文章摘要
超声引导下单点和两点胸椎旁神经阻滞对胸腔镜手术患者血流动力学和应激反应的影响
Affects for hemodynamics and stress reaction by ultrasound-guided single or double level thoracic paravertebral block in video-assisted thoracoscopic surgery
  
DOI：10.12089/jca.2019.07.012
中文关键词: 椎旁阻滞  血流动力学  应激反应
英文关键词: Paravertebral block  Hemodynamics  Stress reaction
基金项目:
作者单位E-mail
罗太君 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
李坤 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
高广阔 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
刘涛 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
陈玢 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
王春 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
张宗德 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科  
刘伟 101149,北京市结核病胸部肿瘤研究所,首都医科大学附属北京胸科医院麻醉科 lw1200@sina.com 
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中文摘要:
      
目的 比较单点和两点椎旁神经阻滞对胸腔镜手术患者血流动力学和应激反应的影响。
方法 选择拟在本院行胸腔镜下肺癌切除患者60例，男26例，女34例，年龄55~75岁，BMI 18~25 kg/m2，ASA I—III级。随机分为单点椎旁注射组（S组）、两点椎旁注射组（D组）和对照组（C组），每组20例。S组患者超声引导下在T4~5椎旁间隙注射0.75%罗哌卡因15 ml和2%利多卡因5ml混合溶液，D组患者分别在T3~4和T5~6椎旁间隙注射0.75%罗哌卡因7.5 ml和2%利多卡因2.5 ml混合溶液，C组患者不予穿刺给药。记录三组患者术中麻醉诱导前（T0）、单肺通气1 h（T1）、单肺通气结束时（T2）、术毕（T3）、术后1 h（T4）、4 h（T5）和24 h（T6）的HR和MAP；采集三组患者T0、T1、T2和T3时桡动脉血，检测血液中血糖（Glu）、皮质醇（Cor）和8-异前列腺素F2α（8-iso-PGF2α，8-iso）浓度；随访记录术后1、4、24和48 h静息和咳嗽时VAS评分；记录穿刺部位血肿、气胸、感染等阻滞相关并发症发生情况；记录术后48 h内恶心呕吐、头晕、低血压、皮肤瘙痒等镇痛不良反应发生情况。
结果 三组不同时点HR和MAP差异无统计学意义。与C组比较，T2和T3时D组Glu明显降低（P<0.05），T3时D组8-iso明显降低（P<0.05），术后1、4、24、48 h S组和D组静息和咳嗽时VAS评分明显降低（P<0.05），S组和D组不同时点静息和咳嗽时VAS评分差异无统计学意义。三组无一例发生穿刺部位血肿、气胸、感染等阻滞相关并发症。三组术后48 h内恶心呕吐、头晕、低血压发生率差异无统计学意义，无一例皮肤瘙痒发生。
结论 超声引导下两点胸椎旁神经阻滞较单点胸椎旁神经阻滞更能阻断胸腔镜手术中外周伤害性刺激向中枢的传导，减少应激类物质的产生，降低应激反应程度。
英文摘要:
      
Objective To compare the hemodynamics and stress reaction of ultrasound-guided single- or double-level TPVB in patients undergoing video-assisted thoracoscopic surgery.
Methods Sixty patients with lung resection in our hospital for thoracoscopic surgery were selected, 26 males and 34 females, aged 55 - 75 years, with BMI 18 - 25 kg/m2, falling into ASA physical status I - III. The patients were randomly assigned to single-level TPVB (group S), double-level TPVB (group D) and control group (group C), 20 cases in each group. Patients in group S received single level ultrasound-guided TPVB at T4-5 levels, using mixed solution with 0.75% ropivacaine 15 ml and 2% lidocaine 5 ml. Patients in group D received double-level ultrasound-guided TPVB at T3-4 and T5-6 levels, using mixed solution with 0.75% ropivacaine 7.5ml + 2% lidocaine 2.5 ml. Patients in group C do not receive TPVB. HR and MAP were recorded before anesthesia (T0), 1 h after one lung ventilation (T1), at the end of one lung ventilation (T2), at the end of operation (T3), 1 h (T4), 4 h (T5) and 24 h after operation (T6). Arterial blood was collected at the time of T0, T1, T2 and T3 in three groups, and blood glucose (Glu), cortisol and 8-isoprostaglandin F2α (8-iso-PGF2α, 8-iso) were measured. Resting and cough VAS score were recorded at 1, 4, 24, and 48 h after surgery. The incidence of block related complications such as hematoma, pneumothorax and infection were recorded, and the incidence of nausea, vomiting, dizziness, hypotension, pruritus and other adverse analgesic reactions within 48 h after operation were also recorded.
Results There was no significant difference in HR and MAP among three groups at different time points. Compared with group C, Glu was significantly lower in group D at T2 and T3 (P < 0.05), and 8-iso was significantly lower in group D at T3 (P < 0.05), the resting and cough VAS pain scores were significantly lower in group S and group D at 1, 4, 24, and 48 h after surgery (P < 0.05), but there was no statistically difference in resting or cough VAS score between group S and group D at different time points. There were no block related complications such as hematoma, pneumothorax and infection in the three groups, there was no significant difference in the incidence of nausea, vomiting, dizziness and hypotension within 48 h after operation among three groups, and no pruritus was occurred in any group.
Conclusion Ultrasound-guided double-level TPVB is more effective than single-level TPVB in blocking the transmission of peripheral noxious stimuli to the central nervous system during VATS, reducing the production of stressors and decreasing the degree of stress response.
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