超声引导连续胸椎旁神经阻滞复合右美托咪定麻醉对食管癌手术患者围术期应激反应的影响

Effect of ultrasound-guided paravertebral nerve block combined with dexmedetomidine on stress reaction in patients undergoing esophagus cancer operation

目的探讨超声引导连续胸椎旁神经阻滞复合右美托咪定麻醉对食管癌手术患者围术期应激反应的影响。方法择期食管癌开胸手术患者90例,采用随机数字表法分为连续胸椎旁神经阻滞复合右美托咪定全身麻醉组（A组）、单纯全身麻醉复合右美托咪定组（B组）和单纯全身麻醉组（C组）,每组30例。3组患者均实施双腔支气管插管人工通气下全身静脉麻醉;A组和B组全身麻醉过程中持续泵注右美托咪定;A组于全身麻醉诱导前在麻醉准备间行床旁坐位超声引导下连续胸椎旁神经阻滞并留置聚氯乙烯连续镇痛导管,术后采用连续椎旁神经阻滞连续镇痛复合患者静脉自控镇痛;B组和C组患者术后单纯采用静脉自控镇痛。记录患者术中全身麻醉药物用量及麻醉前（T_0）、诱导前（T_1）、气管插管即刻（T_2）、手术2 h（T_3）、术毕（T_4）、术后1 h（T_5）、4 h（T_6）、8 h（T_7）、24 h（T_8）、48 h（T_9）的收缩压（SBP）、舒张压（DBP）、心率（HR）和血氧饱和度（Sp O2）,记录T_5～T_9时视觉模拟量表（VAS）疼痛评分和Ramsay镇静评分,并于T_1、T_3、T_4、T_8、T_9时中心静脉采静脉血检测血糖、肾上腺素（E）、去甲肾上腺素（NE）和多巴胺（DA）水平。结果 A组患者术中异丙酚、瑞芬太尼用量明显少于B组和C组（P〈0.05）。3组患者T_2和T_3时的SBP、DBP均较T_1时降低（P〈0.05）。T_1～T_4时,3组患者之间SBP、DBP、Sp O2比较差异均无统计学意义（P〉0.05）。T_1、T_2时,3组患者之间HR比较差异均无统计学意义（P〉0.05）;T_3、T_4时A组、B组患者HR均低于C组同时间点（P〈0.05）。术后T_5～T_9时,A组患者VAS疼痛评分明显低于B组和C组（P〈0.05）;3组患者之间术后T_5～T_9Ramsay镇静评分比较差异均无统计学意义（P〉0.05）。3组患者T_3、T_4时NE、E水平均低于T_1时（P〈0.05）,DA水平均高于T_1时（P〈0.05）;T_8、T_9时血糖水平均高于T_1、T_3、T_4时（P〈0.05）。A组患者T_8、T_9时NE水平均低于T_1时（P〈0.05）;B组、C组患者T_8、T_9时NE水平均高于T_1、T_3、T_4时（P〈0.05）。A组患者T_8时E、DA水平均低于T_1、T_3、T_4时（P〈0.05）;T_9时的E水平高于T_3、T_4时（P〈0.05）;A组患者T_9时DA水平高于T_1时（P〈0.05）,但低于T_3、T_4时（P〈0.05）。B组、C组患者T_8时E水平均低于T_1时（P〈0.05）,但高于T_3、T_4时（P〈0.05）;B组、C组患者T_8时DA水平均高于T_1时（P〈0.05）,低于T_3、T_4时（P〈0.05）。B组、C组患者T_9时的E、DA均高于T_1、T_3、T_4时（P〈0.05）。3组患者T_1时血糖、NE、E和DA水平比较差异均无统计学意义（P〉0.05）。A组患者T_8、T_9时血糖、NE、E、DA水平均低于B组和C组同时间点（P〈0.05）,T_3、T_4时与B组和C组比较差异均无统计学意义（P〉0.05）。B组患者T_3、T_4、T_8、T_9时血糖、NE、E、DA水平与C组比较差异均无统计学意义（P〉0.05）。结论超声引导连续胸椎旁神经阻滞复合右美托咪定麻醉合并术后连续静脉自控镇痛用于食管癌手术的复合麻醉及术后镇痛安全有效,可减少术中全身麻醉药物的使用,更好地抑制应激反应。

