不同剂量右美托咪定复合罗哌卡因行胸椎旁神经阻滞在肺癌根治术中的应用

Application of different doses of dexmedetomidine combined with ropivacaine in thoracic paravertebral nerve block for radical resection of lung cancer

目的观察不同剂量右美托咪定复合罗哌卡因行胸椎旁神经阻滞(TPVB)对肺癌根治术的影响。方法选取2016年10月至2017年1月收治的胸腔镜下行肺癌根治术患者80例,随机分为四组,每组20例:罗哌卡因组(C组)、0.5μg/kg右美托咪定复合罗哌卡因组(D1组)、1.0μg/kg右美托咪定复合罗哌卡因组(D2组)、2.0μg/kg右美托咪定复合罗哌卡因组(D3组)。C组神经阻滞用药为0.5%罗哌卡因,D1、D2和D3组分别应用0.5、1.0、2.0μg/kg右美托咪定复合罗哌卡因,罗哌卡因终浓度为0.5%。于患者入室后麻醉诱导前完成TPVB,测定阻滞完善后30 min开始麻醉诱导,术后行静脉镇痛。记录入室5 min(T_0)、麻醉诱导前(T_1)、气管插管后(T_2)、切皮时(T_3)、手术结束时(T4)各时点平均动脉压(MAP)、心率(HR);记录术中丙泊酚、瑞芬太尼的用量、术中心动过缓发生情况、术后苏醒时间、麻醉后监测治疗室(PACU)停留时间、术后24 h视觉模拟评分(VAS)、追加镇痛药及恶心呕吐发生情况。结果在T_2时各组均有不同程度插管反应(MAP、HR变化)。在T_2时,D2组和D3组MAP、HR均较T_0时降低(P均<0.05),C组和D1组MAP、HR变化不明显,故分别高于D2组和D3组(P均<0.05);在T_3、T4时,D3组HR均低于其他三组(P均<0.05)。与C组和D1组比较,D2和D3组术中丙泊酚的用量明显减少(P均<0.05);四组苏醒时间无明显差别(P>0.05),但D3组PACU停留时间较其他三组延长(P均<0.05),心动过缓发生率稍增加,但差异无统计学意义(P>0.05);与C组和D1组比较,D2和D3组术后24 h内追加镇痛药和恶心呕吐发生率稍降低,但差异无统计学意义(P均>0.05)。结论麻醉诱导前30 min应用1.0μg/kg和2.0μg/kg右美托咪定复合罗哌卡因行TPVB,可减轻气管插管反应、减少术中丙泊酚用量、减轻术后疼痛;应用2.0μg/kg右美托咪定时术中心动过缓发生率较高,患者PACU停留时间延长。

Objective To observe the effect of different doses of dexmedetomidine combined with ropivacaine used for thoracic paravertebral nerve block（TPVB） in radical resection of lung cancer. Methods Eighty patients scheduled for radical resection of lung cancer were randomly divided into four groups（n = 20,each） ： control group（group C,0. 5%ropivacaine） and group D1,group D2 and group D3（0. 5-,1. 0-,2. 0 μg/kg dexmedetomidine mixed with 0. 5%ropivacaine respectively）. The anesthesia induction was started at 30 min after the paravertebral block was completed and perfected,and the intravenous analgesia was performed after the operation. The mean arterial pressure（MAP） and heart rate（HR） were recorded at 5 min（T0）,before anesthesia induction（T1）,after tracheal intubation（T2）,at skin incision（T3）,and at the end of operation（T4）. The dosage of propofol and remifentanil during operation,the occurrence of bradycardia during operation,the awakening time after operation,the post-anesthesia care unit（PACU） time after anesthesia,visual analogue scale（VAS） during postoperative 24 hours,number of additional analgesics and cases of nausea and vomiting were also recorded. Results At T2,all groups had different degrees of intubation response（changes of MAP and HR）. Compared with T0,MAP and HR decreased in group D2 and group D3 at T2（all P〈0. 05）,but MAP and HR in group C and group D1 did not change significantly so that were higher than those in group D2 and group D3（all P〈0. 05）. HR in group D3 was lower than that in other three groups at T3 and T4（all P〈0. 05）. Compared with group C and group D1,the dosage of propofol in D2 and D3 groups decreased significantly（all P〈0. 05）. There was no significant difference in awakening time among four groups,but the PACU stay lengthened significantly in group D3 compared with other groups（all P〈0. 05）. The number of bradycardia cases increased slightly,but no statistical difference was found（P〈0. 05）. Compared with group C and group D1,number of additional analgesics within 24 hours after operation and the incidence of nausea and vomiting decreased in group D2 and group D3,but no significant differences was seen（all P〈0. 05）. Conclusion Application of 1. 0 μg/kg and 2. 0 μg/kg dexmedetomidine combined with ropivacaine at 30 min before induction of anesthesia for thoracic paravertebral nerve block can reduce the response of endotracheal intubation,the dosage of propofol during operation and postoperative pain; however,the incidences of bradycardia slightly increase and the PACU stay lengthen when 2. 0 μg/kg dexmedetomidine is used.