穴位局部皮下镇痛对全麻术后患者免疫功能的影响

Effect of Subcutaneous Injection of Lidocaine in Zusanli(ST 36)and Jiaji(EX-B 2)Regions on Immune Function in Patients Undergoing Laparoscopic Cholecystectomy

目的:观察经腹腔镜胆囊切除术后几种镇痛模式的镇痛效果及其对患者血清白介素-1β(IL-1β)、肿瘤坏死因子-α(TNF-α)和T淋巴细胞亚群的影响。方法 :选择经腹腔镜胆囊切除手术患者80例,随机分为T 8夹脊穴组、足三里组、皮下镇痛组、静脉镇痛组,各20例。各组均采用相同的麻醉诱导和麻醉维持方式,T 8夹脊穴组及足三里组采用T 8夹脊穴下及足三里穴下留置硬膜外导管,皮下镇痛组留置针位于右前臂前侧近肘处皮下,静脉镇痛组留置针位于右前臂内侧静脉。气管导管拔出后连接自控镇痛泵(PCA)。记录患者麻醉前(T 0)、拔管后(T 1)以及术后镇痛6h(T 2)、24h(T 3)和48h(T 4)的生命体征、视觉模拟评分(VAS),同时记录患者在镇痛过程中按压PCA次数以及舒芬太尼的总用量,并分别于T 0、T 1以及T 3、T 4采集外周静脉血,用酶联免疫吸附法检测血清中IL-1β和TNF-α含量,用流式细胞仪检测外周血CD4+、CD8+的计数,并计算CD4+/CD8+比值。结果:各时间点VAS与T 1相比有显著降低(P<0.05)。与皮下镇痛组和静脉镇痛组相比,T 8夹脊穴组及足三里组PCA按压次数以及舒芬太尼的用量显著减少(P<0.05)。各组T 1时间点血清IL-1β和TNF-α含量与T 0相比均显著上升(P<0.05);与皮下镇痛组和静脉镇痛组比较,T 3和T 4时T 8夹脊穴组及足三里组均有显著降低(P<0.05)。与T 0比较,T 3和T 4时各组CD4+/CD8+比值均有显著的降低(P<0.05)。结论:4种镇痛模式均能提供良好的术后镇痛;与传统静脉镇痛相比,穴位局部皮下镇痛能减少麻醉性镇痛药物的用量,同时可能对术后患者的免疫功能抑制有一定的改善作用。

Objective To observe the effect of acupoint injection of Lidocaine on serum IL-1β,TNF-αand T-lymphocyte subset activities in patients undergoing laparoscopic cholecystectomy（LC）,so as to reveal its mechanisms underlying relieving postoperative pain and potentiating rehabilitation.Methods Eighty patients scheduled for elective LC surgery（grade I or II,according to American Standards of Association,ASA）were randomly divided into four groups,namely intravenous analgesia（IVA）,right forearm-injection（forearm-I）,Jiaji（EX-B 2,Thorax 8）-injection（EX-B 2-I）,and Zusanli-injection（ST 36-I）,with20 patients in each group.The conventional anesthetic induction and maintenance with Penehyclidine Hydrochloride,Midazolam,Sulfentanil,Propofol,Atracurium Besilate,and Remifentanil were same in all the 4groups.For patients of the forearm-I,EX-B 2-I and ST 36-I groups,5% Lidocaine was injected into the subcutaneous layer of the anterior side of right forearm near the elbow,EX-B 2and ST 36 regions,respectively.Analgesia pump（filled with Sulfentanil,Ramosetron＋normal saline）was connected after the tracheal extubation.The visual analog scale（VAS）was used to assess the patient’s pain reaction after tracheal extubation（T 1）,and 6h（T 2）,24h（T 3）and 48h（T 4）after surgery.The times of PCA pressing and the total dose of Sufentanil in the process of postoperative analgesia were recorded as well.The contents of serum IL-1βand TNF-αwere analyzed by ELISA,and the counts of CD4＋and CD8＋T cells were detected by flow cytometry.Results Compared with T 1in the same one group,the VAS scores at time-points of T 2,T 3and T 4after surgery of all the IVA,forearm-I,ST 36-I and EX-B 2-I groups were reduced significantly（P〈0.05）.The times of PCA pump pressing and the doses of the administrated Sufentanil were considerably lower in the ST 36-I and EX-B 2-I groups than in the IVA and forearm-I groups（P〈0.05）.In comparison with pre-anesthesia in the same one group,serum TNF-αand IL-1βcontents at T 1were remarkably increased,while the ratios of CD4＋/CD8＋at T 4in the 4groups were evidently down-regulated（P〈0.05）.The contents of serum TNF-αand IL-1βat T 3and T 4were obviously lower in both ST 36-I and EX-B 2-I groups than in the IVA and forearm-Ⅰ groups（P〈0.05）.No significant differences were found among the 4groups in the VAS scores at the 4time-points,in the serum TNF-αand IL-1βcontents at T 0and T 1,in the counts of CD4＋and CD8＋T cells and ratios of CD4＋/CD8＋at T 0,T 3and T 4,and between the ST 36-I and EX-B 2-I groups in all the 8indexes（P〉0.05）.Conclusion Acupoint injection of Lidocaine is effective in relieving pain in LC patients,which is demonstrated by reducing VAS score,PCA pump pressing times,and administrated Sufentanil dose,and may be associated with its effects in down-regulating serum TNF-αand IL-1βcontents.