肋间神经阻滞辅助右美托咪定对肺癌患者术后免疫功能的影响
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摘要
目的观察肋间神经辅助右美托咪定对肺癌患者免疫功能的影响。方法选择2017年6月至2018年9月在深圳市人民医院拟行肺癌根治术的患者60例,采用随机数表法将患者随机分为对照组和观察组,每组30例。所有患者均使用气管插管全身麻醉,吸入七氟烷和静脉注射瑞芬太尼维持麻醉。观察组在麻醉诱导前静脉注射右美托咪定0.3μg/kg (15 min内),随后以0.3μg/(kg·h)持续输注至缝皮前,在关胸前,使用0.5%罗哌卡因20 mL行肋间神经阻滞,对照组使用等剂量生理盐水。记录术中七氟烷和瑞芬太尼用量,测定并比较两组患者麻醉诱导前(T0)、手术结束时(T1)、手术结束后24 h (T2)外周静脉血CD3+、CD4+、CD4+/CD8+水平,采用视觉模拟评分(VAS)对两组患者术后4 h、8 h、24 h的疼痛程度进行评分,记录术后自控静脉镇痛(PCIA)按压次数、镇痛不全和术后不良反应的发生率。结果对照组患者的七氟烷和瑞芬太尼的用量分别是(71.4±12.5) mL和(1 093.7±244.1)μg,明显高于观察组的(59.8±11.9) mL和(920.1±225.1)μg,差异均有统计学意义(P<0.05);观察组患者T1和T2时点CD3+、CD4+和CD4+/CD8+分别是(54.1±5.2)%、(30.0±3.2)%、(1.6±0.7)和(57.3±6.0)%、(35.6±3.5)%、(2.0±0.7),明显高于对照组的(50.5±3.2)%、(25.5±3.7)%、(1.2±0.3)和(50.6±3.2)%、(26.6±3.5)%、(1.3±0.3),差异均有统计学意义(P<0.05);对照组患者术后4 h和8 h的VAS评分分别为(3.7±1.0)分和(3.6±0.8)分,明显高于同组术后24 h的(1.4±0.6)分,也高于观察组术后4 h和8 h的(1.5±0.5)分和(1.4±0.5)分,差异均有统计学意义(P<0.05);对照组和观察组患者PCIA按压次数分别为(6.4±3.4)次和(1.2±0.8)次,镇痛不全分别为7例(23.3%)和1例(3.3%),术后恶心呕吐分别为10例(33.3%)和2例(6.7%),差异均有统计学意义(P<0.05)。结论肋间神经辅助右美托咪定用于肺癌根治术患者,可减少术中麻醉药物的使用,提高术后镇痛质量,减少术后不良反应,改善患者免疫功能。
Objective To observe the effect of intercostal nerve block combined with dexmedetomidine on immune function in patients with lung cancer. Methods A total of 60 patients who were scheduled to undergo radical resection of lung cancer in Shenzhen People's Hospital from June 2017 to September 2018 were randomly divided into a control group and an observation group, with 30 cases in each group. All patients received general anesthesia with tracheal intubation. Inhalation of sevoflurane and intravenous injection of remifentanil were used to maintain anesthesia. The observation group received a bolus dose of intravenous dexmedetomidine 0.3 μg/kg within 15 minutes before anesthesia induction, then IV infusion of 0.3 μg/(kg·h) was continued during surgery before skin enclosure, and intercostal nerve block was performed with 20 m L of 0.5% ropivacaine before closing the thoracotomy. The control group used equal dose of normal saline. The consumptions of intraoperative sevoflurane and remifentanil dosage were recorded. The levels of CD3+, CD4+, CD4+/CD8+in peripheral venous blood were measured and compared between the two groups before anesthesia induction(T0), at the end of operation(T1), and at 24 hours after operation(T2). The Visual Analogue Scale(VAS)was used to evaluate postoperative pain effect at 4 h, 8 h, 24 h after operation. The press times of patient control intravenous analgesia(PCIA), the incidence of analgesia, and adverse effects after operation were recorded. Results The consumptions of sevoflurane and remifentanil in the control group were(71.4±12.5) m L and(1 093.7±244.1) μg, which were significantly higher than(59.8±11.9) m L and(920.1±225.1) μg in the observation group(P<0.05). The levels of CD3+,CD4+, and CD4+/CD8+in the observation group were respectively(54.1±5.2)%,(30.0±3.2)%,(1.6±0.7) at T1,(57.3±6.0)%,(35.6±3.5)%, and(2.0±0.7) at T2, which were significantly higher than corresponding(50.5±3.2)%,(25.5±3.7)%,(1.2±0.3),(50.6±3.2)%,(26.6±3.5)%,(1.3± 0.3) in the control group(P<0.05). The VAS scores at 4 h and 8 h after operation in the control group was(3.7±1.0) and(3.6±0.8), respectively, which was significantly higher than(1.4±0.6) at 24 h after operation in the control group and corresponding(1.5±0.5) and(1.4±0.5) at 4 h and 8 h after operation in the observation group(P<0.05). In the control group and the observation group, the press times of PCIA were(6.4±3.4) and(1.2±0.8), respectively; the