肋间神经阻滞联合羟考酮用于单孔胸腔镜肺癌根治术后多模式镇痛效果观察

Multimodal analgesic effect of intercostal nerve blocking combined with oxycodone in lung cancer patients after uniportal video-assisted thoracoscopic radical resection of lung cancer

目的探讨肋间神经阻滞联合羟考酮用于单孔胸腔镜肺癌根治术后多模式镇痛效果观察。方法选择2018年9月至2019年1月安徽省立医院择期行全身麻醉下单孔胸腔镜肺癌根治术患者120例为研究对象,采用随机数字表法将患者分为舒芬太尼组(A组)、肋间神经阻滞+舒芬太尼组(B组)、舒芬太尼+羟考酮组(C组)、肋间神经阻滞联合舒芬太尼和羟考酮组(D组),每组30例。手术结束时停止麻醉维持药物,并给予相应静脉自控镇痛(PCIA),其中A组患者在缝皮时给予舒芬太尼150μg和昂丹司琼16 mg,用生理盐水稀释至100 mL,行PCIA;B组患者在关胸前胸腔镜下给予7.5 g·L^-1罗哌卡因注射液20 mL行肋间神经阻滞,缝皮时同A组方法行PCIA;C组患者关胸前静脉注射羟考酮5 mg,缝皮时以舒芬太尼150μg、羟考酮20 mg、昂丹司琼16 mg用生理盐水稀释至100 mL,行PCIA;D组患者在关胸前胸腔镜下给予7.5 g·L^-1罗哌卡因注射液20 mL行肋间神经阻滞和静脉单次注射羟考酮5 mg,缝皮时同C组方法行PCIA。采用视觉模拟评分法(VAS)对各组患者术后2、4、8、12、18、24、36、48 h静息(平静呼吸)和运动(翻身、咳嗽及深呼吸)时的疼痛进行评分;记录术后PCIA各时间段患者自控镇痛(PCA)按压次数;记录患者术后镇痛过程中相关不良反应发生情况;评估患者对镇痛的总体满意度。结果术后2、4、8、12、36 h,B组患者的静息VAS评分均显著低于A组(P<0.05),术后2、4、8、36 h,B组患者的运动VAS评分均显著低于A组(P<0.05)。术后2、4、8、12、18、24、36、48 h,C、D组患者的静息VAS评分和运动VAS评分均显著低于A组,术后8、12、18、24 h,B组患者的静息VAS评分和运动VAS评分显著高于D组(P<0.05)。术后2、4、8、12、18、24、36、48 h,B组患者的静息VAS评分和运动VAS评分与C组比较差异均无统计学意义(P>0.05),C组患者的静息VAS评分和运动VAS评分与D组比较差异均无统计学意义(P>0.05)。4组患者术后镇痛过程中均未发生呼吸抑制和寒战,呕吐、头晕、低血压发生率比较差异均无统计学意义(χ^2=0.715、3.961、2.842,P>0.05)。D组患者术后恶心发生率显著低于A组(χ^2=7.867,P<0.05),C组和D组患者嗜睡发生率显著高于A组(χ^2=4.435、7.161,P<0.05),但2组患者嗜睡均可唤醒。A组患者术后各时段镇痛泵按压次数均高于D组(P<0.05)。B组患者术后6~12 h、12~24 h及24~48 h镇痛泵按压次数均高于D组(P<0.01)。A、B组患者术后6~12 h、12~24 h镇痛泵按压次数显著高于0~6 h(P<0.05);C、D组患者术后6~12 h、12~24、24~48 h镇痛泵按压次数显著高于0~6 h(P<0.05)。A组患者术后镇痛满意12例(40.0%),B组患者术后镇痛满意17例(56.7%),C组患者术后镇痛满意19例(63.3%),D组患者术后镇痛满意24例(80.0%),D组患者术后镇痛满意率显著高于A组(χ^2=10.635,P<0.05)。结论肋间神经阻滞联合羟考酮能够明显改善单孔胸腔镜肺癌根治术后PCIA镇痛效果,无明显不良反应,患者术后镇痛满意度增加。

