直视下单次椎旁神经阻滞用于肺切除患者术后镇痛的效果

Effect of single dose of paravertebral nerve block under direct vision for postoperative analgesia in patients undergoing thoracotomy for lung resection

目的探讨直视下单次椎旁神经阻滞应用于开胸行肺切除患者术后镇痛的效果。方法选取2012年6月—2013年5月在浙江大学医学院附属第二医院择期行开胸肺切除术的患者238例,根据术后采用的镇痛方法分入单次椎旁神经阻滞联合连续静脉注射镇痛组(联合镇痛组,73例)和单纯连续静脉注射镇痛组(单纯镇痛组,165例)。单纯镇痛组患者术后连续静脉注射镇痛药镇痛;联合镇痛组患者在连续静脉注射镇痛药的基础上,于术毕关胸前行术侧单次椎旁神经阻滞。记录并比较两组患者的手术时间、术中出血量、肺切除方式、术后48h内追加镇痛药的患者构成比、术后肺部并发症(肺不张、肺部感染、呼吸衰竭)发生率、术后第1天氧合指数(OI)值,并以术后6、12、24、48h静止和运动时的疼痛视觉模拟评分(VAS评分)作折线图计算并比较AUC(分别为AUCVAS静和AUC_(VAS动))。结果两组间患者的手术时间、术中出血量、肺切除方式的差异均无统计学意义(P值均>0.05)。联合镇痛组患者术后AUCVAS静和AUC_(VAS动)均显著小于单纯镇痛组(P值均<0.05),术后48h内追加镇痛药的患者构成比和术后肺部并发症发生率均显著低于单纯镇痛组(P值均<0.05),术后第1天OI值显著高于单纯镇痛组(P<0.05)。结论直视下单次椎旁神经阻滞联合静脉注射镇痛药的镇痛方法应用于开胸行肺切除患者的术后镇痛效果好,且肺部并发症少,有利于患者早期康复。

Objective To explore the effect of single dose of paravertebral nerve block under direct vision on postoperative analgesia in patients undergoing thoracotomy for lung resection. Methods A total of 238 patients who underwent elective thoracotomy for lung resection in the Second Affiliated Hospital of Zhejiang University between June 2012 and May 2013 were assigned to two groups： combined analgesia group （n = 73） and simple analgesia group （n = 165）. Intravenous injection of analgesic was performed in all patients for postoperative analgesia. Paravertebral nerve block was additionally conducted in the combined analgesia group before closing the chest. Operation time, intraoperative blood loss, the extent of pulmonary resection, the need for supplementary intravenous analgesia and postoperative pulmonary complications （atelectasis, pulmonary infection, and respiratory failure）, oxygenation index （OI） on day one postoperatively, the area under the curve （AUC） of visual analog scale （VAS） at 6 h, 12 h, 24 h, and 48 h postoperatively at rest （AUCvASrest） and cough （AUOvAs=,,0h） were recorded and compared between groups. Results There were no significant differences in operation time, intraoperative blood loss, or the extent of pulmonary resection between groups （all P〉0.05）. Compared with the simple analgesia group, there were smaller AUOvASrest and AUCvAScough, lower proportion of patients in need of supplementary intravenous analgesic and lower incidence of postoperative pulmonary complications in the combined analgesia group （all P〈0.05）. OI in the combined analgesia group was significantly higher than that in the simpleanalgesia group on day one postoperatively （P〈0.05）. Conclusion Single dose of paravertebral nerve block under direct vision combined with intravenous injection of analgesic can achieve effective postoperative analgesia in patients undergoing thoracotomy for lung resection, with lower pulmonary complications and earlier recovery. （Shanghai Med J, 2016, 39： 101-103）