全麻联合超声引导下椎旁神经阻滞在胸-腹腔镜食管癌根治术中的应用
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摘要
目的评估全麻联合超声引导下椎旁神经阻滞(ultrasound-guided paravertebral nerve block,USG-PVB)在胸-腹腔镜食管癌根治术(thoracoscopic and laparoscopic esophagectomy,TLE)中的应用效果。方法选择择期行TLE的患者48例,男40例,女8例,年龄52~72岁,BMI15.1~26.2kg/m~2,ASAⅠ或Ⅱ级,随机分为两组:全麻联合USG-PVB组(P组)和全麻组(G组),每组24例。两组全麻方法相同,P组于全麻诱导前行椎旁神经阻滞(paravertebral nerve block,PVB)。记录术中麻醉药物、血管活性药物和PACU药物用量;记录拔管时间、PACU停留时间、苏醒期躁动情况;记录苏醒时、出PACU时及术后1、2、3、5d静息和咳嗽时VAS评分;测试患者术前1d和术后7d简易智力状态检查量表(MMSE)评分;记录术后住院时间和术后7dPOCD发生率。结果与G组比较,P组术中丙泊酚、瑞芬太尼、舒芬太尼用量明显减少,去氧肾上腺素用量明显增多(P<0.05);拔管时间明显缩短,苏醒期躁动发生率明显降低,PACU舒芬太尼用量明显减少,PACU停留时间和术后住院时间明显缩短(P<0.01或P<0.05);苏醒时、出PACU时和术后1、2、5d静息和咳嗽时VAS评分、术后3d咳嗽时VAS评分均明显降低(P<0.01或P<0.05)。术后7d两组POCD发生率差异无统计学意义。结论全麻联合USG-PVB可减少围术期镇痛药物用量,减轻患者术后早期疼痛及躁动,缩短住院时间,有利于患者术后快速康复。
Objective To evaluate the effects of general anesthesia combined with paravertebral block guided by ultrasound in patients undergoing thoracoscopic and laparoscopic esophagectomy.Methods Forty-eight patients accepted thoracoscopic and laparoscopic esophagectomy,40 males and 8 females,aged 52-72 years,BMI 15.1-26.2 kg/m~2,ASA physical statusⅠ orⅡ,were recruited and randomly divided into general anesthesia group(group G,n =24)and general anesthesia combined with paravertebral block guided by ultrasound group(group P,n = 24).Both group P and group G received the same general anesthesia.Patients in group P received paravertebral block guided by ultrasound before anesthesia induction.Medication including anesthetics and vasoactive agents in operating room and in PACU were calculated.Extubation time,PACU residence time,restlessness in PACU and VAS(visual analogue scale)in quiet and coughing conditions in analepsia,lefting PACU and 1,2,3,5 dafter operation were recorded.The mini-mental state examination(MMSE)scores of patients 1 dbefore surgery and 7 dafter surgery were measured.The incidence of postoperative cognitive disfunction(POCD)was recorded.The length of postoperative hospitalization was recorded.Results Compared to group G,the intraoperative consumption of propofol,ramifentanil and sulfentanyl were significantly decreased in group P,and the consumption of phenylephrine was remarkbly higher in group P(P < 0.05).The extubation time,incidence of postoperative agitation,dose of sulfentanyl used in PACU,PACU stay time and length of postoperative hospitalization were significantly reduced in group P(P < 0.01 or P < 0.05).The VAS scores in quiet and coughing conditions in analepsia,lefting PACU and 1,2,5 dafter operation and the VAS scores in coughing conditions 3 dafter operation were remarkably decreased in group P(P < 0.05).There was no significant difference in POCD incidence between the two groups.Conclusion The general anesthesia combined with ultrasound-guided paravertebral nerve block can effectively reduce the consumption of perioperative opioid analgesic drugs,relieve the early postoperative pain and agitation of the patients undergoing thoracoscopic and laparoscopic esophagectomy and shorten the hospital stay,thus facilitating the postoperative recovery.