number of cases with analgesic insufficiency was 7(23.3%) and 1(3.3%), respectively; postoperative nausea and vomiting occurred in 10 cases(33.3%) and 2 cases(6.7%), respectively; all differences were statistically significant(P<0.05). Conclusion Intercostal nerve block combined with dexmedetomidine for patients with lung cancer undergoing radical resection can reduce the consumption of intraoperative anesthetics, improve the quality of postoperative analgesia, reduce postoperative adverse reactions and improve immune function.
Objective To observe the effect of intercostal nerve block combined with dexmedetomidine on immune function in patients with lung cancer. Methods A total of 60 patients who were scheduled to undergo radical resection of lung cancer in Shenzhen People's Hospital from June 2017 to September 2018 were randomly divided into a control group and an observation group, with 30 cases in each group. All patients received general anesthesia with tracheal intubation. Inhalation of sevoflurane and intravenous injection of remifentanil were used to maintain anesthesia. The observation group received a bolus dose of intravenous dexmedetomidine 0.3 μg/kg within 15 minutes before anesthesia induction, then IV infusion of 0.3 μg/(kg·h) was continued during surgery before skin enclosure, and intercostal nerve block was performed with 20 m L of 0.5% ropivacaine before closing the thoracotomy. The control group used equal dose of normal saline. The consumptions of intraoperative sevoflurane and remifentanil dosage were recorded. The levels of CD3+, CD4+, CD4+/CD8+in peripheral venous blood were measured and compared between the two groups before anesthesia induction(T0), at the end of operation(T1), and at 24 hours after operation(T2). The Visual Analogue Scale(VAS)was used to evaluate postoperative pain effect at 4 h, 8 h, 24 h after operation. The press times of patient control intravenous analgesia(PCIA), the incidence of analgesia, and adverse effects after operation were recorded. Results The consumptions of sevoflurane and remifentanil in the control group were(71.4±12.5) m L and(1 093.7±244.1) μg, which were significantly higher than(59.8±11.9) m L and(920.1±225.1) μg in the observation group(P<0.05). The levels of CD3+,CD4+, and CD4+/CD8+in the observation group were respectively(54.1±5.2)%,(30.0±3.2)%,(1.6±0.7) at T1,(57.3±6.0)%,(35.6±3.5)%, and(2.0±0.7) at T2, which were significantly higher than corresponding(50.5±3.2)%,(25.5±3.7)%,(1.2±0.3),(50.6±3.2)%,(26.6±3.5)%,(1.3± 0.3) in the control group(P<0.05). The VAS scores at 4 h and 8 h after operation in the control group was(3.7±1.0) and(3.6±0.8), respectively, which was significantly higher than(1.4±0.6) at 24 h after operation in the control group and corresponding(1.5±0.5) and(1.4±0.5) at 4 h and 8 h after operation in the observation group(P<0.05). In the control group and the observation group, the press times of PCIA were(6.4±3.4) and(1.2±0.8), respectively; the number of cases with analgesic insufficiency was 7(23.3%) and 1(3.3%), respectively; postoperative nausea and vomiting occurred in 10 cases(33.3%) and 2 cases(6.7%), respectively; all differences were statistically significant(P<0.05). Conclusion Intercostal nerve block combined with dexmedetomidine for patients with lung cancer undergoing radical resection can reduce the consumption of intraoperative anesthetics, improve the quality of postoperative analgesia, reduce postoperative adverse reactions and improve immune function.