Objective To explore the analgesia effect of intercostal nerve blocking combined with oxycodone multimodal analgesia in lung cancer patients after uniportal video-assisted thoracoscopic radical resection of lung cancer.Methods A total of 120 patients who underwent uniportal video-assisted thoracoscopic radical resection of lung cancer under the general anesthesia in the Anhui Provincial Hospital from September 2018 to January 2019 were selected as the study objects.The patients were divided into fentanyl group(group A),intercostal nerve blockade+sufentanil group(group B),sufentanil+oxycodone group(group C),intercostal nerve blockade combined with oxycodone and sufentanil group(group D)according to the random number table method,with 30 cases in each group.After operation,all patients were given patient controlled intravenous analgesia(PCIA).The patients in the group A were given sufentanil 150μg and ondansetron 16 mg which were diluted to 100 mL with normal saline during suturing skin.The patients in the group B were given ropivacaine(7.5 g·L^-1)20 mL for intercostal nerve blockade before closing the chest and were given sufentanil 150μg and ondansetron 16 mg which were diluted to 100 mL with normal saline during suturing skin.The patients in the group C were given oxycodone 5 mg through intravenous injection before closing the chest and were given sufentanil 150μg,oxycodone 20 mg and ondansetron 16 mg which were diluted to 100 mL with normal saline during suturing skin.The patients in the group D were given ropivacaine(7.5 g·L^-1)20 mL for intercostal nerve blockade and oxycodone 5 mg before closing the chest;and they were given sufentanil 150μg,oxycodone 20 mg and ondansetron 16 mg which were diluted to 100 mL with normal saline during suturing skin.The analgesia scores of patients at rest(calm breathing)and movement(turing over,cough or deep breath)status at 2,4,8,12,18,24,36,48 h after operation were observed and recorded by visual analogue scale(VAS).The press number of patient controlled analgesia(PCA)at each time point of PCIA after operation was recorded;the analgesia-related adverse events were recorded after surgery;the overall satisfaction of patients with analgesia was evaluated.Results The resting and moving state VAS scores of patients in group B were significanlty lower than those in the group A at 2,4,8,12,36 h after operation(P<0.05).The resting and moving state VAS scores of patients in group C and group D were significanlty lower than those in the group A at 2,4,8,12,18,24,36,48 h after operation(P<0.05).The resting and moving state VAS scores of patients in group B were significanlty higher than those in the group D at 8,12,18,24 h after operation(P<0.05).There was no statistical difference in resting and moving state VAS scores of patients between group B and group C at 2,4,8,12,18,24,36,48 h after operation(P>0.05).No obvious chills and respiratory depression were found in all patients.There was no significant difference in the incidence of vomiting,dizziness and hypotension(χ^2=0.715,3.961,2.842;P>0.05).The incidence of nausea of patients in group D was significantly lower than that in group A(χ^2=7.867,P<0.05);the incidence of drowsiness of patients in group C and group D was significantly higher than that in the group A(χ^2=4.435,7.161;P<0.05).The times of pressing analgesia pump of patients in group A were higher than those in group D at each time piont after operation(P<0.05).The times of pressing analgesia pump of patients in group B were much more than those in group D in 6-12 h,12-24 h and 24-48 h after operation(P<0.01).The times of pressing analgesia pump of patients in group A and group B in 6-12 h and 12-24 h were much more than those in 0-6 h after operation(P<0.05).The times of pressing analgesia pump of patients in group C and group D in 6-12 h,12-24 h and 24-48 h after operation were much more than those in 0-6 h after operation(P<0.05).The satisfaction rate of analgesia of patients in group A,group B,group C,group D was 40.0%(12/30),56.7%(17/30),63.3%(19/30),80.0%(24/30),respectively;the satisfaction rate of postoperative analgesia of patients in group D was significantly higher than that in group A(χ^2=10.635,P<0.05).Conclusions Intercostal nerve blocking combined with oxycodone can effectively improve postoperation pain caused by uniportal video-assisted thoracic surgery for lung cancer,and no obvious adverse reactions were found;patients′satisfaction with postoperative analgesia increased.