胸椎旁神经阻滞对非体外循环冠状动脉旁路移植术桥血管通畅性的影响

Effects of thoracic paravertebral block on graft patency in off-pump coronary artery bypass grafting

目的评价胸椎旁神经阻滞对非体外循环冠状动脉旁路移植术桥血管通畅性的影响。方法择期静吸复合全麻下行非体外循环冠状动脉旁路移植术患者50例,年龄60~75岁,体重50~80 kg,ASA分级Ⅱ或Ⅲ级,NYHA心功能分级Ⅱ或Ⅲ级。采用随机数字表法分为2组:对照组(C组,n=30)和胸椎旁神经阻滞组(T组,n=20)。T组在超声引导下于T_(4),5间隙行胸椎旁神经阻滞,两侧分别注射试验剂量1%利多卡因5 ml,2 min后分别注射0.375%罗哌卡因15 ml。依据冠状动脉解剖将桥血管划分为4部分:左胸廓内动脉-前降支(动脉桥);中间支或第1对角支;钝缘支;后降支或左室后支。于桥血管移植结束后,测量其血流量,计算搏动指数。分别于置入漂浮导管即刻(T_(1))、锯开胸骨即刻(T_(2))、全部桥血管吻合完毕(T_(3))和出室前5 min(T_(4))时,记录CVP、平均肺动脉压、心排量、体循环阻力指数和肺循环阻力指数。记录术中心血管不良事件的发生情况和舒芬太尼用量。结果与G组比较,T组T_(3)和T_(4)时CVP、体循环阻力指数和肺循环阻力指数降低,心排量升高,术中心动过速发生率降低,低血压发生率升高,舒芬太尼用量减少,左胸廓内动脉-前降支血流量增加,搏动指数降低(P<0.05)。结论胸椎旁神经阻滞可改善非体外循环冠状动脉旁路移植术左胸廓内动脉-前降支的通畅性。

Objective To evaluate the effects of thoracic paravertebral block(TPVB)on graft patency in off-pump coronary artery bypass grafting.Methods Fifty American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients,aged 60-75 yr,weighing 50-80 kg,undergoing elective off-pump coronary artery bypass grafting under combined intravenous-inhalational anesthesia,were divided into 2 groups using a random number table method:control group(group C,n=30)and TPVB group(group T,n=20).In group T,TPVB was performed at T_(4),5 interspace under the guidance of ultrasound,a test dose of 1%lidocaine 5 ml was injected on both sides,and 2 min later 0.375% ropivacaine 15 ml was injected.According to the anatomy of coronary artery,the graft was divided into 4 parts:left internal thoracic artery-anterior descending branch(arterial graft),the middle branch or the first diagonal branch,blunt marginal branche,and right posterior descending branch or left ventricular posterior branch.The blood flow was measured and pulsatility index was calculated after graft transplantation.Central venous pressure,mean pulmonary artery pressure,cardiac output,systemic resistance index and pulmonary resistance index were recorded immediately after placement of floating catheter(T_(1)),immediately after sawing sternum(T_(2)),immediately after anastomosis of all grafts(T_(3))and 5 min before leaving the room(T_(4)).The intraoperative cardiovascular adverse events and consumption of sufentanil were recorded.Results Compared with group G,central venous pressure,systemic resistance index and pulmonary resistance index were significantly decreased,cardiac output were increased,the incidence of intraoperative tachycardia was decreased,the incidence of hypotension was increased,the consumption of sufentanil was reduced,the flow of left internal thoracic artery-anterior descending branch was increased,and the pulsatility index was decreased at T_(3) and T_(4) in group T(P<0.05).Conclusion TPVB can improve the patency of left internal thoracic artery-anterior descending branch in off-pump coronary artery bypass grafting.