术前超声引导下星状神经节阻滞对胸腔镜手术患者的肺保护作用及机制

Pulmonary protection effect and mechanism of preoperative ultrasound-guided stellate ganglion block on thoracoscopic surgery patients

目的探讨术前超声引导下星状神经节阻滞(SGB)对胸腔镜手术单肺通气(OLV)患者的肺保护作用及机制。方法选择2021年1月至2022年4月于南京医科大学附属苏州医院行胸腔镜下OLV肺叶切除术的84例患者为研究对象,按照随机数字表法将患者分为观察组和对照组,每组42例。观察组患者麻醉诱导前实施超声引导下SGB;对照组患者不做穿刺操作。2组患者采用相同的麻醉诱导和维持方案。记录患者入手术室后(T_(0))、OLV开始前(T_(1))、OLV开始后30 min(T_(2))、OLV开始后60 min(T_(3))、术毕(T_(4))、拔管后30 min(T_(5))时血流动力学、呼吸力学参数和动脉血气指标。比较各时间点2组患者氧合指数(OI)和肺内分流率(Qs/Qt)以及pH值。分别于T_(0)、T_(3)、T_(5)时,抽取2组患者静脉血,应用酶联免疫吸附法检测血清中肺表面活性物质相关蛋白-A(SP-A)、超氧化物歧化酶(SOD)、丙二醛(MDA)、白细胞介素(IL)-6及IL-10水平,记录患者术后SGB相关并发症及术后72 h内肺部并发症发生情况。结果2组患者T_(1)、T_(2)、T_(3)时的平均动脉压(MAP)和心率(HR)显著低于T_(0)时(P<0.05);T_(4)和T_(5)时的MAP和HR与T_(0)时比较差异无统计学意义(P>0.05),2组患者其他时间点间的MAP和HR比较差异无统计学意义(P>0.05)。T_(1)、T_(2)、T_(3)时,观察组患者的MAP显著低于对照组(P<0.05);T_(2)、T_(3)时,观察组患者的HR显著低于对照组(P<0.05);其他时间点,2组患者的MAP和HR比较差异无统计学意义(P>0.05)。T_(0)~T_(5)各时间点2组患者的脉搏氧饱和度(SpO_(2))比较差异无统计学意义(P>0.05)。2组患者T_(2)、T_(3)时的气道峰压(Ppeak)、呼吸频率(RR)显著高于T_(1)和T_(4)时,潮气量(TV)显著低于T_(1)和T_(4)时(P<0.05);T_(2)、T_(3)时,观察组患者的Ppeak、TV显著低于对照组(P<0.05);T_(1)、T_(4)时,2组患者的Ppeak、TV比较差异无统计学意义(P>0.05);T_(1)~T_(4)时,2组患者的RR、呼气末二氧化碳分压(PetCO_(2))比较差异无统计学意义(P>0.05)。T_(0)~T_(5)时,2组患者的pH比较差异无统计学意义(P>0.05)。2组患者T_(1)与T_(0)时的OI比较差异无统计学意义(P>0.05);2组患者T_(2)~T_(5)的OI显著低于T_(0)和T_(1)时(P<0.05);T_(2)~T_(5)时,观察组患者的OI值显著高于对照组(P<0.05)。2组患者T_(2)~T_(5)时的Qs/Qt值显著高于T_(0)、T_(1)时(P<0.05);T_(2)~T_(5)时,观察组患者的Qs/Qt显著低于对照组(P<0.05)。2组患者T_(3)和T_(5)时的血清SP-A、IL-6水平显著高于T_(0)时(P<0.05);T_(3)、T_(5)时,观察组患者的SP-A、IL-6水平显著低于对照组(P<0.05)。对照组患者T_(3)和T_(5)时血清IL-10水平低于T_(0)时,观察组患者T_(3)和T_(5)时的血清IL-10水平高于T_(0)时(P<0.05);T_(3)、T_(5)时,观察组患者的血清IL-10水平显著高于对照组(P<0.05)。对照组患者T_(3)和T_(5)时血清MDA水平显著高于T_(0)时(P<0.05);观察组患者T_(3)和T_(5)时血清MDA水平与T_(0)时比较差异无统计学意义(P>0.05);T_(3)、T_(5)时,观察组患者血清MDA水平显著低于对照组(P<0.05)。T_(3)、T_(5)时,对照组患者血清SOD水平显著低于T_(0)时,观察组患者血清SOD水平显著高于T_(0)时(P<0.05);T_(3)、T_(5)时,观察组患者血清SOD水平显著高于对照组(P<0.05)。观察组患者中4例出现单侧喉返神经阻滞症状,1例患者出现臂丛神经阻滞,均于术后24 h内好转,术后随访未见其他不良反应。术后72 h内对照组有1例患者出现低氧血症。结论术前超声引导下SGB可以显著改善胸腔镜手术OLV患者的OI,减少肺内分流,抑制炎症反应和氧化应激,从而发挥肺保护作用。

