超声引导自控胸椎旁神经阻滞对多发肋骨骨折患者肺功能的影响

Effect of ultrasound guided patient-controlled paravertebral block on pulmonary function in patients with multiple fractured ribs

目的：探讨静脉自控镇痛（ PCIA）和超声引导下自控胸椎旁神经阻滞（ PCPB）对多发肋骨骨折患者肺功能的影响。方法选择2015年5月至2016年3月在宁波市第六医院择期行多发肋骨骨折内固定术的美国麻醉医师协会分级（ ASA）为Ⅱ～Ⅲ级的患者60例，男性30例，女性30例，年龄16～70岁，平均（54.6±15.2）岁，按照镇痛方式随机将患者分为PCIA组和PCPB组，每组30例。PCIA组采用舒芬太尼，患者自控镇痛（ PCA）单次剂量2 ml（含舒芬太尼2μg）；PCPB组术毕于患侧肋骨骨折部位相应中心区域为穿刺点，椎旁注射0.2％罗哌卡因15 ml，随后行PCPB，药物采用罗哌卡因，PCA剂量5 ml（含罗哌卡因10 mg），镇痛至术后72 h。分别于术前、镇痛后30 min、60 min、1 d、2 d、3 d时采集动脉血，检测pH值、动脉血氧分压（ PaO2）、动脉二氧化碳分压（ PaCO2）、氧合指数（ PaO2／FiO2）和肺泡氧分压.动脉血氧分压差（ PA.aDO2），并检测术前及术后3 d第一秒用力呼气量（FEV1）和FEV1占用力肺活量百分比（FEV1％）。结果与 PCIA 组比较，PCPB 组镇痛后30 min、60 min、1 d、2 d、3 d时PaO2[（85.1±9.7）mmHg比（72.4±12.3）mmHg，（90.3±12.4）mmHg比（73.5±7.8）mmHg，（94.2±8.2）mmHg比（86.1±5.6）mmHg，（98.5±7.0）mmHg比（88.8±7.5）mmHg，（99.6±9.8）mmHg比（91.3±8.6）mmHg，P＜0.05]和PaO2／FiO2升高[（405.1±46.0）mmHg比（340.1±58.9） mmHg，（430.5±59.1）mmHg比（344.0±65.4）mmHg，（448.3±39.1）mmHg 比（410.1±26.7）mmHg，（460.1±33.5）mmHg比（423.2±36.5）mmHg，（465.1±28.2）mmHg比（435.1±40.8）mmHg，P＜0.05]， PA.aDO2下降[（22.9±4.6）mmHg 比（36.6±5.1）mmHg，（17.7±4.7）mmHg 比（34.5±2.9）mmHg，（13.8±4.1）mmHg比（21.9±3.2）mmHg，（13.5±4.6）mmHg比（19.2±3.8）mmHg，（12.4±2.0）mmHg比（17.7±2.4）mmHg，P＜0.05]，术后3 d FEV1、FEV1％明显上升[（2.9±0.4）mmHg 比（2.2±0.5） mmHg，（78.1±4.7）mmHg比（64.8±4.3）mmHg；P＜0.01]。结论超声引导自控胸椎旁神经阻滞较静脉自控镇痛可有效改善多发肋骨骨折患者术后肺通气和氧合功能。

Objective To investigated the effects of patient controlled intravenous analgesia and ultrasound guided patient.controlled paravertebral block on pulmonary function in patients with multiple fractured ribs. Methods From May 2015 to March 2016,60 patients with multiple rib fractures in Ningbo NO.6 Hospital with American Society of Anesthesiologists Ⅱ-Ⅲ underwent internal fixation, including 30 males and 30 females aged from 16 to 70 years （ mean age （ 54.6 ± 15.2 ） years ） . All patients were randomly divided into 2 groups （n=30 each）：patient controlled intravenous analgesia（PCIA） group and patient controlled thoracic paravertebral block（PCPB） group.PCIA solution contained sufentanil 2 μg/kg in 100 ml of normal saline. The PCIA pump was set up to deliver a 2 ml bolus dose with 15 minutes lockout interval and background infusion at 2 ml/hour.In PCPB group,the patients received paravertebral injection of 0.2% ropivocaine 15 ml on the corresponding area of fractured side under ultrasound guidance at the end of operation,and then received PCPB.PCPB solution contained 0.75% ropivacaine 67 ml in 250 ml of normal＆amp;nbsp;saline,and the pump was set up to deliver a 5 ml bolus dose, with 15 minutes lock out interval and background infusion at 5 ml/hour. Both analgesia lasted to 72 hours after operation.Before the operation,at 30 minutes,60 minutes,1 day,2 days,3 days after analgesia,arterial blood samples were collected to test the levels of pH,PaO2 ,PaCO2 ,PaO2/FiO2 and PA.aDO2 . The pulmonary function was also examined before and 3 days after the operation through FEV1 and FEV1%. Results Compared with PCIA group at 30 minutes, 60 minutes, 1 day, 2 days, 3 days after analgesia, the level of PaO2 （ （ 85.1 ± 9.7 ） mmHg vs. （ 72.4 ± 12.3）mmHg,（90.3±12.4）mmHg vs. （73.5±7.8）mmHg,（94.2±8.2）mmHg vs. （86.1±5.6）mmHg, （98.5±7.0）mmHg vs. （88.8±7.5）mmHg,（99.6±9.8）mmHg vs. （91.3±8.6）mmHg,P〈0.05）） and PaO2/FiO2 were significantly increased （ （ 405.1 ± 46.0 ） mmHg vs. （ 340.1 ± 58.9 ） mmHg, （ 430.5 ± 59.1） mmHg vs. （ 344.0 ± 65.4 ） mmHg, （ 448.3 ± 39.1 ） mmHg vs. （ 410.1 ± 26.7 ） mmHg, （ 460.1 ± 33.5）mmHg vs. （423.2±36.5）mmHg,（465.1±28.2）mmHg vs. （435.1±40.8）mmHg,P〈0.05））, the level of PA.aDO2 was decreased （（22.9±4.6）mmHg vs. （36.6±5.1）mmHg,（17.7±4.7）mmHg vs.（34.5±2.9）mmHg,（13.8±4.1）mmHg vs. （21.9±3.2）mmHg,（13.5±4.6）mmHg vs. （19.2± 3.8）mmHg,（12.4±2.0）mmHg vs. （17.7±2.4）mmHg,P〈0.05））, and FEV1,FEV1% were significantly increased at 3 days after operation in PCPB group （（2.9±0.4）mmHg vs. （2.2±0.5）mmHg, （78.1± 4.7） mmHg vs. （ 64.8 ± 4.3 ） mmHg; P〈0.01 ） ） . Conclusion Ultrasound guided patient.controlled paravertebral block improves the arterial oxygenation function and accelerates the recovery of pulmonary function in patients with multiple.fractured ribs after internal fixation operation.