Objective To evaluate the effects of general anesthesia combined with paravertebral block guided by ultrasound in patients undergoing thoracoscopic and laparoscopic esophagectomy.Methods Forty-eight patients accepted thoracoscopic and laparoscopic esophagectomy,40 males and 8 females,aged 52-72 years,BMI 15.1-26.2 kg/m~2,ASA physical statusⅠ orⅡ,were recruited and randomly divided into general anesthesia group(group G,n =24)and general anesthesia combined with paravertebral block guided by ultrasound group(group P,n = 24).Both group P and group G received the same general anesthesia.Patients in group P received paravertebral block guided by ultrasound before anesthesia induction.Medication including anesthetics and vasoactive agents in operating room and in PACU were calculated.Extubation time,PACU residence time,restlessness in PACU and VAS(visual analogue scale)in quiet and coughing conditions in analepsia,lefting PACU and 1,2,3,5 dafter operation were recorded.The mini-mental state examination(MMSE)scores of patients 1 dbefore surgery and 7 dafter surgery were measured.The incidence of postoperative cognitive disfunction(POCD)was recorded.The length of postoperative hospitalization was recorded.Results Compared to group G,the intraoperative consumption of propofol,ramifentanil and sulfentanyl were significantly decreased in group P,and the consumption of phenylephrine was remarkbly higher in group P(P < 0.05).The extubation time,incidence of postoperative agitation,dose of sulfentanyl used in PACU,PACU stay time and length of postoperative hospitalization were significantly reduced in group P(P < 0.01 or P < 0.05).The VAS scores in quiet and coughing conditions in analepsia,lefting PACU and 1,2,5 dafter operation and the VAS scores in coughing conditions 3 dafter operation were remarkably decreased in group P(P < 0.05).There was no significant difference in POCD incidence between the two groups.Conclusion The general anesthesia combined with ultrasound-guided paravertebral nerve block can effectively reduce the consumption of perioperative opioid analgesic drugs,relieve the early postoperative pain and agitation of the patients undergoing thoracoscopic and laparoscopic esophagectomy and shorten the hospital stay,thus facilitating the postoperative recovery.
引文
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[10]俞红丽,于布为.麻醉手术后痛觉过敏的研究进展.上海医学,2009,32(6):532-536.
[11]庆淑梅,曹亚楠,孙振涛,等.椎旁神经阻滞用于开胸术老年患者超前镇痛的效果.中华麻醉学杂志,2016,36(2):168-170.
[12]Liebert AD,Chow RT,Bicknell BT,et al.Neuroprotective effects against POCD by photobiomodulation:evidence from assembly/disassembly of the cytoskeleton.J Exp Neurosci,2016,10:1-19.
[13]Wang W,Wang Y,Wu H,et al.Postoperative cognitive dysfunction:current developments in mechanism and prevention.Med Sci Monit,2014,20:1908-1912.
[14]Bilotta F,Qeva E,Matot I.Anesthesia and cognitive disorders:a systematic review of the clinical evidence.Expert Rev of Neurother,2016,16(11):1311-1320.
[2]王春影,岳子勇.椎旁神经阻滞在胸科手术术后镇痛的应用.临床肺科杂志,2017,22(12):2309-2311,2314.
[3]莫家伟.胸腹腔镜微创手术与开放手术对食管癌患者术后早期肺功能的影响.河北医药,2013,35(12):1806-1808.
[4]章蔚,柴小青,魏昕,等.Narcotrend监测下全身麻醉联合椎旁神经阻滞用于胸腹腔镜联合食管癌根治术效果观察.山东医药,2016,56(40):72-74.
[5]董森林,顾尔伟,张雷,等.全麻联合硬膜外阻滞在腔镜食管癌根治术中的应用.临床麻醉学杂志,2016,32(1):53-57.
[6]姜徽,李元海,周磊,等.不同镇痛方法对老年食管癌患者术后疼痛及早期认知功能的影响.临床麻醉学杂志,2016,32(5):472-475.
[7]Singleton PA,Mirzapoiazova T,Hasina R,et al.Increasedμ-opioid receptor expression in metastatic lung cancer.Br J Anaesth,2014,113Suppl 1:i103-i108.
[8]朱雁铃,彭捷,吴友平,等.全麻复合胸椎旁阻滞对单孔胸腔镜手术术后疼痛及快速康复的影响.临床麻醉学杂志,2015,31(12):1153-1156.
[9]Ding X,Jin S,Niu X,et al.A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy:an updated meta-analysis.PloS One,2014,9(5):e96233.
[10]俞红丽,于布为.麻醉手术后痛觉过敏的研究进展.上海医学,2009,32(6):532-536.
[11]庆淑梅,曹亚楠,孙振涛,等.椎旁神经阻滞用于开胸术老年患者超前镇痛的效果.中华麻醉学杂志,2016,36(2):168-170.
[12]Liebert AD,Chow RT,Bicknell BT,et al.Neuroprotective effects against POCD by photobiomodulation:evidence from assembly/disassembly of the cytoskeleton.J Exp Neurosci,2016,10:1-19.
[13]Wang W,Wang Y,Wu H,et al.Postoperative cognitive dysfunction:current developments in mechanism and prevention.Med Sci Monit,2014,20:1908-1912.
[14]Bilotta F,Qeva E,Matot I.Anesthesia and cognitive disorders:a systematic review of the clinical evidence.Expert Rev of Neurother,2016,16(11):1311-1320.