穴位局部皮下镇痛对全麻术后患者免疫功能的影响
|
摘要
目的:观察经腹腔镜胆囊切除术后几种镇痛模式的镇痛效果及其对患者血清白介素-1β(IL-1β)、肿瘤坏死因子-α(TNF-α)和T淋巴细胞亚群的影响。方法 :选择经腹腔镜胆囊切除手术患者80例,随机分为T 8夹脊穴组、足三里组、皮下镇痛组、静脉镇痛组,各20例。各组均采用相同的麻醉诱导和麻醉维持方式,T 8夹脊穴组及足三里组采用T 8夹脊穴下及足三里穴下留置硬膜外导管,皮下镇痛组留置针位于右前臂前侧近肘处皮下,静脉镇痛组留置针位于右前臂内侧静脉。气管导管拔出后连接自控镇痛泵(PCA)。记录患者麻醉前(T 0)、拔管后(T 1)以及术后镇痛6h(T 2)、24h(T 3)和48h(T 4)的生命体征、视觉模拟评分(VAS),同时记录患者在镇痛过程中按压PCA次数以及舒芬太尼的总用量,并分别于T 0、T 1以及T 3、T 4采集外周静脉血,用酶联免疫吸附法检测血清中IL-1β和TNF-α含量,用流式细胞仪检测外周血CD4+、CD8+的计数,并计算CD4+/CD8+比值。结果:各时间点VAS与T 1相比有显著降低(P<0.05)。与皮下镇痛组和静脉镇痛组相比,T 8夹脊穴组及足三里组PCA按压次数以及舒芬太尼的用量显著减少(P<0.05)。各组T 1时间点血清IL-1β和TNF-α含量与T 0相比均显著上升(P<0.05);与皮下镇痛组和静脉镇痛组比较,T 3和T 4时T 8夹脊穴组及足三里组均有显著降低(P<0.05)。与T 0比较,T 3和T 4时各组CD4+/CD8+比值均有显著的降低(P<0.05)。结论:4种镇痛模式均能提供良好的术后镇痛;与传统静脉镇痛相比,穴位局部皮下镇痛能减少麻醉性镇痛药物的用量,同时可能对术后患者的免疫功能抑制有一定的改善作用。
Objective To observe the effect of acupoint injection of Lidocaine on serum IL-1β,TNF-αand T-lymphocyte subset activities in patients undergoing laparoscopic cholecystectomy(LC),so as to reveal its mechanisms underlying relieving postoperative pain and potentiating rehabilitation.Methods Eighty patients scheduled for elective LC surgery(grade I or II,according to American Standards of Association,ASA)were randomly divided into four groups,namely intravenous analgesia(IVA),right forearm-injection(forearm-I),Jiaji(EX-B 2,Thorax 8)-injection(EX-B 2-I),and Zusanli-injection(ST 36-I),with20 patients in each group.The conventional anesthetic induction and maintenance with Penehyclidine Hydrochloride,Midazolam,Sulfentanil,Propofol,Atracurium Besilate,and Remifentanil were same in all the 4groups.For patients of the forearm-I,EX-B 2-I and ST 36-I groups,5% Lidocaine was injected into the subcutaneous layer of the anterior side of right forearm near the elbow,EX-B 2and ST 36 regions,respectively.Analgesia pump(filled with Sulfentanil,Ramosetron+normal saline)was connected after the tracheal extubation.The visual analog scale(VAS)was used to assess the patient's pain reaction after tracheal extubation(T 1),and 6h(T 2),24h(T 3)and 48h(T 4)after surgery.The times of PCA pressing and the total dose of Sufentanil in the process of postoperative analgesia were recorded as well.The contents of serum IL-1βand TNF-αwere analyzed by ELISA,and the counts of CD4+and CD8+T cells were detected by flow cytometry.Results Compared with T 1in the same one group,the VAS scores at time-points of T 2,T 3and T 4after surgery of all the IVA,forearm-I,ST 36-I and EX-B 2-I groups were reduced significantly(P<0.05).The times of PCA pump pressing and the doses of the administrated Sufentanil were considerably lower in the ST 36-I and EX-B 2-I groups than in the IVA and forearm-I groups(P<0.05).In comparison with pre-anesthesia in the same one group,serum TNF-αand IL-1βcontents at T 1were remarkably increased,while the ratios of CD4+/CD8+at T 4in the 4groups were evidently down-regulated(P<0.05).The contents of serum TNF-αand IL-1βat T 3and T 4were obviously lower in both ST 36-I and EX-B 2-I groups than in the IVA and forearm-Ⅰ groups(P<0.05).No significant differences were found among the 4groups in the VAS scores at the 4time-points,in the serum TNF-αand IL-1βcontents at T 0and T 1,in the counts of CD4+and CD8+T cells and ratios of CD4+/CD8+at T 0,T 3and T 4,and between the ST 36-I and EX-B 2-I groups in all the 8indexes(P>0.05).Conclusion Acupoint injection of Lidocaine is effective in relieving pain in LC patients,which is demonstrated by reducing VAS score,PCA pump pressing times,and administrated Sufentanil dose,and may be associated with its effects in down-regulating serum TNF-αand IL-1βcontents.
