胸椎旁神经阻滞联合全身麻醉用于单操作孔胸腔镜肺癌根治术患者的改良效果

Modifiying efficacy of thoracic paravertebral block combined with general anesthesia in patients undergoing single-port video-assisted thoracoscopic radical operation for lung cancer

目的 评价胸椎旁神经阻滞联合全身麻醉用于单操作孔胸腔镜肺癌根治术患者的改良效果.方法 选择行单操作孔胸腔镜下肺癌根治术患者66例,年龄18~64岁,BMI 20~24 kg∕m^2,ASA分级Ⅰ或Ⅱ级,性别不限,采用随机数字表法分为2组(n=33):全身麻醉联合胸椎旁神经阻滞组(TPVB+GA组)和全身麻醉组(GA组).TPVB+GA组于麻醉诱导前在超声引导下行胸4和胸7椎旁神经阻滞,两点分别注入0.5%罗哌卡因10 ml.静脉注射咪达唑仑、依托咪酯、舒芬太尼和罗库溴铵行麻醉诱导;吸入七氟醚,静脉输注瑞芬太尼行麻醉维持.术后采用舒芬太尼、氟比洛芬酯和托烷司琼行PCIA.PACU期间VAS评分>3分时,静脉注射舒芬太尼0.1μg∕kg;镇静躁动评分>5分时,静脉注射丙泊酚0.5~1.0 mg∕kg;MAP较基础水平升高大于30%时,静脉注射尼卡地平0.2 mg∕次;HR>100次∕min时,静脉注射艾司洛尔20 mg∕次.分别于切皮后5 min、胸腔镜套管置入5、20、30和60 min时记录呼气末七氟醚浓度.分别于麻醉诱导前、胸腔镜套管置入后5 min、关闭胸腔即刻和术后6、24 h时,采集静脉血样,采用ELISA法测定血浆去甲肾上腺素浓度.记录术中瑞芬太尼用量、PACU期间舒芬太尼、丙泊酚、尼卡地平、艾司洛尔的使用情况以及停留时间、术后恶心呕吐发生情况.结果 与GA组比较,TPVB+GA组术中呼气末七氟醚浓度和瑞芬太尼用量降低,术中及术后各时点去甲肾上腺素浓度降低,PACU期间舒芬太尼、丙泊酚、尼卡地平和艾司洛尔的使用率降低,停留时间缩短(P<0.05).2组均未见术后恶心呕吐发生.结论 相对于单纯全身麻醉而言,胸椎旁神经阻滞联合全身麻醉用于单操作胸腔孔肺癌根治术患者,有助于实现低阿片类药物麻醉模式,减少吸入麻醉药的用量,提高麻醉恢复质量,更有利于术中、术后应激反应及术后痛敏反应的抑制.

Objective To evaluate the modifying efficacy of thoracic paravertebral block ( TPVB) combined with general anesthesia in the patients undergoing single-port video-assisted thoracoscopic radical operation for lung cancer. Methods Sixty-six American Society of Anesthesiologists physical status Ⅰ orⅡ patients of both sexes, aged 18-64 yr, with body mass index of 20-24 kg∕m^2 , undergoing elective sin-gle-port video-assisted thoracoscopic radical resection of lung cancer, were divided into TPVB plus general anesthesia group ( group TPVB+GA, n=33) and general anesthesia group ( group GA, n=33) using a random number table method. Ultrasound-guided TPVB was performed at T4 and T7 before induction of gen-eral anesthesia, and 0. 5% ropivacaine 10 ml was injected into the two sites. General anesthesia was in-duced with midazolam, etomidate, sufentanil and rocuronium. Anesthesia was maintained by inhaling sevoflurane and infusing remifentanil. Patient-controlled intravenous analgesia ( PCIA ) with fentanyl 2μg∕kg, flurbiprofen 100 mg and 10 mg in 100 ml of normal saline. Sufentanil 0. 1μg∕kg was intravenously injected when VAS score≥4 during postanesthesia care unit ( PACU) . Propofol 0. 5-1. 0 mg∕kg was intra-venously injected when Sedation-Agitation Scale scores>5 during PACU. Nicardipine 0. 2 mg was injected intravenously when mean arterial pressureheart was increased by 30% of baseline value during PACU. Es-molol 20 mg was given inravenously when heart rate was>100 bpm during PACU. The end-tidal concentra-tion of sevoflurane was recorded at 5 min after incision and at 5, 20, 30 and 60 min after inserting thoraco-scopic cannula. Venous blood samples were collected before operation, at 5 min after inserting thoracoscop-ic cannula, at closing chest and at 6 and 24 h after operation for determination of plasma norepinephrine concentrations by enzyme-linked immunosorbent assay. The consumption of remifentanil during opertion, requirement for sufentanil, propofol, nicardipine and esmolol during PACU, duration of PACU stay and development of postoperative nausea and vomiting were recorded. Results Compared with group GA, the intraoperative end-tidal concentration of sevoflurane and consumption of remifentanil were significantly re-duced, the concentration of norepinephrine was decreased at each time point during and after surgery, and the requirement for sufentanil, propofol, nicardipine and esmolol was decreased during PACU, and dura-tion of PACU stay was shortened during stay in PACU in group TPVB+GA ( P<0. 05) . Postoperative nause-a and vomiting was not found in the two groups. Conclusion TPVB combined with general anesthesia is helpful in carrying out anesthetic model of low-consumption opioids and in improving the quality of recovery from anesthesia and is more helpful in inhibiting intraoperative and postoperative stress responses and post-operative pain responses than general anesthesia alone when used for the single-port video-assisted thoraco-scopic radical operation for lung cancer.