超声引导下Ⅱ型胸神经阻滞对全麻下行乳腺癌手术患者炎性介质水平的影响

Effects of ultrasound-guided thoracic nerve block on inflammatory mediators levels in patients undergoing breast cancer surgery under general anesthesia

目的探讨超声引导下Ⅱ型胸神经阻滞对全麻下行乳腺癌手术患者炎性介质水平的影响。方法共纳入196例择期行乳腺癌手术治疗患者,将患者随机分为单纯全麻组(G组)和全麻辅合超声引导下Ⅱ型胸神经阻滞组(PG组)。所有患者均接受利多卡因(1 mg/kg),异丙酚和瑞芬太尼的麻醉诱导和维持。调整瑞芬太尼剂量以使术中BIS值保持在40~60。采用靶控输注(TCI)泵(Orchestra;Fresenius-Kabi,德国),分别使用Schnider和Minto的药代动力学模型计算丙泊酚和瑞芬太尼用量。PG组全麻诱导后给予超声引导下Ⅱ型胸神经阻滞。术中监测心电图、无创血压、脉搏血氧饱和度、体温、双谱指数(40~60,BIS vista monitor revision 3.0;Aspect Medical Systems,USA)。当双谱指数>60时,给予异丙酚0.5μg/kg(间隔为1 min或更长时间)静脉注射。当心率降至<50次/min时,静脉注射阿托品0.5 mg。手术后,将确认自发呼吸和意识恢复的患者移至术后重症监护室,进行24 h监测。术后24 h,将患者的血液样本收集在肝素管中进行酶联免疫吸附试验,检测血浆白细胞介素(IL)-2、IL-4和干扰素-γ(IFN-γ)水平及中性粒细胞、淋巴细胞计数。结果PG组瑞芬太尼消耗量少于G组。G组术后IL-2浓度明显低于术前水平(P<0.01),PG组无明显降低(P>0.05)。G组和PG组术后IL-4和IFN-γ的浓度与术前比较差异无统计学意义(P>0.05)。G组与PG组中性粒细胞术后所占比例都较术前增加,但PG组术后中性粒细胞较G组少(P=0.001)。术后G组、PG组淋巴细胞较术前明显减少(P<0.05或<0.01),但术后PG组淋巴细胞百分比高于G组(P=0.001)。与术前比较,术后G组和PG组中性粒细胞与淋巴细胞的比例(NLR)显著升高。与G组比较,PG组的NLR显著降低(P<0.01)。结论与单纯全身麻醉相比,Pecs-Ⅱ阻滞可减轻乳腺癌患者的炎性反应。

Objective To investigate the effects of ultrasound-guided thoracic nerve block on inflammatory mediators levels in patients undergoing breast cancer surgery under general anesthesia.Methods A total of 196 patients with breast cancer were randomly divided into general anesthesia group(group G)and ultrasound-guided thoracic nerve block group(PG group).All the patients received induction and maintenance of anesthesia with lidocaine(1mg/kg),propofol and remifentanil.The dosage of remifentanil was adjusted to keep the BIS value between 40 and 60.Target controlled infusion(TCI)pump was used to calculate the dosage of propofol and remifentanil by Schnider and Minto pharmacokinetic model,respectively.The patients in PG group were given ultrasound-guided thoracic nerve block after induction of general anesthesia,and the ECG,noninvasive blood pressure,pulse oxygen saturation,body temperature and bispectral index were monitored during the operation.When the bispectral index was greater than 60,propofol was given intravenously at intervals of 1min or more.Atropine 0.5mg was injected intravenously when the heart rate was below 50 beats/min.After the operation,the patients with spontaneous breathing and consciousness recovery were transferred to the postoperative ICU for the next 24 hours of monitoring.At 24h after operation,the blood specimens of patients were collected for enzyme-linked immunosorbent assay(ELISA).The plasma levels of nterleukin(IL)-2,IL-4 and interferon-γ(IFN-γ),neutrophils and lymphocyte counts were detected.Results The consumption of remifentanil in PG group was significantly less than that in G group,and the levels of IL-2 in group G were significantly lower than those before operation(P<0.01),however,which in PG group were not significantly decreased(P>0.05).There were no significant differences in the levels of IL-4 and IFN-γin both groups before operation and after operation(P>0.05).After operation,the numbers of neutrophils and lymphocytes in both groups were increased,but the percentage of neutrophils in group PG was significantly less than that in group G(P<0.01).Moreover the numbers of lymphocytes in both groups were decreased significantly after operation(P<0.05 or P<0.01),but the percentage of lymphocytes in group PG was significantly higher than that in group G(P<0.01).As compared with that before operation,the ratio of neutrophils to lymphocytes(NLR)in group G and group PG was significantly increased,however,the NLR in PG group was significantly lower than that in group G(P<0.01).Conclusion As compared with simple general anesthesia,PECSⅡblock can relieve the inflammatory reaction in patients with breast cancer.