Objective To observe the effect of acupoint injection of Lidocaine on serum IL-1β,TNF-αand T-lymphocyte subset activities in patients undergoing laparoscopic cholecystectomy(LC),so as to reveal its mechanisms underlying relieving postoperative pain and potentiating rehabilitation.Methods Eighty patients scheduled for elective LC surgery(grade I or II,according to American Standards of Association,ASA)were randomly divided into four groups,namely intravenous analgesia(IVA),right forearm-injection(forearm-I),Jiaji(EX-B 2,Thorax 8)-injection(EX-B 2-I),and Zusanli-injection(ST 36-I),with20 patients in each group.The conventional anesthetic induction and maintenance with Penehyclidine Hydrochloride,Midazolam,Sulfentanil,Propofol,Atracurium Besilate,and Remifentanil were same in all the 4groups.For patients of the forearm-I,EX-B 2-I and ST 36-I groups,5% Lidocaine was injected into the subcutaneous layer of the anterior side of right forearm near the elbow,EX-B 2and ST 36 regions,respectively.Analgesia pump(filled with Sulfentanil,Ramosetron+normal saline)was connected after the tracheal extubation.The visual analog scale(VAS)was used to assess the patient's pain reaction after tracheal extubation(T 1),and 6h(T 2),24h(T 3)and 48h(T 4)after surgery.The times of PCA pressing and the total dose of Sufentanil in the process of postoperative analgesia were recorded as well.The contents of serum IL-1βand TNF-αwere analyzed by ELISA,and the counts of CD4+and CD8+T cells were detected by flow cytometry.Results Compared with T 1in the same one group,the VAS scores at time-points of T 2,T 3and T 4after surgery of all the IVA,forearm-I,ST 36-I and EX-B 2-I groups were reduced significantly(P<0.05).The times of PCA pump pressing and the doses of the administrated Sufentanil were considerably lower in the ST 36-I and EX-B 2-I groups than in the IVA and forearm-I groups(P<0.05).In comparison with pre-anesthesia in the same one group,serum TNF-αand IL-1βcontents at T 1were remarkably increased,while the ratios of CD4+/CD8+at T 4in the 4groups were evidently down-regulated(P<0.05).The contents of serum TNF-αand IL-1βat T 3and T 4were obviously lower in both ST 36-I and EX-B 2-I groups than in the IVA and forearm-Ⅰ groups(P<0.05).No significant differences were found among the 4groups in the VAS scores at the 4time-points,in the serum TNF-αand IL-1βcontents at T 0and T 1,in the counts of CD4+and CD8+T cells and ratios of CD4+/CD8+at T 0,T 3and T 4,and between the ST 36-I and EX-B 2-I groups in all the 8indexes(P>0.05).Conclusion Acupoint injection of Lidocaine is effective in relieving pain in LC patients,which is demonstrated by reducing VAS score,PCA pump pressing times,and administrated Sufentanil dose,and may be associated with its effects in down-regulating serum TNF-αand IL-1βcontents.
引文
[1]Weisse C S,Pato C N,McAllister C G,et al.Differential effects of controllable and uncontrollable acute stress on lymphocyte proliferation and leukocyte percentages in humans[J].Brain Behav Immun,1990,4(4):339-351.
