硬膜外腔阻滞对胸部手术应激反应的影响

Effect of epidural anesthesia on the stress response to major thoracic surgery

目的 观察硬膜外腔阻滞对胸部手术应激激素和细胞因子的影响。方法20例食管癌手术病人,随机分为两组,每组10例,即全麻复令硬膜外腔阻滞(GEA)组和全麻(GA)组,分别测定麻醉诱导前、手术2h、手术4h、术毕、术后1d及术后3d的血浆去甲肾上腺素、肾上腺素、血清促肾上腺皮质激素(ACTH)、皮质醇、C-反应蛋白、IL-6及IL-10的水平。结果 血浆去甲肾上腺素和血清皮质醇GEA组术中术后无显著改变,但GA组术毕和术后1d显著升高(P<0.05),术后3d恢复至术前水平,组间比较前者有显著差异(P<0.05)。两组血浆肾上腺素、IL-10术中术后均无显著变化。两组血清ACTH、IL-6及CRP术中术后均显著升高(P<0.05),组间比较无显著差异。结论 硬膜外腔阻滞可以减轻胸部手术的应激反应。IL-6是较CRP更灵敏的反映组织损伤的炎性指标。

Objective To evaluate the influence of epidural block on the stress response to major thoracic surgery. Methods Twenty ASA I - II patients undergoing esophagectomy were randomized to receive either combined general-epidural anesthesia (GEA , n = 10) or general anesthesia (GA , n = 10) . The patients were premedicated with intramuscular pethidine 50 mg, prornethazine 25mg and scopolamine 0.3mg 30min before operation, fn GEA group epidural block was performed before general anesthesia at T9-10 and epidural catheter was advanced cephalad for 4 cm in the epidural space. Anesthesia was induced with fentanyl 2μg.kg-1 , propofol 1 .5-2.0mg.kg1 and vecuronium 0. 1mg.kg-1 . Carlen's double lumen tube was inserted and the patients were mechanically ventilated with 100% O2 . PaCO2 was maintained within normal range during both unilateral and bilateral lung ventilation. Anesthesia was maintained with isoflurane, vecuronium and epidural infusion of 2% lidocaine with 0.33% tetracaine (4-6ml.h1 ) . After operation PCEA with 0. 125% bupivacaine plus fentanyl 2μg.ml was started (background infusion 4ml. h 1, bolus 2ml, lock-out time 20min) . In GA group the induction and maintenance of anesthesia were more of the same except epidural infusion. After operation intravenous PCA with morphine 1 mg/ml was started ( background infusion 0.5 ml . h , bolus 1 mg, lock-out lime 6 min) . Peripheral venous blood samples were taken before induction, 2 and 4h after skin incision, at the end of surgery and on the morning of post-operative day 1 and 3, for determination of plasma norepinephrine, epinephrine, serum cortisol, ACTH, interleukin (IL)-6, IL-10 and C-reactive protein (CRP) levels. Results In GEA group there were no significant changes in plasma norepinephrine and cortisol concentration during and after operation. But in GA group there was significant increase in plasma norepinephrine and cortisol level at the end of operation and on the 1st day after operation ( P<0.01) and the plasma level of norepinephrine and cortisol returned to the baseline on the 3rd day after operation. Epinephrine and IL-10 levels remained unchanged in both groups. ACTH, IL-6 and CRP levels increased significantly during and after surgery (P<0.05), but there were no differences between the two groups.Conclusion Epidural block can reduce the stress tomajor thoracic surgery, IL-6 is a more sensitive inflammatory indicator of tissue injury than CRP.