引文
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[12] BOLAND JW, POCKLEY AG. Influence of opioids on immune function in patients with cancer pain:from bench to bedside[J]. Br J Pharmacol, 2017, 175(11):2726-2736.
[13]王立婷,吴安石.术后镇痛与快速康复外科[J].北京医学, 2015, 37(8):774-776.
[14] RICE DC, CATA JP, MENA GE, et al. Posterior intercostal nerve block with liposomal bupivacaine:an alternative to thoracic epidural analgesia[J]. Ann Thorac Surg, 2015, 99(6):1953-1960.
[15] AHMED Z, SAMAD K, ULLAH H. Role of intercostal nerve block in reducing postoperative pain following video-assisted thoracoscopy:a randomized controlled trial[J]. Saudi J Anaesth, 2017, 11(1):54-57.
[16]蒋明浩,王云姣,郭曲练.老年患者腰椎术后应用右美托咪定对舒芬太尼术后镇痛的影响[J].中国现代医学杂志, 2017, 27(18):106-109.
[2] TOHME S, SIMMONS RL, TSUNG A. Surgery for cancer:a trigger for metastases[J]. Cancer Res, 2017, 77(7):1548-1552.
[3] SEKANDARZAD MW, VAN ZUNDERT AA, LIRK PB, et al. Perioperative anesthesia care and tumor progression[J]. Anesth Analg,2017, 124(5):1697-1708.
[4]张睿,史敏科,王小雨,等.不同浓度罗哌卡因肋间神经阻滞在开胸手术后早期镇痛中的应用[J].临床麻醉学杂志, 2015, 31(4):323-325.
[5]姜鹏,刘凯,王若峥. T细胞免疫与肿瘤关系研究进展[J].新疆医科大学学报, 2015, 38(1):21-25.
[6]唐慧,董虹,高建梅,等.不同血清微环境体外培养的CIK细胞中CD4+/CD8+和Th1/Th2的动态改变[J].中华临床医师杂志(电子版), 2013, 20:9131-9137.
[7]周志鹏,宋歌,王航,等.右美托咪定对结肠癌根治术患者围术期应激反应及细胞免疫功能的影响[J].中国免疫学杂志, 2017, 33(11):1694-1698.
[8]张国庆,华丽,张国梁.右美托咪定复合瑞芬太尼用于肺癌切除术后的镇痛效果及对机体免疫功能的影响[J].中国药房, 2016, 27(30):4215-4217.
[9]曾涟,阳丽云,蒋卓汛.麻醉药物和方式对恶性肿瘤生长及转移的影响[J].广西医科大学学报, 2016, 33(3):557-559.
[10] PAGE GG, BLAKELY WP, BEN-ELIYAHU S. Evidence that postoperative pain is a mediator of the tumor-promoting effects of surgery in rats[J]. Pain, 2001, 90(1-2):191-199.
[11] BYRNE K, LEVINS KJ, BUGGY DJ. Can anesthetic-analgesic technique during primary cancer surgery affect recurrence or metastasis?[J]. Can J Anaesth, 2016, 63(2):184-192.
[12] BOLAND JW, POCKLEY AG. Influence of opioids on immune function in patients with cancer pain:from bench to bedside[J]. Br J Pharmacol, 2017, 175(11):2726-2736.
[13]王立婷,吴安石.术后镇痛与快速康复外科[J].北京医学, 2015, 37(8):774-776.
[14] RICE DC, CATA JP, MENA GE, et al. Posterior intercostal nerve block with liposomal bupivacaine:an alternative to thoracic epidural analgesia[J]. Ann Thorac Surg, 2015, 99(6):1953-1960.
[15] AHMED Z, SAMAD K, ULLAH H. Role of intercostal nerve block in reducing postoperative pain following video-assisted thoracoscopy:a randomized controlled trial[J]. Saudi J Anaesth, 2017, 11(1):54-57.
[16]蒋明浩,王云姣,郭曲练.老年患者腰椎术后应用右美托咪定对舒芬太尼术后镇痛的影响[J].中国现代医学杂志, 2017, 27(18):106-109.