超声引导下胸椎旁神经阻滞在胸腔镜肺叶切除术围术期快速康复中的应用

Application of ultrasound-guided thoracic paravertebral block in enhanced recovery after surgery for video-assisted thoracoscopic surgery lobectomy: a clinical research

目的探讨超声引导下椎旁神经阻滞(TPVB)对促进胸腔镜(VATS)肺叶切除手术患者围术期快速康复的效果。方法选取拟行VATS手术的患者90例作为研究对象,ASAⅠ～Ⅲ级,患者随机平均分为胸椎旁神经阻滞联合全麻组(P组)、硬膜外阻滞联合全麻组(E组)和单纯全麻组(G组),每组各30例。P组患者于全麻诱导前在超声引导下行TPVB;E组患者硬膜外穿刺置管;3组全身麻醉方式相同,所有患者术后均使用静脉自控镇痛泵。记录3组患者:入室后(T1)、切皮时(T2)、拔管前(T3)时生命体征(MAP、HR)的变化;术后6 h(T4)、12 h(T5)、24 h(T6)安静及咳嗽时VAS评分;镇痛期间不良反应(恶心呕吐、嗜睡和躁动)的发生率;按压镇痛泵次数及患者首次进食情况。结果 T2时刻对比T1时刻MAP值变化明显(P<0.05);在T2时刻,3组间MAP值变化明显(P<0.05)。在T3时刻,G组与P组、E组比较,MAP值明显升高(P<0.05);而且G组与T1时刻比较MAP值明显升高(P<0.05),P、E两组间对比差异无统计学意义(P>0.05)。在T2时刻,E组与P组比较HR明显降低(P<0.05);G组与E组比较HR明显升高(P<0.05),E组在T2时刻与T1时刻相比HR明显降低;在T3时刻,G组与P组、E组比较,HR明显升高(P<0.05),P、E两组间对比差异无统计学意义(P>0.05)。T4、T5、T6患者咳嗽时,P组与E组VAS评分明显低于G组(P<0.05),P、E两组间对比差异无统计学意义(P>0.05);T5、T6患者安静状态时P组与E组VAS评分明显低于G组(P<0.05),P、E两组间对比差异无统计学意义(P>0.05);G组患者术后恶心呕吐、躁动、嗜睡等不良反应发生率显著高于P组和E组(P<0.05),而P组和E组间差异无统计学意义(P>0.05)。G组自控镇痛按压次数明显多于P组与E组(P<0.05),首次进食时间明显长于P组与E组(P<0.05),而P组和E组间差异无统计学意义(P>0.05)。结论超声引导下行胸椎旁神经阻滞定位准确,效果确切,减少手术患者在围术期由于伤害性刺激造成的应激反应,优化镇痛,减少术后并发症,更符合加速康复外科理念下加速安全康复的要求。

Objective To investigate the effect of ultrasound-guided paravertebral nerve block(TPVB) on the perioperative recovery of patients undergoing thoracoscopic lobectomy(VATS). Methods Ninety patients for selected VATS lobectomy(ASA Ⅰ-Ⅲ) were randomly divided into parathoracic nerve block combined with general anesthesia group(Group P), epidural block combined with general anesthesia group(Group E) and simple general anesthesia group(Group G). TPVB(T5) was performed under ultrasound guidance before general anesthesia induction in Group P, epidural catheterization(T6-T7) were performed in Group E, and general anesthesia was performed in all the three groups. All patients were given with intravenous patient-controlled anesthesia(PCA) after operation. Thevital signs(MAP and HR) were recorded at entering the operation room(T1), during skin incision(T2) and before extubation(T3). VAS scores 6 hours(T4), 12 hours(T5) and 24 hours(T6) after operation during rest and cough. The adverse reactions(nausea, vomiting, drowsiness and restlessness) during analgesia, the use of PCA and the patient′s first feeding condition were also recorded. Results The MAPs at T1 and T2 were significant different between the(P<0.05). The MAPs of the three groups were significantly different among the 3 groups(P<0.05). At T3, MAP of Group G was significantly higher than those of Group P and E(P<0.05). The MAP of Group G at T3 was significantly higher than that at T1(P<0.05). There was no significant difference of MAPs between Group P and E at T3(P>0.05). HR of Group E was significantly lower than that of Group P at T2(P<0.05). HR of Group G was significantly higher than that of Group E(P<0.05). HR of Group E was significantly lower at T2 than T1(P<0.05). At T3, HR of Group G was significantly higher than those of Group E and P,(P<0.05), though there was no significant difference in HR between Group P and E(P>0.05). At T4, T5 and T6, the coughing VAS of Group P and E were significantly lower than those of Group G(P<0.05), though there was no significant difference between Group P and E(P>0.05). At T5 and T6, the rest VAS of Group P and E were significantly lower than those of Group G(P<0.05), though there was no significant difference between Group P and E(P>0.05). The incidence of postoperative nausea, vomiting, restlessness and lethargy in Group G was significantly higher than those in Group P and E(P<0.05), and there was no significant difference between Group P and E(P>0.05). The use of PCA in Group G was significantly more than those of Group P and E(P<0.05), and there was no significant difference between Group P and E(P>0.05). The time of first in Group G was significantly longer than those of Group P and E(P<0.05), and there was no significant difference between Group P and E(P>0.05). Conclusion Ultrasound-guided thoracic paravertebral nerve block is accurate and effective. It can reduce the stress reaction caused by noxious stimulation during perioperative period, optimize analgesia, reduce postoperative complications, and accelerate ERAS.