纳布啡预处理联合超声引导椎旁神经阻滞对胸腔镜下肺癌根治术患者细胞免疫功能的影响

Effect of the pretreatment of nalbuphine pretreatment combined with ultrasound - guided paraspinal nerve block on the cellular immune function of the patients with lung cancer under thoracoscopic surgery

目的 观察纳布啡预处理联合超声引导下椎旁神经阻滞用于胸腔镜下肺癌根治术患者镇痛,探讨纳布啡预处理联合超声引导椎旁神经阻滞的优化效果.方法 选取行胸腔镜下肺癌根治术患者60例,年龄40～70岁,体重55 ～ 80 kg,美国麻醉医师协会评分标准（ASA）分级Ⅰ级或Ⅱ级,TNM分期Ⅰ期或Ⅱ期,采用随机数字表法,将患者以随机数字表法随机分为3组（n=20）：对照组（A组）、纳布啡预处理组（B组）、纳布啡预处理＋罗哌卡因组（C组）.入室后C组在局麻下行超声引导术侧胸T4、T7和T9三点靶向横突根部阻滞,每点注入0.5％罗哌卡因10 ml,确定阻滞平面后开始麻醉诱导.于全麻诱导前3 min于B、C组静脉注射纳布啡20 mg,A组静脉注射等容量生理盐水.采用瑞芬太尼和异丙酚双通道靶控输注维持麻醉.于麻醉诱导前5 min时（T0）、手术开始后1h时（T1）、术毕时（T2）、术毕24 h时（T3）,取中心静脉血样,检测T0～T3血浆去甲肾上腺素（NE）、肾上腺素（E）及皮质醇（Cor）浓度及T淋巴细胞亚群CD3＋、CD4＋、CD8＋水平和CD4＋/CD8＋比值.记录术中丙泊酚用量、瑞芬太尼用量及麻醉恢复期血管活性药使用率.结果 与T0时比较,A组T2时CD3＋：50.6 ±6.0、CD4＋：28.4 ±6.2和CD4＋/CD8＋：1.3±0.1降低,T3时CD3＋：40.5±5.1、CD4＋：27.3 ±6.4和CD4 ＋/CD8＋：1.8±0.3降低,B组T2时CD3＋：54.4 ±6.0、CD4＋：32.5 ±6.9降低,T3时CD3＋：52.3 ±5.7、CD4＋：38.7 ±7.6降低,C组T2时CD3＋：63.3±7.5、CD4＋：38.2 ±7.0降低,T3时CD3＋：60.4±7.4、CD4＋：42.5 ±7.4降低（P=0.000）;与A组比较,B组、C组T2、T3时CD3＋、CD4＋细胞水平升高,B组T2时CD4＋/CD8＋：1.9±0.1,T3时2.1±0.2升高,C组T2时CD4＋/CD8＋：2.2±0.2,T3时2.2±0.2升高（P=0.000）;与B组比较,C组T2、T3时CD3＋、CD4＋细胞水平和CD4 ＋/CD8＋比值升高（P=0.000）.与A、B组比较,C组T1 ～ T3 NE、E和Cor浓度及术中丙泊酚用量、瑞芬太尼用量、麻醉恢复期血管活性药使用率降低;与A组比较,B组T1～ T3 NE、E和Cor浓度及术中丙泊酚用量、瑞芬太尼用量、麻醉恢复期血管活性药使用率降低.结论 纳布啡预处理联合超声引导下椎旁神经阻滞可改善胸腔镜下肺癌根治术患者细胞免疫功能.

