帕瑞昔布钠联合连续股神经阻滞对老年患者围术期Th1/Th2平衡的影响

Effects of parecoxib sodium combined with continuous femoral nerve block on the balance of Th1/Th2 in elderly patients after total knee arthroplasty

目的：观察帕瑞昔布钠联合连续股神经阻滞对老年患者全膝关节置换术（total knee arthroplasty,TKA）术后疼痛及围术期 Th1/Th2平衡的影响。方法选择择期行 TKA患者50例,男33例,女17例,年龄65~80岁,ASAⅠ或Ⅱ级。采用随机数字法将患者分为帕瑞昔布钠联合股神经阻滞镇痛组（A组）和帕瑞昔布钠联合静脉自控镇痛组（B 组）,每组25例。两组均采用快速诱导喉罩全麻,均于手术切皮前30 min 静脉滴注帕瑞昔布钠40 mg,首次注射8 h 后再次静脉滴注帕瑞昔布钠40 mg。A组术毕术侧股神经穿刺置管并连接电子镇痛泵,B 组术后静脉接电子镇痛泵。记录术后6、12、24、36、48 h 静息及运动时的 VAS 评分,分别在麻醉前（T0）、术毕（T1）、术后24 h （T2）、48 h（T3）、72 h（T4）抽取外周静脉血4 ml,采用 ELISA法测定血浆 IFN-γ和 IL-10浓度,采用放射免疫分析法测定血浆皮质醇（Cor）浓度。记录术后48 h 内患者不良反应发生情况。结果术后6、12 h A组静息时 VAS 评分明显低于B组,术后各时点 A组运动时 VAS 评分明显低于B组（P 〈0.05）；与 T0时比较,T1~T3时两组血浆 Cor 浓度明显升高,T2、T3时 A组血浆 IFN-γ浓度明显降低,T2~T4时B组血浆 IFN-γ浓度明显降低,T1~T4时两组血浆 IL-10浓度明显升高（P 〈0.05）；T1~T3时 A组血浆 Cor 浓度明显低于B组,T2~T4时 A组血浆 IFN-γ浓度明显高于B组,T1~T4时 A组血浆 IL-10浓度明显低于B组（P 〈0.05）。A组患者术后恶心、呕吐及皮肤瘙痒发生率明显低于B组（P 〈0.05）。结论帕瑞昔布钠联合连续股神经阻滞具有良好的镇痛效果,术后不良反应发生率更低,可以有效减少患者 Cor 的分泌,同时延缓 IFN-γ分泌的减少和 IL-10分泌的增加,有效保护患者的免疫功能。

Objective To study the effects of parecoxib sodium combined with continuous femoral nerve block on the balance of Th1/Th2 in elderly patients after total knee arthroplasty. Methods Fifty elderly patients,33 males and 1 7 females,aged 65 to 80 years,with ASA Ⅰ or Ⅱtreated with total knee arthroplasty were randomly divided into two groups （n =25 each）：parecoxib sodium combined with continuous femoral nerve block group （group A）and parecoxib sodium com-bined with intravenous analgesia group （group B）.Quick induce laryngeal mask anesthesia and intra-venous parecoxib sodium 40 mg at 30 min before skin incision were adopted in both groups.After the first 8 h,parecoxib sodium of 40 mg was intravenously injected again.The patients in group A re-ceived femoral nerve puncture and continuous electronic analgesia pump.The patients in group B re-ceived postoperative intravenous electronic analgesia pump.Visual analogue score（VAS）during rest and movement at 6,12,24,36,48 h after operation,side effects in two groups were recorded,venous blood samples were taken before anesthesia （T0 ）,at the end of operation （T1 ）,and 24 h（T2 ）,48 h （T3 ）,72 h （T4 ）after operation for determination of plasma IFN-γ,IL-10 and cortisol （Cor）. Results The values of VAS were significantly lower in group A compared with group B in rest at 6, 12 h after operation,the values of VAS were significantly lower in group A compared with group B in moving at every time points after surgery （P 〈0.05 ）.The plasma Cor concentrations were signifi-cantly increased at T1-T3 compared with baseline value at T0 in two groups（P 〈0.05 ）.The plasma Cor concentrations in group A were significantly decreased compared with group B at T1-T3 （P 〈0.05）.The plasma IFN-γconcentrations were significantly lower at T2 and T3 compared with baseline value at T0 in group A,the plasma IFN-γ concentrations were significantly lower at T2-T4 compared with baseline value at T0 in group B （P 〈0.05）,the plasma IFN-γ concentrations were significantly increased in group A compared with group B at T2-T4 （P 〈0.05 ）.The plasma IL-10 concentrations were significantly increased compared with baseline value at T1-T4 in two groups （P 〈 0.05 ）,the plasma IL-10 concentrations were significantly decreased in group A compared with group B at T1-T4 （P 〈0.05）.Compared with group B,the incidence of postoperative nausea,vomiting and pruritus in group A was lowered significantly （P 〈0.05）.Conclusion Parecoxib sodium combined with continu-ous femoral nerve block on postoperative pain in elderly patients after total knee arthroplasty can a-chieve good effect of postoperative analgesia and fewer complications, lower cortisol secretion, slowing down the decrease of IFN-γ secretion and the increase of IL-10 secretion.This method could effectively protect the immune function of patients undergoing arthroplasty.