全身麻醉复合硬膜外麻醉对胸科手术应激反应的影响

The effects of general anesthesia combined with epidural anesthesia on the stress response in thoracic surgery

目的 了解胸科手术时全身麻醉复合硬膜外阻滞 (GEA)与单纯全麻 (GA)两组病人应激激素、细胞因子变化 ,并观察GEA对胸部手术应激反应的影响。方法 将 2 0例肺叶或肺叶局部切除手术病人随机分为GEA和GA两组 ,于术前 ,切皮时 ,切皮后 2、4、6h、术后第 1、3日晨取血测定白细胞介素 6 (IL 6 )、皮质醇、促肾上腺皮质激素 (ACTH)浓度。结果 ( 1)两组病人IL 6、ACTH及皮质醇浓度于切皮后逐渐升高 ,切皮后 4～ 6h达高峰 ,GEA组皮质醇浓度在切皮后 2h明显低于对照组 ,其余时点组间比较差异无显著意义。 ( 2 )IL 6与皮质醇浓度呈正相关 (r =0 2 31)。结论 ( 1)胸部手术引炎性因子改变 ,其分泌不受硬膜外阻滞影响。 ( 2 )胸部手术使应激激素升高 ,硬膜外阻滞对此有一定的抑制作用。 ( 3)IL 6与皮质醇可能有相互影响。

Objective To study the effects of general anesthesia combined with epidural anesthesia (GEA) and pure general anesthesia (GA) on the surgical stress response and cytokines in pulmonary surgery. Methods Twenty patients submitted to elective pulmonary surgery were randomly divided into 2 groups of 10 patients: GEA group receiving general anesthesia combined with thoracic epidural analgesia and GA group receiving only general anesthesia. Blood samples were taken before induction, at incision, 2 h, 4 h, 6 h following the incision, and in the 1st and 3rd postoperative day. IL-6, ACTH and cortisol were detected with radioimmunoassay. Results (1) The concentration of ACTH was similar in the 2 groups before operation, was remarkably increased 2 hours poatoperatively (P<0.05), reached the peak values 2～4 hours after the incision in most patients (P<0.01), and returned to the preoperative levels one day after operation without a significant difference at every time point between the two groups. (2) The concentration of cortisol decreased transiently during incision in the GEA group (P<0.05), then increased gradually, was significantly higher than the preoperative level (P<0.01), and remained at the high level till the morning of the 1st day after operation (P<0.01). In the GA group the cortisol concentration was higher than that before operation 2 hours after incision (P<0.01),and remained at the level higher than that before operation 4 h and 6 h after incision (P<0.01),and returned to the normal level by the morning of the 3rd day. The cortisol concentration 2 hours after incision in GEA group was significantly lower than that in GA group (P<0.05),however, the peak concentrations of these 2 groups were not significantly different (P>0.05) In the GA group the IL-6 concentration began to increase after operation, became significantly different from that before operation 4 hours after operation (P<0.01), reached the peak level in the morning of the first postoperative day (P<0.05), and returned to the preoperative level in the third day. In the GEA group the IL-6 concentration began to increase 2 hours after operation (P<0.05), and returned to the preoperative level in the morning of the first postoperative day. The concentration of IL-6 was positively correlated with that of cortisol (r=0.231). Conclusion Pulmonary surgery performed with two different anesthetic techniques causes inflammatory cytokine responses. The additional epidural anesthesia doesn′t influence cytokine production. It incompletely inhibits the stress response in the early phase. IL-6 and cortisol may have some effects on each other.