Objective Based on the study on the effect of the nalbuphine pretreatment combined with ultrasound-guided paraspinal nerve block on the cellular immune function of the patients with lung cancer undergoing thoracoscopic surgery,to evaluate the optimization effect of the nalbuphine pretreatment combined with ultrasound-guided percutaneous nerve block.Methods Sixty patients with lung cancer undergoing thoracoscopic surgery.Age 40-70 year.Weight 55-80 kg.America society of Anesthesiologists score standard （ASA） class Ⅰ or Ⅱ.TNM stage stage Ⅰ or Ⅱ.Use a random number table method.The patients were randomly divided into 3 groups （n =20）：Control group （group A）,nalbuphine pretreatment group （group B）,nalbuphine pretreatment ＋ Ropivacaine group （group C）.After entering the operating room group C after the local anesthesia was blocked anesthesia guided by ultrasound-guided in the surgical side of T4,T7 and T9 at the root of the transverse process.Inject 0.5% ropivacaine 10 ml per point.The anesthesia induction was initiated after the block plane was determined.Before the induction of general anesthesia,the group B and group C were injected nalbuphine 20 mg intravenously.as the same way,group A was injected equal volume physiological saline.The anesthesia was maintained by two-channel target using remifentanil and propofol.5 min before anesthesia induction （T0）,1 h after surgery （T1）,when the surgery finished （T2）,and 24 hours after the surgery finished （T3）.Take the central vein blood sample.To detect the concentration of the norepinephrine （NE）,epinephrine （E） and cortisol （Cor） and the T lymphocyte subgroup CD3 ＋,CD4 ＋,CD8 ＋ level and CD4 ＋/CD8 ＋ ratio in the T0-T3 plasma.Record the dosage of propofol,remifentanil and the utilization rate of vasoactive drug in the convalescent period.Results Compared with T0,the cell level of CD3 ＋：50.6 ± 6.0,CD4 ＋：28.4 ± 6.2 and the ratio of CD4＋/CD8 ＋：1.3 ±0.1 were decreased in group A at T2,and the cell level of CD3 ＋：40.5 ± 5.1,CD4 ＋：27.3 ± 6.4 and the ratio of CD4 ＋/CD8 ＋：1.8 ± 0.3 were decreased in group A at T3,the cell levels of CD3 ＋：54.4 ± 6.0and CD4 ＋：32.5 ± 6.9 were decreased in group B at T2,the cell levels of CD3 ＋：52.3 ± 5.7and CD4 ＋：38.7 ± 7.6 were decreased in group B at T3,the cell levels of CD3 ＋：63.3 ± 7.5 and CD4 ＋ 3：8.2 ± 7.0 were decreased in group C at T2,the cell levels of CD3 ＋：60.4 ±7.4and CD4 ＋：42.5 ± 7.4 were decreased in group C at T3 （P =0.000）;Compared with group A,the cell level of CD3 ＋ and CD4＋ were increased in group B,C at T2 and T3 （ibid）,the ratio of CD4＋/CD8＋：1.9±0.1 was increased in group B at T2,CD4＋/CD8＋：2.1 ±0.2 at T3,the ratio of CD4 ＋/CD8 ＋：2.2 ± 0.2 was increased in group C at T2,CD4 ＋/CD8 ＋：2.2 ± 0.2 at T3 （P =0.000）;Compared with group B,the cell level of CD3 ＋,CD4 ＋ and the ratio of CD4 ＋/CD8 ＋ were increased in group C at T2 and T3 （ibid） （P =0.000）.Compared with group A and B,the concentration of the norepinephrine （NE）,epinephrine （E）,cortisol （Cor） and the dosage of propofol,remifentanil in the period of the surgery and the utilization rate of vasoactive drug in the convalescent period were decreased in group C at T1-T3;Compared with group A,the concentration of the norepinephrine （NE）,epinephrine （E）,cortisol （Cor） and the dosage of propofol,remifentanil in the period of the surgery and the utilization rate of vasoactive drug in the convalescent period were decreased in group B at T1-T3.Conclusion The pretreatment of nalbuphine pretreatment combined with ultrasound-guided paraspinal nerve block can improve the the cellular immune function of the patients with lung cancer under thoracoscopic surgery.