胸神经阻滞对乳腺癌根治性切除术患者镇痛效果及免疫功能影响

Effect of pectoral nerve block on the analgesic effect and immune function in patients undergoing radical mastectomy

目的观察右美托咪定联合罗哌卡因行胸神经阻滞(PECS)对乳腺癌根治性切除术患者镇痛效果及其免疫功能的影响。方法择期全身麻醉下行乳腺癌根治术女性患者60例,随机数字表分为右美托咪定联合罗哌卡因PECS组(DP组)、单纯罗哌卡因PECS组(P组)、空白对照组(C组),比例1∶1∶1,每组20例。麻醉诱导完成后,3组患者均在超声引导下行PECS,针尖进入胸小肌、前锯肌之间时,DP组给予1μg/kg右美托咪定复合0.375%罗哌卡因混合液20 mL,P组给予0.375%罗哌卡因20 mL,C组给予0.9%氯化钠20 mL;然后退针至胸大肌、胸小肌之间时,3组按照各自配方再给予10 mL。将麻醉诱导前30 min及术毕2、4、8、12、24、48 h分别为T_(0)、T_(1)、T_(2)、T_(3)、T_(4)、T_(5)、T_(6),于T_(0)、T_(1)、T_(5)、T_(6)时抽取静脉血标本,测定T淋巴细胞亚群(CD3^(+)、CD4^(+)、CD8^(+))及NK细胞水平;观察并记录T_(1)、T_(2)、T_(3)、T_(4)、T_(5)、T_(6)静息及运动状态视觉模拟评分(VAS);记录术中麻醉药物用量,镇痛泵按压有效次数,补救镇痛例数;记录术毕初始下床时间,住院时间;记录术中、术后严重不良事件。结果与T_(0)时比较,3组患者于T_(1)、T_(5)、T_(6)时CD3^(+)、CD4^(+)、NK细胞活性均明显降低(P<0.05);C、P组于T_(1)、T_(5)时,DP组于T_(1)时CD4^(+)/CD8^(+)比值明显降低(P<0.05);C组于T_(1)、T_(5)时,P、DP组于T_(1)时CD8^(+)活性明显升高(P<0.05)。与C组比较,P、DP组于T_(1)、T_(5)时CD3^(+)、CD4^(+)细胞活性均明显升高(P<0.05);P组于T_(5)时,DP组于T_(1)、T_(5)、T_(6)时NK细胞活性均较C组明显升高(P<0.05)。与C组比较,P组于T_(2)、T_(3)、T_(4),DP组于T_(2)、T_(3)、T_(4)、T_(5)时点,运动状态VAS评分均明显降低(P<0.05)。P、DP组术中麻醉药物用量、镇痛泵按压有效次数均明显低于C组(P<0.05)。P、DP组术毕初始下床时间均明显早于C组(P<0.05)。结论右美托咪定联合罗哌卡因PECS对乳腺癌根治患者镇痛确切,免疫抑制轻。

Objective To observe the analgesic effect and immune function of dexmedetomidine combined with ropivacaine in pectoral nerve block(PECS)in patients undergoing radical mastectomy.Methods A total of sixty women undergoing radical mastectomy under elective general anesthesia were enrolled and randomly divided into the dexmedetomidine mixed ropivacaine PECS group(group DP),the simple ropivacaine PECS group(group P),the blank control group(group C),with a ratio of 1:1:1,20 cases in each group.After completion of anesthesia induction,all three groups had descending PECS with the needle point between the pectoralis and anterior serratus muscle,group DP was given 20 mL of mixed solution of 1μg/kg dexmedetomidine and 0.375%ropivacaine.,group P was given 0.375%ropivacaine 20 mL,and group C was given 0.9%sodium chloride 20 mL.Then when the needle was returned to the pectoralis major and minor muscle,the three groups were given another 10mL according to their respective formula.Venous blood samples were taken at 30 min before the induction of anesthesia(T_(0)),2 h after operation(T_(1)),24 h after operation(T_(5)),48 h after operation(T_(6))for detection of T lymphocyte subsets CD3^(+),CD4^(+),CD8^(+)and natural killer(NK)cells levels.The Visual simulation scores(VAS)of resting and motion stateat 2 h(T_(1)),4 h(T_(2)),8 h(T_(3)),12 h(T_(4)),24 h(T_(5))and 48 h(T_(6))after operation were observed and recorded.The dosage of intraoperative anesthetic drugs,the effective times of analgesic pump pressing and the number of remedial analgesia cases were recorded.The initial time of getting out of bed after operation and the hospitalization days were recorded.Intraoperative and postoperative serious adverse events were recorded.Results Compared with T_(0),the levels of CD3^(+),CD4^(+)and NK cells were markedly reduced in groups C,P and DP at T_(1),T_(5)and T_(6)(P<0.05).The ratio of CD4^(+)/CD8^(+)in group C and P decreased significantly at T_(1)and T_(5),while that in group DP decreased significantly at T_(1)(P<0.05).The level of CD8^(+)in group Cwas significantly increased at T_(1)and T_(5),while that in group P and DPincreased significantlyat T_(1)(P<0.05).Compared with group C,the levels of CD3^(+)and CD4^(+)was significantly higher in group P and group DP at T_(1)and T_(5)(P<0.05).In group P at T_(5),group DP at T_(1),T_(5)and T_(6),the levels of NK cell were significantly higher(P<0.05).Compared with group C,the activity state VAS scores in group P at T_(2),T_(3),T_(4),and group DP at T_(2),T_(3),T_(4),T_(5)were markedly reduced(P<0.05).The dosage of intraoperative anesthetic drugs and the effective times of analgesic pump pressing in group P and group DP were significantly lower than those in group C(P<0.05).The initial time of getting out of bed after operation in group P and group DP was significantly earlier than that in group C(P<0.05).Conclusion Dexmedetomidine mixed ropivacaine PECS has precise analgesia and mild immune suppression in breast cancer patients.