[2]Pergolizzi J,Bger R H,Budd K,et al.Opioids and the management of chronic severe pain in the elderly:consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization StepⅢopioids[J].Pain Pract,2008,8(4):287-313.
[3]诸毅辉,成词松,陈玉华,等.足三里穴位注射镇痛效应与中缝大核共存神经递质5-HT SP表达的关系[J].辽宁中医杂志,2007,34(12):1816-1817.
[4]张丙茹,李苏,袁培云,等.足三里穴位注射预防医院感染及对患者免疫功能的影响[J].中国针灸,2006,26(9):625-628.
[5]王珂,刘惠芬,周文华,等.“足三里”和“肾俞”穴位埋线对大鼠吗啡镇痛耐受和运动行为敏化的影响[J].中国针灸,2008,28(7):509-513.
[6]Rahim T,Kamyar T T,Nasser M,et al.The effect of acupuncture on relieving pain after inguinal surgeries[J].Korean Pain,2013,26(1):46-50.
[7]Hyo-Jeong L,Jae-Ho L,Eun-Ok L.Retraction:substance P and beta-endorphin mediate electro-acupuncture induced analgesia in mouse cancer pain model[J].J Exp Clin Cancer Res,2009,28(1):102-137.
[8]Qiao Y,Wu F,Wang J,et al.Effects of injection of anti-corticotropin release hormone serum in the lateral ventricles and electroacupuncture analgesia on pain threshold in rats with adjuvant arthritis[J].Neural Regen Res,2012,7(21):1630-1636.
[9]张雪羽,李文慧,温塘芳,等.小剂量吗啡内关穴注射治疗急性心肌梗死之胸痛[J].中国针灸,2008,28(9):642-644.
[10]陈泉芳,孔晋亮,王威,等.地塞米松两种给药途径对控制肺癌化疗所致胃肠道反应的疗效比较[J].结直肠肛门外科,2011,17(6):351-354.
[11]崔晶晶,高俊虹,王玉敏,等.针药结合增效机制研究的新思路探讨[J].针刺研究,2010,35(2):146-149.
[12]刘俊岭,陈振荣.“九五”国家攀登计划预选项目“经络的研究”进展[J].针刺研究,2002,27(3):230-237.
[13]Hall J M,Cruser D,Podawiltz A,et al.Psychological stress and the cutaneous immune response:roles of the HPA axis and the sympathetic nervous systeminatopic dermatitis and psoriasis[J].Dermatol Res Pract,2012:403908.
[14]Olfe J,Domanska G,Schuett C,et al.Different stress-related phenotypes of BALB/c mice from in-house or vendor:alterations of the sympathetic and HPA axis responsiveness[J].BMC Physiol,2010,10(2):1-11.
[15]Kim E H,Ryu da H,Hwang S.The expression of corticotropin-releasing factor and its receptors in the spinal cord and dorsal root ganglion in a rat model of neuropathic pain[J].Anat Cell Biol,2011,44(1):60-68.
[16]LaJevic M D,Suleiman S,Cohen R L,et al.Activation of p 38 mitogen-activated protein kinase by norepinephrine in T-lineage cells[J].Immunology,2011,132(2):197-208.
[17]Van Westerloo D J,Choi G,Lwenberg E C,et al.Acute stress elicited by bungee jumping suppresses human innate immunity[J].Mol Med,2011,17(3/4):180-188.
[18]Sara M,Sandrini R S,Jonathan W,et al.Elucidation of the mechanism by which catecholamine stress hormones liberate iron from the innate immune defense proteins transferrin and lactoferrin[J].J Bacteriol,2010,192(2):587-594.
[19]Anne C,Nicola M,Hilary A C.Predictive value of interleukin 1gene polymorphisms for surgery[J].Ann Rheum Dis,2000,59(3):695-699.
[20]Xia H M,Fang Y,Huang P L.Tumor necrosis factor alpha affect hydrocortisone expression in mice adrenal cortex cells mainly through tumor necrosis factor alpha-receptor 1[J].Chin Med J,2011,124(17):2728-2732.
[21]梁洁,郑丽宏,王国年,等.经皮穴位电刺激对直肠癌根治术患者围术期T淋巴细胞免疫功能和术后镇痛效果的影响[J].中华麻醉学杂志,2008,28(3):208-210.