Objective To explore the protection effect and mechanism of preoperative ultrasound-guided stellate ganglion block(SGB)on lung in patients undergoing one-lung ventilation(OLV)during thoracoscopic surgery.Methods Eighty-four patients who underwent OLV during thoracoscopic lobectomy at the Affiliated Suzhou Hospital of Nanjing Medical University from January 2021 to April 2022 were selected as research subjects,and the patients were divided into the observation group and control group by using a random number table,with 42 patients in each group.Patients in the observation group received ultrasound-guided SGB before anesthesia induction,while patients in the control group did not undergo puncture procedures.Patients in both groups received the same anesthesia induction and maintenance protocols.Hemodynamic,respiratory and arterial blood gas parameters were recorded at various time points:upon entering the operating room(T_(0)),before OLV(T_(1)),30 minutes after OLV initiation(T_(2)),60 minutes after OLV initiation(T_(3)),completion of surgery(T_(4)),and 30 minutes after extubation(T_(5)).Oxygenation index(OI),intrapulmonary shunt rate(Qs/Qt)and pH values of patients in the two groups were compared at these time points.Venous blood were collected from patients in both groups at T_(0),T_(3) and T_(5),and enzyme-linked immunosorbent assay was employed to measure the levels of surfactant protein-A(SP-A),superoxide dismutase(SOD),malondialdehyde(MDA),interleukin-6(IL-6)and interleukin-10(IL-10).Postoperative SGB-related complications and pulmonary complications within 72 hours were recorded.Results The mean arterial pressure(MAP)and heart rate(HR)in both groups were significantly lower at T_(1),T_(2),and T_(3) compared to T_(0)(P<0.05);the MAP and HR at T_(4) and T_(5) had no statistically significant difference compared to those at T_(0)(P>0.05);there was no significant difference in MAP and HR at other time points(P>0.05).MAP in the observation group at T_(1),T_(2) and T_(3) was significantly lower than that in the control group(P<0.05),and HR in the observation group at T_(2) and T_(3) was significantly lower than that in the control group(P<0.05);there were no significant differences in MAP and HR between the two groups at other time points(P>0.05).There were no significant differences in pulse oxygen saturation(SpO_(2))between the two groups at T_(0)-T_(5)(P>0.05).At T_(2) and T_(3),peak airway pressure(Ppeak)and respiratory rate(RR)were significantly higher than those at T_(1) and T_(4),and tidal volume(TV)was significantly lower than that at T_(1) and T_(4) in both groups(P<0.05).Ppeak and TV in the observation group at T_(2) and T_(3) were significantly lower than those in the control group(P<0.05);there were no significant differences in Ppeak and TV between the two groups at T_(1) and T_(4)(P>0.05).RR and partial pressure of end-tidal carbon dioxide(PetCO_(2))at T_(1)-T_(4) showed no significant differences between the two groups(P>0.05).The pH values at T_(0)-T_(5) showed no significant differences between the two groups(all P>0.05).The OI at T_(1) had no significant difference compared to that at T_(0) in both groups(P>0.05);OI at T_(2)-T_(5) in both groups was significantly lower than that at T_(0)(P<0.05);OI in the observation group at T_(2)-T_(5) was significantly higher than that in the control group(P<0.05).Qs/Qt at T_(2)-T_(5) was significantly higher than that at T_(0) and T_(1) in both groups(all P<0.05);Qs/Qt in the observation group at T_(2)-T_(5) was significantly lower than that in the control group(P<0.05).At T_(3) and T_(5),serum SP-A and IL-6 levels in both groups were significantly higher than those at T_(0)(P<0.05);serum SP-A and IL-6 levels in the observation group at T_(3) and T_(5) were significantly lower than those in the control group(P<0.05).At T_(3) and T_(5),serum IL-10 level in the control group were significantly lower than that at T_(0),while serum IL-10 level in the observation group were significantly higher than that at T_(0)(P<0.05).Serum IL-10 level in the observation group at T_(3) and T_(5) were higher than that in the control group(P<0.05).At T_(3) and T_(5),serum MDA level in the control group was significantly higher than that at T_(0)(P<0.05);serum MDA level in the observation group showed no significant difference compared to that at T_(0)(P>0.05);serum MDA level in the observation group was significantly lower than that in the control group(P<0.05).At T_(3) and T_(5),serum SOD level in the control group was significantly lower than that at T_(0),while serum SOD level in the observation group was significantly higher than that at T_(0)(P<0.05);serum SOD level in the observation group was significantly higher than that in the control group(P<0.05).Four patients in the observation group experienced symptoms of unilateral recurrent laryngeal nerve block,and one patient experienced brachial plexus nerve block,but all improved within 24 hours after surgery.No other adverse reactions were observed during follow-up.Within 72 hours postoperatively,one patient in the control group experienced hypoxemia.Conclusion Preoperative ultrasound-guided SGB has lung-protective effects on patients undergoing OLV in thoracoscopic surgery,which significantly improves OI,reduces intrapulmonary shunts,and inhibits inflammatory response and oxidative stress.