麻醉因素对胸腔镜术后患者转归的影响:不同镇痛方式的比较

Effect of anesthesia factor on postoperative outcome in patients undergoing thoracoscopy:a comparison between different analgesic methods

目的通过比较不同镇痛方式评价麻醉因素对胸腔镜术后患者转归的影响。方法择期单孔胸腔镜手术患者100例,年龄18~64岁,BMI 18.5~24.0 kg/m2,ASA分级Ⅰ或Ⅱ级,性别不限。采用随机数字表法分为4组(n=25):对照组(C组)、竖脊肌平面阻滞(ESPB)组(E组)、胸椎旁神经阻滞(TPVB)组(T组)和ESPB联合TPVB组(ET组)。麻醉诱导前即刻行超声引导下神经阻滞,E组、T组和ET组分别行患侧ESPB、TPVB和ESPB联合TPVB。T组和E组分别注入0.5%罗哌卡因20 ml混合地塞米松5 mg,ET组于椎旁间隙注入0.5%罗哌卡因5 ml,后退针尖触及横突骨质另注入15 ml。神经阻滞操作完成后15 min时,采用针刺法检测阻滞平面,达T4-6脊神经支配区域为阻滞成功。术毕行PCIA治疗并入PACU。VAS评分>3分时,静脉注射氟比洛芬酯50 mg补救镇痛。于神经阻滞操作前即刻(T0)、手术30 min(T1)、气管拔管后30 min(T2)和术后24 h(T3)时抽取外周静脉血5 ml,采用ELISA法检测血浆皮质醇(Cor)和促肾上腺皮质激素(ACTH)浓度。于气管拔管后15 min(T4)、术后6、12、24和48 h(T5-8)时记录患者咳嗽VAS评分;术后48 h随访,记录PCIA按压次数、氟比洛芬酯用量及恶心和呕吐的发生情况。结果与C组比较,余3组T4-6时咳嗽VAS评分降低,PCIA按压次数减少,氟比洛芬酯用量、术后恶心和呕吐发生率、T1,2时血浆Cor和ACTH浓度降低(P<0.05);与E组比较,T组和ET组T4时咳嗽VAS评分、PCIA按压次数和氟比洛芬酯用量降低(P<0.05);与T组比较,ET组各指标差异无统计学意义(P>0.05)。结论TPVB改善胸腔镜术后患者转归的效果优于ESPB和TPVB联合ESPB。

Objective To evaluate the effect of anesthesia factor on postoperative outcome in patients undergoing thoracoscopy through a comparison between different analgesic methods.Methods One hundred patients of both sexes,aged 18-64 yr,with body mass index of 18.5-24.0 kg/m^2,of American Society of Anesthesiologists physical statusⅠorⅡ,scheduled for elective single-hole thoracoscopic surgery,were divided into 4 groups(n=25 each)using a random number table method:control group(group C),erector spinae plane block(ESPB)group(group E),thoracic paravertebral nerve block(TPVB)group(group T),and ESPB combined with TPVB group(ET group).Before induction of anesthesia,ultrasound-guided nerve block was performed,and ESPB,TPVB,and ESPB combined with TPVB were performed on the affected side in E,T and ET groups,respectively.The mixture of 0.5%ropivacaine 20 ml and dexamethasone 5 mg was injected in T and E groups,and 0.5%ropivacaine 5 ml was injected into the paravertebral space,the needle tip was retracted to touch the transverse bone,and then another 15 ml was injected in group ET.The block plane was detected by acupuncture at 15 min after completion of the nerve block,and successful nerve block was defined as the block plane reaching T4-6 in the areas innervated by the spinal nerve.Both groups received patient-controlled intravenous analgesia(PCIA)and were admitted to postanesthesia care unit after surgery.Flurbiprofen axetil 50 mg was intravenously injected as rescue analgesic when the visual analog scale(VAS)score was more than 3.Venous blood samples were collected immediately before nerve block operation(T0),30 min after operation(T1),30 min after tracheal extubation(T2),and 24 h after operation(T3)for determination of the concentrations of plasma cortisol and adrenocorticotropic hormone(ACTH)by enzyme-linked immunosorbent assay.The VAS score for cough was recorded at 15 min after tracheal extubation(T4)and 6,12,24 and 48 h after surgery(T5-8).The patients were followed up at 48 h after surgery.The pressing times of PCIA,consumption of flurbiprofen,and development of nausea and vomiting were recorded.Results Compared with group C,VAS scores for cough were significantly decreased at T4-6,the pressing times of PCIA was reduced,and the consumption of flurbiprofen,and incidence of nausea and vomiting and plasma Cor and ACTH concentrations at T1-2 were decreased in the other three groups(P<0.05).Compared with group E,VAS scores for cough at T4,pressing times of PCIA and consumption of flurbiprofen were significantly decreased in T and ET groups(P<0.05).There was no significant difference in each index between ET group and T group(P>0.05).Conclusion TPVB performs better than ESPB and TPVB combined with ESPB in improving the postoperative outcome of patients undergoing thoracoscopy.