[2]Pergolizzi J,Bger R H,Budd K,et al.Opioids and the management of chronic severe pain in the elderly:consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization StepⅢopioids[J].Pain Pract,2008,8(4):287-313.
[3]诸毅辉,成词松,陈玉华,等.足三里穴位注射镇痛效应与中缝大核共存神经递质5-HT SP表达的关系[J].辽宁中医杂志,2007,34(12):1816-1817.
[4]张丙茹,李苏,袁培云,等.足三里穴位注射预防医院感染及对患者免疫功能的影响[J].中国针灸,2006,26(9):625-628.
[5]王珂,刘惠芬,周文华,等.“足三里”和“肾俞”穴位埋线对大鼠吗啡镇痛耐受和运动行为敏化的影响[J].中国针灸,2008,28(7):509-513.
[6]Rahim T,Kamyar T T,Nasser M,et al.The effect of acupuncture on relieving pain after inguinal surgeries[J].Korean Pain,2013,26(1):46-50.
[7]Hyo-Jeong L,Jae-Ho L,Eun-Ok L.Retraction:substance P and beta-endorphin mediate electro-acupuncture induced analgesia in mouse cancer pain model[J].J Exp Clin Cancer Res,2009,28(1):102-137.
[8]Qiao Y,Wu F,Wang J,et al.Effects of injection of anti-corticotropin release hormone serum in the lateral ventricles and electroacupuncture analgesia on pain threshold in rats with adjuvant arthritis[J].Neural Regen Res,2012,7(21):1630-1636.
[9]张雪羽,李文慧,温塘芳,等.小剂量吗啡内关穴注射治疗急性心肌梗死之胸痛[J].中国针灸,2008,28(9):642-644.
[10]陈泉芳,孔晋亮,王威,等.地塞米松两种给药途径对控制肺癌化疗所致胃肠道反应的疗效比较[J].结直肠肛门外科,2011,17(6):351-354.
[11]崔晶晶,高俊虹,王玉敏,等.针药结合增效机制研究的新思路探讨[J].针刺研究,2010,35(2):146-149.
[12]刘俊岭,陈振荣.“九五”国家攀登计划预选项目“经络的研究”进展[J].针刺研究,2002,27(3):230-237.
[13]Hall J M,Cruser D,Podawiltz A,et al.Psychological stress and the cutaneous immune response:roles of the HPA axis and the sympathetic nervous systeminatopic dermatitis and psoriasis[J].Dermatol Res Pract,2012:403908.
[14]Olfe J,Domanska G,Schuett C,et al.Different stress-related phenotypes of BALB/c mice from in-house or vendor:alterations of the sympathetic and HPA axis responsiveness[J].BMC Physiol,2010,10(2):1-11.
[15]Kim E H,Ryu da H,Hwang S.The expression of corticotropin-releasing factor and its receptors in the spinal cord and dorsal root ganglion in a rat model of neuropathic pain[J].Anat Cell Biol,2011,44(1):60-68.
[16]LaJevic M D,Suleiman S,Cohen R L,et al.Activation of p 38 mitogen-activated protein kinase by norepinephrine in T-lineage cells[J].Immunology,2011,132(2):197-208.
[17]Van Westerloo D J,Choi G,Lwenberg E C,et al.Acute stress elicited by bungee jumping suppresses human innate immunity[J].Mol Med,2011,17(3/4):180-188.
[18]Sara M,Sandrini R S,Jonathan W,et al.Elucidation of the mechanism by which catecholamine stress hormones liberate iron from the innate immune defense proteins transferrin and lactoferrin[J].J Bacteriol,2010,192(2):587-594.
[19]Anne C,Nicola M,Hilary A C.Predictive value of interleukin 1gene polymorphisms for surgery[J].Ann Rheum Dis,2000,59(3):695-699.
[20]Xia H M,Fang Y,Huang P L.Tumor necrosis factor alpha affect hydrocortisone expression in mice adrenal cortex cells mainly through tumor necrosis factor alpha-receptor 1[J].Chin Med J,2011,124(17):2728-2732.
[21]梁洁,郑丽宏,王国年,等.经皮穴位电刺激对直肠癌根治术患者围术期T淋巴细胞免疫功能和术后镇痛效果的影响[J].中华麻醉学杂志,2008,28(3):208-210.