超声引导下胸椎旁神经阻滞对结核性脓胸手术患者麻醉复苏室内复苏质量的影响

Effect of ultrasound guided thoracic paravertebral nerve block on quality of recovery from general anesthesia in patients with tuberculous empyema surgery in post anesthesia recovery unit

目的研究超声引导下胸椎旁神经阻滞(TPVB)对支气管内全身麻醉下行结核性脓胸手术患者麻醉复苏室(PACU)内复苏质量的影响。方法选取2018年5月至2019年12月长沙市中心医院收治的40例结核性脓胸行肺纤维板剥脱并脓胸病灶清除术的患者,按照随机数字表法分为A、B两组,每组20例。A组为支气管内全身麻醉组;B组为支气管内全身麻醉联合超声引导下胸椎旁神经阻滞组。两组患者术中脑电双频指数值(BIS)维持在40~50范围内,根据BIS及血流动力学变化调整丙泊酚和舒芬太尼用量。观察记录两组患者麻醉诱导前(T0)、手术切皮前(T1)、手术切皮后(T2)、手术结束时(T3)、拔管时(T4)及出PACU时(T5)各个时间点的平均动脉压(MAP)、心率(HR),观察记录拔管后5、30 min、出PACU时患者静息与咳嗽状态下的疼痛视觉模拟评分(VAS);记录两组患者手术中丙泊酚与舒芬太尼的使用剂量以及麻醉复苏室内舒芬太尼药物追加的剂量,观察患者自主呼吸恢复时间、意识恢复时间、拔管时间、拔管时镇静-躁动评分(SAS),观察拔管后至出PACU期间的恶心、呕吐、嗜睡、血压降低等不良反应情况。结果与A组患者相比,B组患者T2、T3、T4、T5时HR和MAP均低于A组(P<0.05),生命体征更为平稳。B组患者拔管后各时间点静息和咳嗽状态VAS评分均低于A组(P<0.05)。B组患者术中舒芬太尼与丙泊酚的用量分别为(35.92±8.12)μg和(749.56±95.30)mg,显著低于A组[(45.74±4.42)μg和(862.83±105.34)mg,P<0.05];B组术后麻醉复苏室内舒芬太尼用量为(5.26±2.10)μg,显著少于A组[(10.35±5.86)μg](P<0.05);B组患者自主呼吸恢复时间(12.92±5.12)min、意识恢复时间(20.56±5.10)min、拔管时间(26.87±6.16)min,短于A组[(15.74±4.72)min,(25.83±5.34)min和(35.35±5.80)min](P<0.05)。B组术后恶心、呕吐、嗜睡、低血压的发生率分别为10%、10%、35%、20%,显著低于A组(30%、20%、75%和45%)(P<0.05)。结论胸椎旁神经阻滞可以减少支气管内全身麻醉下行结核性脓胸纤维板剥离并病灶清除术中患者阿片类镇痛药用量,加快患者的麻醉复苏速度,减轻复苏时的躁动,提高麻醉复苏质量。

Objective To study on the effect of ultrasound-guided thoracic paravertebral nerve(TPVB)block on quality of recovery from general anesthesia in tuberculosis patients with fiberboard exfoliation in post anesthesia recovery unit(PACU).Methods From May 2018 to December 2019,40 tuberculosis patients in Changsha Central Hospital with pulmonary fibreboard exfoliation and focal abscess lesions cleaning were randomly divided into two groups,with 20 patients in each group.The patients in group A received endobronchial general anesthesia and in group B received ultrasound-guided TPVB combined with endobronchial general anesthesia.Patients in the two groups were maintained under anesthesia by propofol,and the bispectral index(BIS)was maintained within the range of 40-50.The dosage of propofol and sufentanil was adjusted according to changes in BIS and hemodynamics.The mean arterial pressure(MAP),heart rate(HR)in two groups of patients were recorded at before anesthesia induction(T0),before cutting leather(T1),cut skin after(T2),the end of operation(T3),extubation time(T4),and T5(time of leaving PACU).The visual analogue scale(VAS)of all patients in resting and cough state was recorded at 5,30 min after extubation and the time of leaving PACU.The dosage of propofol and sufentanil in the operation and the additional dosage of sufentanil in PACU were recorded in both two groups.And the respiratory recovery time,consciousness recovery time,extubation time and sedation agitation scale(SAS)were observed.The adverse reactions such as nausea,vomiting,drowsiness and hypotension were observed in PACU.Results Compared with group A,MAP and HR of patients at T2,T3,T4,T5 in group B were more stable during anesthesia,and VAS of patients in group B were lower than that in group A at each time point after extubation(P<0.05).The dosage of sufentanil and propofol in group B were(35.92±8.12)μg and(749.56±95.30)mg respectively,which were significantly lower than those in group A[(45.74±4.42)μg and(862.83±105.34)mg,P<0.05];the dosage of sufentanil in postoperative anesthesia recovery room of group B was(5.26±2.10)μg,significantly less than that of group A(10.35±5.86)μg(P<0.05).The respiratory recovery time,consciousness recovery time and extubation time in group B were(12.92±5.12)min,(20.56±5.10)min and(26.87±6.16)min,which were shorter than those in group A[(15.74±4.72)min,(25.83±5.34)min and(35.35±5.80)min,P<0.05].The incidence of postoperative nausea,vomiting,lethargy and hypotension in group B were 10%,10%,35%and 20%,which were significantly lower than those in group A(30%,20%,75%and 45%,P<0.05).Conclusions Ultrasound-guided paravertebral nerve block may significantly reduce the dosage of opioid analgesics for general anesthesia in tuberculosis patients with fiberboard exfoliation,accelerate the speed of anesthesia recovery,reduce the agitation during recovery,and improve the quality of anesthesia recovery.