胸横肌平面阻滞对心肺转流下瓣膜置换术患者应激反应和术后镇痛的影响

Effect of transversus thoracic muscle plane block on stress response and postoperative analgesia in patients with valve replacement under cardiopulmonary bypass

目的探讨胸横肌平面(TTP)阻滞对心肺转流(CPB)下瓣膜置换术患者应激反应和术后镇痛的影响。方法选择2019年9—11月择期行瓣膜置换术的患者40例,男29例,女11例,年龄35~65岁,BMI 18~25 kg/m^(2),ASAⅡ或Ⅲ级,心功能Ⅱ或Ⅲ级。采用随机数字表法分为两组:双侧TTP阻滞联合全麻组(A组)和单纯全麻组(B组),每组20例。A组麻醉诱导前在超声引导下经胸骨旁4、5肋间隙行双侧TTP阻滞,B组不做处理,两组麻醉方法相同,术后均采用舒芬太尼静脉自控镇痛。记录术中舒芬太尼、瑞芬太尼、右美托咪定、丙泊酚用量。于麻醉诱导前、CPB前、术毕、术后12 h及术后24 h抽取静脉血,测定血浆血管紧张素Ⅱ(AngⅡ)和β内啡肽(β-EP)浓度。记录术后6、12、24 h静息和咳嗽时VAS疼痛评分。记录术毕至术后12 h、术后12~24 h镇痛泵有效按压次数。记录术后机械通气时间、ICU停留时间、肺部并发症及心力衰竭发生例数。结果A组术中舒芬太尼、右美托咪定、丙泊酚用量明显少于B组(P<0.05)。两组术中瑞芬太尼用量差异无统计学意义。与麻醉诱导前比较,CPB前、术毕、术后12、24 h两组AngⅡ浓度明显升高(P<0.05),术毕、术后12、24 h两组β-EP浓度明显升高(P<0.05)。术毕、术后12、24 h A组AngⅡ和β-EP浓度明显低于B组(P<0.05)。A组术后6、12 h静息和咳嗽时VAS疼痛评分明显低于B组,术毕至术后12 h镇痛泵有效按压次数明显少于B组,术后机械通气时间明显短于B组(P<0.05)。两组术后肺部并发症及心力衰竭发生率差异无统计学意义。结论双侧TTP阻滞可减少CPB下瓣膜置换术患者术中麻醉药物用量,减轻应激反应,并提供良好的术后镇痛。

Objective To investigate the effect of transversus thoracic muscle plane(TTP)block on stress response and postoperative analgesia in patients undergoing valve replacement under cardiopulmonary bypass(CPB).Methods Forty patients undergoing elective valve replacement from Sepetmber to November 2019,29 males and 11 females,aged 35-65 years,BMI 18-25 kg/m^(2),ASA physical statusⅡorⅢand cardiac functionⅡorⅢ,were randomly divided into two groups:bilateral TTP block combined with general anesthesia group(group A)and single general anesthesia group(group B),20 patients in each group.Before anesthesia induction,patients in group A underwent bilateral TTP block through parasternal 4 and 5 intercostal spaces under ultrasound guidance,while patients in group B did not undergo treatment.The anesthesia methods were the same in both groups,and patients in both groups received intravenous self-controlled analgesia with sufentanil after surgery.The dosage of sufentanil,remifentanil,dexmedetomidine,and propofol were recorded.Venous blood was drawn before anesthesia,before CPB,at the end of operation,12 and 24 hours after operation respectively,and plasma concentrations of angiotensinⅡ(AngⅡ)andβ-endorphin(β-EP)were measured.VAS scores at rest and cough 6,12,and 24 hours after operation and the number of effective pressing analgesic pumps within the end of operation to 12 hours after operation,12 to 24 hours after operation were recorded.The duration of mechanical ventilation,ICU stay,pulmonary complications and the incidence of heart failure in the two groups were recorded.Results The dosages of sufentanil,dexmedetomidine,and propofol in group A were significantly lower than those in group B(P<0.05).Compared with preanesthesia,the AngⅡconcentration in the two groups increased significantly at the time before CPB,the end of operation,12 and 24 hours after operation(P<0.05),theβ-EP concentration in the two groups increased significantly at the end of operation,12 and 24 hours after operation(P<0.05).The concentration of AngⅡandβ-EP in group A was significantly lower than that in group B at the end of operation,12 and 24 hours after operation(P<0.05).The VAS scores at rest and cough 6 and 12 hours after operation,the effective pressing times at the end of operation to 12 hours after operation and the postoperative mechanical ventilation time in group A were significantly lower than those in group B(P<0.05).Conclusion Bilateral TTP block can reduce the dosage of anesthetic drugs,reduce stress response,and provide good postoperative analgesia for patients with valve replacement under CPB.