椎旁神经阻滞用于开胸术老年患者超前镇痛的效果

Efficacy of paravertebral block for preemptive analgesia in elderly patients undergoing thoracotomy

目的评价椎旁神经阻滞用于开胸术老年患者超前镇痛的效果。方法选择择期左侧开胸食管癌根治术患者60例，年龄65～70岁，体重指数18～23kg／m^2，ASA分级Ⅰ或Ⅱ级，采用随机数字表法分为2组（n=30）：全凭静脉麻醉组（Ⅰ组）和全凭静脉麻醉联合椎旁神经阻滞组（B组）。静脉输注右美托咪定0．4μg·kg^-1·min^-1，依次静脉注射咪达唑仑0．04mg／kg、异丙酚2mg／kg、舒芬太尼0．5μg／kg、罗库溴铵0．8mg／kg进行麻醉诱导，B组在麻醉诱导后，在超声引导下行椎旁神经阻滞，于左侧T4-8肋间椎旁间隙分别注入0．5％罗哌卡因5ml。麻醉维持：静脉输注异丙酚6～8mg·kg^-1·h^-1瑞芬太尼0．1～0．3μg·kg^-1·min^-1，间断静脉注射罗库溴铵维持肌松。PCIA方法：舒芬太尼2μg／kg＋地佐辛10mg＋右美托咪定100μg，用生理盐水100ml稀释，背景输注速率2ml／h，PCA剂量2ml，锁定时间15min。术后维持Prince—Henry评分≤3分。于切皮前5min、切皮后5min、开胸后5min记录MAP和HR，记录术中麻醉药用量、气管拔管时间、气管拔管后30min时SpO2、PCIA单位时间用药量、术后肺部并发症发生情况、入ICU情况及术后恢复时间。结果2组未见心血管事件发生。与I组比较，B组术中异丙酚、瑞芬太尼和罗库溴铵用量降低，气管拔管时间缩短，气管拔管后30min时SpO2升高，PCIA单位时间用药量减少，术后并发症发生率和入ICU率降低，术后恢复时间缩短（P〈0．05）。结论椎旁神经阻滞用于开胸术老年患者具有良好的超前镇痛效果。

Objective To evaluate the efficacy of paravertebral block for preemptive analgesia in elderly patients undergoing thoraeotomy. Methods Sixty patients, aged 65-70 yr, with body mass index of 18-23 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ , scheduled for elective radical resection for esophageal cancer through a left thoracotomy, were randomly divided into total intravenous anesthesia group （group Ⅰ） and total intravenous anesthesia combined with paravertebral block group （ group B） with 30 patients in each group. Anesthesia was induced with iv infusion of dexmedetomidine 0.4 μg·kg^-1·min^-1 , and iv injection of midazolam 0. 04 mg/kg, propofol 2 mg/kg, sufentanil 0.5 μg/kg and rocuronium 0. 8 mg/kg. In group B, paravertebral block was performed under the guidance of altrasound after induction of anesthesia, a paravertebral catheter was placed at T4-5 in the paravertebral space on the left side, and 0.5% ropivaeaine 5 ml was injected via the catheter into the paravertebral space. Anesthesia wasmaintained with iv infusion of propofol 6-8 mg · kg^-1 · h^-1 and remifentanil 0. 1-0. 3μg·kg^-1·min^-1, and intermittent iv blouses of rocuronium. Patient-controlled intravenous analgesia （PCIA） was used after operation. PCIA solution contained sufentanil 2 μg/kg, dezocine 10 mg, and dexmedetomidine 100 μg in 100 ml of normal saline. The PCIA pump was set up with a 2 ml bolus dose, a 15 min lockout interval, and background infusion at a rate of 2 ml/h. Prince-Henry score was maintained ≤ 3 after operation. At 5 min before skin incision, 5 min after skin incision, and 5 min after thoracotomy, the mean arterial pressure and heart rate were recorded. The intraoperative consumption of anesthetics, the extubation time, SpO2 at 30 min after extubation, amount of drugs consumed per hour during PCIA, occurrence of postoperative pulmonary complications, patients who required intensive care unit admission, and postoperative re- covery time were recorded. Results No cardiovascular events were found in the two groups. Compared with group I, the intraoperative consumption of propofol, remifentanil and rocuronium was significantly decreased, extubation time was shortened, the SpO2 at 30 min after extubation was increased, the amount of drugs consumed per hour during PCIA was reduced, the incidence of postoperative complications and the number of patients who required ICU admission were decreased, and the postoperative recovery time was shortened in group B （P〈0. 05）. Conclusion Paravertebral block produces good efficacy for preemptive analgesia in elderly patients undergoing thoracotomy.