右美托咪定行胸椎旁神经阻滞对开胸手术患者应激反应的影响

Effect of thoracic paravertebral block combined with Dexmedetomidine on stress reaction in patients undergoing thoracic surgery

目的评价右美托咪定(Dex)用于胸椎旁神经阻滞(TPVB)对开胸手术患者应激反应的影响。方法选取行开胸食管癌根治术患者72例,采用随机数字表法将其分为单纯全身麻醉组(C组)、罗哌卡因组(R组)、Dex+罗哌卡因组(DR组)。R组和DR组患者于全身麻醉诱导前行超声引导下TPVB(T_4~T_9),R组在椎旁间隙内注入0.5%罗哌卡因30 ml,DR组在椎旁间隙内注入0.5%罗哌卡因+1 μg/kg Dex混合液30 ml。3组患者术后常规连接静脉镇痛泵。记录3组患者麻醉诱导前(T_0)、气管插管即刻(T_1)、手术2 h(T_2)、术毕(T_3),及术后1(T_4)、6(T_5)、12(T_6)、24(T_7)、36(T_8)和48 h(T_9)时的心率(HR)、平均血压(MAP);记录T_4~T_9静息和咳嗽疼痛视觉模拟评分法(VAS)评分;于T_0、T_2、T_3、T_6、T_7及T_9静脉采血测定肾上腺素(E)、去甲肾上腺素(NE)浓度及血糖。结果 (1)不同时间静息及咳嗽VAS评分、血浆E、NE浓度及血糖浓度变化有差异(P<0.05),不同时间MAP、HR变化差异无统计学意义(P>0.05);(2)3组静息及咳嗽VAS评分、血浆E、NE浓度及血糖浓度变化差异有统计学意义(P<0.05),DR组镇痛效果较好,应激反应较轻;(3)3组静息及咳嗽VAS评分、血浆E、NE浓度及血糖浓度变化趋势差异有统计学意义(P<0.05)。结论 Dex用于TPVB可增强罗哌卡因的阻滞效果,延长阻滞时间,减轻开胸手术患者的应激反应。

Objective To evaluate the effect of thoracic paravertebral block （TPVB） combined with Dexmedetomidine on stress reaction in patients undergoing thoracic surgery. Methods Seventy -two patients scheduled for esophageal surgery were randomly divided into three groups： pure general anesthesia group （group C）, Ropivacaine group （group R） and Dexmedetomidine combined with Ropivacaine group （group DR）. TPVB （T4-T9） guided by ultrasound was applied to the patients of the group R and the group DR before induction： the patients in the group R and the group DR received paravertebral injection of 0.5% Ropivacaine 30 ml and 30 ml mixture of 1 μg/kg Dexmedetomidine combined with 0.5% Ropivacaine respectively. All three groups received patient-controlled intravenous analgesia （PCIA） after operation. Heart rate （HR） and mean arterial pressure （MAP） were recorded before anesthesia （Tc）, immediately after endotracheal intubation （T1）, 2 hafter incision （T2 ）, at the end of operation （T3 ）, and 1, 6, 12, 24, 36 and 48h after operation （T4-T 9 ）. The analgesic effect was measured by Visual Analog Scale （VAS） scores at T4-T 9. Blood samples were obtained via internal jugular vein at T0 , T2 , T3 , T6, T7 and T9 . The plasma concentrations of epinephrine and norepinephrine and the value of blood glucose （BG） were determined. Results The VAS scores, the plasma concentrations of epinephrine and norepinephrine, and the value of BG were significantly different between different time points （P〈0.05）. There was no difference in MAP or HR between different time points （P〉0.05）. The VAS scores, the plasma concentrations of epinephrine and norepinephrine, and the value of BG were significantly different among the three groups ^〈 0.05）. The analgesic effect was better and the stress reaction was milder in the group DR. The change trends of the VAS scores, the plasma concentrations of epinephrine and norepinephrine, and the value of BG were significantly different among the three groups （P〈0.05）. Conclusions Dexmedetomi- dine combined with thoracic paravertebral block can significantly enhance the effect of nerve block, prolong the duration with Ropivacaine, and decrease the stress reaction in the patients undergoing thoracic surgery.