Objective T_o investigate the effect of ultrasound-guided paravertebral nerve block combined with dexmedetomidine on stress reaction in patients undergoing esophagus cancer operation. Methods Ninety patients scheduled for esophageal surgery were randomly divided into three groups with 30 cases in each group,which included ultrasound-guided paravertebral nerve block combined with dexmedetomidine group（ group A）,general anesthesia combined with dexmedetomidine group（ group B） and general anesthesia group（ group C）. All the patients in the three groups were given total intravenous anesthesia under bronchial cannula. T_he group A and group B were given dexmedetomidine continuously during the process of general anesthesia. T_he patients in group A were given the general anesthesia combined with ultrasound-guided paravertebral block and were placed polyvinyl chloride continuous analgesia catheter to give dexmedetomidine in the operation and the patients were given paravertebral nerve block analgesia combined with controlled intravenous analgesia after operation. T_he patients in group B and group C were given controlled intravenous analgesia after operation. T_he dosage of propofol and remifen-tanil was recorded. T_he systolic blood pressure（ SBP）,diastolic blood pressure（ DBP）,heart rate（ HR） and pulseoxygen saturation（ Spo2） were recorded at the time of before operation（ T_0）,before anesthesia（ T_1）,trachea cannula（ T_2）,two hours in operation（ T_3）,operation finished（ T_4）,post-operation one hour（ T_5）,post-operation four hours（ T_6）,post-operation eight hours（ T_7）,post-operation twenty-four hours（ T_8） and post-operation forty-eight hours（ T_9）. T_he scores of visual analogue scales（ VAS） and Ramsay sedation were recorded at T_5- T_9. T_he value of blood glucose,the plasma concentrations of epinephrine（ E）,noradrenaline（ NE） and dopamine（ DA） were also detected at the time of T_1,T_3,T_4,T_8 and T_9. Results T_he dosage of propofol and remifentanil was lower in group A than that in group B and group C（ P〈0. 05）. T_he SBP,DBP at the time of T_2 and T_3was lower than that of T_4 in the three groups（ P〈0. 05）. T_here was no significant difference in SBP,DBP,Spo2 among the three groups at the time of T_1,T_2,T_3,T_4（ P〈0. 05）. T_here was no significant difference in HR among the three groups at T_1 and T_2（ P〈0. 05）. At T_3 and T_4,the HR in group A and group B was lower than that in group C（ P〈0. 05）. T_he VAS score in group A at T_5- T_9 was lower than that in group B and group C（ P〈0. 05）,but there was no significant difference in Ramsay sedation score among the three groups at T_5- T_9（ P〈0. 05）. T_he level of NE and E at T_3,T_4 in the three groups was lower than that at T_1（ P〈0. 05）,while the level of DA at T_3,T_4 was higher than at T_1（ P〈0. 05）,the sugar content of blood at T_8 and T_9was higher than that at T_1,T_3,T_4（ P〈0. 05）. T_he level of NE at T_8 and T_9was lower than that at T_1 in group A（ P〈0. 05）. T_he level of NE at T_8 and T_9was higher than that at T_1,T_3,T_4 in group B and group C（ P〈0. 05）. T_he level of E and DA at T_8 in group A was lower than that at T_1,T_3,T_4（ P〈0. 05）,E level at T_9 was higher than that at T_3,T_4（ P〈0. 05）,the DA level at T_9 was higher than that at T_1（ P〈0. 05）,but it is lower than that at T_3,T_4（ P〈0. 05）. T_he level of E in group B and group C at T_8 was lower than that at T_1（ P〈0. 05）,but it was higher than that at T_3 and T_4（ P〈0. 05）. T_he level of DA in group B and group C at T_8 was higher than that at T_1（ P〈0. 05）,but it was lower than that at T_3 and T_4（ P〈0. 05）. T_he level of E and DA at T_9 was in group B and group C was higher than that at T_1,T_3,T_4,（ P〈0. 05）. T_here was no significant difference in the sugar content of blood,NE,E and DA at T_1 among the three groups（ P〈0. 05）. T_he sugar content of blood,NE,E and DA at T_8 and T_9in group A were lower than those in group B and group C（ P〈0. 05）. T_here was no significant difference in the sugar content of blood,NE,E and DA at T_3,T_4 between group B and group C（ P〈0. 05）. T_here was no significant difference in the sugar content of blood,NE,E and DA at T_3,T_4,T_8,T_9 between group B and group C（ P〈0. 05）. Conclusion Ultrasound-guided paravertebral nerve block combined with dexmedetomidine and controlled intravenous analgesia could offer favorable anaesthesia effect,and decrease stress reaction for the patients undergoing esophageal surgery.