癌分期1~2期,采用随机数字表法分为2组(n=174):全麻+PCIA组(G组)和全麻+硬膜外麻醉+PCEA组(GE组)。麻醉诱导:TCI丙泊酚和芬太尼,静脉注射罗库溴铵,气管插管术后行机械通气,维持PETCO230~40mmHg。麻醉维持:TCI丙泊酚,静脉输注瑞芬太尼,进胸后即刻及关胸后即刻分别单次追加芬太尼,静脉注射顺苯磺酸阿曲库铵;GE组硬膜外注射0.375%罗哌卡因首次剂量5~8ml,随后以5ml/h的速率持续硬膜外输注,并于关胸前停止输注;术中维持BIS值40~60。术毕G组采用芬太尼、氟比洛芬酯、雷莫司琼或帕洛诺司琼行PCIA,背景输注速率2ml/h,PCA剂量0.5ml,锁定时间15min;GE组采用0.15%~0.18%罗哌卡因250ml行PCEA,背景输注速率4~5ml/h,PCA剂量2~3ml,锁定时间20min。2组均镇痛至术后48h。分别于术后半年、1和2年时,进行电话随访,采用简明健康相关生命质量量表测量评估患者生活质量,计算生理健康评分和心理健康评分。结果与术后半年时比较,2组术后2年时生理健康评分和心理健康评分降低(P<0.05)。与G组比较,GE组术后2年时生理健康评分和心理健康评分升高(P<0.05)。结论与单纯全麻相比,硬膜外阻滞对全麻下肺癌根治术患者术后远期生活质量产生积极影响。

Objective To evaluate the effect of epidural block on postoperative long-term quality of life in patients undergoing radical operation for lung cancer under general anesthesia.Methods A total of 348patients with primary non-small cell lung cancer of both sexes,aged 18-80yr,of American Society of Anesthesiologists physical status Ⅰ-Ⅲ, with body mass index of 18-30kg/m^2,with International Associa- tion for the Study of Lung Cancer staging criteria stage 1-2,scheduled for elective radical operation for lung cancer under general anesthesia,were divided into 2groups (n =174each)using a random number table method:general anesthesia plus patient-controlled intravenous analgesia (PCIA)group (group G)and general anesthesia plus epidural anesthesia plus patient-controlled epidural analgesia group (group GE). Anesthesia was induced by target-controlled infusion of propofol and fentanyl and intravenous injection of rocuronium.The patients were tracheally intubated and mechanically ventilated to maintain the end-tidal pressure of carbon dioxide at 30-40mmHg.Anesthesia was maintained by target-controlled infusion of propofol and intravenous injection of remifentanil.An increment of fentanyl was given immediately after chest opening and closing,and cisatracurium besylate was injected intravenously.In group GE,0.375% ropivacaine was epidurally injected in a initial dose of 5-8ml followed by continuous epidural infusion at 5 ml/h,and infusion was stopped before closing the chest.Bispectral index value was maintained at 40-60 during operation.PCIA was performed at the end of operation with fentanyl,flurbiprofen,ramosetron or palonosetron hydrochloride,and the PCA pump was set up with a 0.5ml bolus dose,a 15-min lockout in- terval and background infusion at a rate of 2ml/h in group G.Patient-controlled epidural analgesia was performed with 0.15%-0.18%ropivacaine 250ml,and the PCA pump was set up to deliver 2-3ml bolus dose with a 20-min lockout interval and background infusion at 4-5ml/h in group GE.Postoperative analgesia was performed until 48h after operation in both groups.Patients were followed up by telephone at half a year and 1and 2-yr after operation.The 12-item short-form scale was used to evaluate the quality of life. Physical component summary (PCS-12)and mental component summary (MCS-12)scores were calculated. Results PCS-12and MCS-12scores were significantly lower at 2yr after operation than at half a year in both groups (P<0.05).Compared with group G,PCS-12and MCS-12scores were significantly increased at 2yr after operation in group GE (P<0.05).Conclusion Compared with general anesthesia alone,epi- dural block provides better effect on postoperative long-term quality of life in patients undergoing radical operation for lung cancer under general anesthesia.