胸椎旁神经阻滞对全麻胸腔镜肺部手术患者术中低血压的影响

Effect of thoracic paravertebral block on intraoperative hypotension in patients undergoing thoracoscopic lung surgery under general anesthesia

回顾性收集2017年1月至2017年12月在全身麻醉下行胸腔镜肺部手术患者的病历资料,年龄≥18岁,ASA分级Ⅰ~Ⅲ级,性别不限。根据患者术前是否接受胸椎旁神经阻滞分为2组:全身麻醉组(G组)和胸椎旁神经阻滞联合全身麻醉组(GP组)。GP组于麻醉诱导前在超声引导下行T3/T4及T6/T7双点胸椎旁神经阻滞。采用舒芬太尼、丙泊酚/依托咪酯及顺式阿曲库铵进行麻醉诱导,术中应用丙泊酚、瑞芬太尼、顺式阿曲库铵和右美托咪定进行维持。按切皮前是否追加舒芬太尼将胸椎旁神经阻滞联合全身麻醉患者分为2个亚组:追加舒芬太尼组和未追加舒芬太尼组,对2组行1∶1倾向得分匹配。记录术中升压药物使用情况、阿片类药物用量、输液量、尿量、出血量和手术时间。与G组比较,GP组术中尿量、输液量和切皮后升压药物使用率升高,术中瑞芬太尼用量减少(P<0.05)。匹配前,与未追加舒芬太尼组比较,追加舒芬太尼组诱导时舒芬太尼用量、术中出血量、输液量和尿量升高,手术时间延长(P<0.05);匹配后,与未追加舒芬太尼组比较,追加舒芬太尼组切皮后升压药使用率升高(P<0.05)。综上所述,胸椎旁神经阻滞可增加全麻胸腔镜肺部手术患者术中低血压的发生率,其原因可能与胸椎旁神经阻滞对交感神经的直接抑制及阿片类药物的使用习惯有关。

The data of patients of both sexes,aged≥18 yr,of American Society of Anesthesiologists physical statusⅠ-Ⅲ,underwent thoracoscopic lung surgery under general anesthesia from January 2017 to December 2017,were retrospectively collected.The patients were divided into 2 groups according to whether they received thoracic paravertebral block(PVB)before operation:general anesthesia group(group G)and thoracic PVB combined with general anesthesia group(GP group).T3/T4 and T6/T7 double point thoracic PVB was performed under ultrasound guidance before anesthesia induction in GP group.Anesthesia was induced with sufentanil,propofol/etomidate and cisatracurium and maintained with propofol,remifentanil,cisatracurium and dexmedetomidine during operation.According to whether sufentanil was added before skin incision,patients received thoracic PVB combined with general anesthesia were divided into 2 subgroups:increment of sufentanil group and non-increment of sufentanil group,and a 1∶1 propensity score matching was performed in two groups.The usage of vasopressor drugs,amount of opioids consumed,volume of fluid infused,urine volume,blood loss and operation time were recorded.Compared with group G,the intraoperative urine volume,volume of fluid infused,and requirement for vasopressor drugs after skin incision were increased,and the intraoperative consumption of remifentanil was reduced in group GP(P<0.05).Before matching,compared with non-increment of sufentanil group,the consumption of sufentanil at induction,intraoperative blood loss,volume of fluid infused and urine volume were significantly increased,and the operation time was prolonged in increment of sufentanil group(P<0.05).After matching,compared with non-increment of sufentanil group,the requirement for vasopressor drugs was significantly increased in increment of sufentanil group(P<0.05).In conclusion,thoracic PVB can increase the incidence of intraoperative hypotension in the patients undergoing thoracoscopic lung surgery under general anesthesia,and the reason may be related to the thoracic PVB-induced direct inhibition of sympathetic nerves and to opioids usage.