连续胸椎旁神经阻滞在乳腺癌全麻手术中的效果观察

殷亚鹏  吴  鹏  崔  魁  李永强  李宪营

漯河市中心医院，河南 漯河 462000

作者简介：殷亚鹏，Email：yypenger@sohu.com

 

【摘要】  目的  探讨全麻复合连续胸椎旁神经阻滞在乳腺癌手术中的麻醉及术后镇痛效果。方法  选取手术治疗乳腺癌患者86例，随机分为2组各43例。对照组行全麻复合静脉自控镇痛，观察组行全麻复合连续胸椎旁神经阻滞。记录2组不同时段血流动力学变化情况，麻醉药用量、疼痛评分及术后恢复情况。结果  麻醉诱导前2组心率、平均动脉压水平差异无统计学意义(P＜0.05)，切皮后5 min和术毕观察组心率和平均动脉压水平均低于对照组，差异有统计学意义(P＜0.05)；观察组丙泊酚(623.17±87.54) mg、舒芬太尼(45.26±6.74) μg用量少于对照组[(772.54±97.63) mg，(53.28±9.02)μg]，清醒时间及拔管时间短于对照组，且术后不同时段疼痛视觉模拟评分均低于对照组，不良反应发生率6.98%(3/43)低于对照组23.26%(10/43)，差异有统计学意义(P＜0.05)。结论  全麻复合连续胸椎旁神经阻滞可有效提高乳腺癌手术麻醉及镇痛效果，有利于维持患者围手术期血流动力学稳定，且术后不良反应发生率低，安全有效。

【关键词】  乳腺癌手术；全身麻醉；连续胸椎旁神经阻滞；麻醉效果；镇痛

【中图分类号】  R614.4    【文献标识码】  A    【文章编号】  1673-5110(2019)04-0406-07  DOI：10.12083/SYSJ.2019.04.127

 

YIN Yapeng，WU Peng，CUI Kui，LI Yongqiang，LI Xianying

Central Hospital of Luohe，Luohe 462000，China

【Abstract】  Objective  To investigate the effect of anesthesia and postoperative analgesia of general anesthesia combined with continuous thoracic paravertebral nerve block (CTPVB) in breast cancer surgery.Methods  Eighty-six patients with breast cancer surgery were selected and grouped according to the random number table method，with 43 cases in each group.The control group underwent general anesthesia combined with intravenous analgesia，and the observation group underwent general anesthesia combined with CTPVB.The changes of heart rate (HR) and mean arterial pressure (MAP) in two different time periods (before anest hesia induction)，T1 (5 min after incision)，T2 (completed surgery) were recorded.The doses of propofol and sufentanil were compared between the two groups.The postoperative awake，extubation time，postoperative pain (VAS) scores and the incidence of adverse reactions at 24 h after surgery.Results  There was no significant difference in HR and MAP between the two groups before anesthesia induction (P＜0.05)．The HR and MAP in the observation group were lower than those in the control group at 5 min after the incision.The difference was statistically significant (P＜0.05)；the amount of propofol (623.17±87.54 mg) and sufentanil (45.26±6.74) μg in the observation group was less than that in the control group (772.54±97.63) mg，(53.28±9.02) μg，awake time and extubation The time was shorter than that of the control group，and the visual analogue scale of pain was lower than that of the control group at different time points.The incidence of adverse reactions was 6.98% (3/43)，whichwas lower than that of the control group 23.26% (10/43)．The difference was statistically significant (P＜0.05)．Conclusion  General anesthesia combined with continuous thoracic paravertebral nerve block can significantly improve the anesthesia and analgesic effect in breast cancer surgery，This method is beneficial to maintain the perioperative hemodynamic stability，and the incidence of postoperative adverse reactions is low，safe and effective.

【Key words】  Breast cancer surgery；General anesthesia；Continuous thoracic paravertebral nerve block；Anesthetic effect；Analgesia

 

        乳腺癌是临床常见恶性肿瘤疾病，具有较高发病率，加之近些年受多种因素影响，乳腺癌发生率呈不断上升趋势^[1-6]，严重威胁广大女性身心健康，其防治已引起临床足够重视。目前，手术是根治早期乳腺癌的最主要有效手段，但该术式属体表手术，疼痛刺激相对较大，而对肌松要求不高，全麻时必须给予足量麻醉药物及镇痛药以满足手术需求^[7-14]。连续胸椎旁神经阻滞(continuous thoracic spinal block，CTPVB)是于胸椎间孔脊神经附近连续注射局麻药物，使该侧交感、感觉及运动神经阻滞，以达到同侧躯体麻醉的一种方法^[15-22]。本研究选取86例手术治疗乳腺癌患者，分组探讨全麻复合CTPVB在乳腺癌手术中的麻醉及术后镇痛效果。

 

1．1  一般资料  选取2013-04—2016-010漯河市中心医院86例行手术治疗乳腺癌患者，按照随机数表法分组，各43例。观察组年龄21～67(45.68±11.84)岁；ASA(美国麻醉师协会)分级：Ⅰ级11例，Ⅱ级23例，Ⅲ级9例。对照组年龄22～68(46.27±11.79)岁；ASA分级：Ⅰ级10例，Ⅱ级23例，Ⅲ级10例。2组年龄、ASA分级等基线资料比较，差异无统计学意义(P＞0.05)。

1．2  纳入排除标准  (1)纳入标准：符合《外科学》中乳腺癌相关诊断标准^[7]；自愿签署知情同意书。(2)排除标准：凝血功能障碍；合并严重糖尿病、高血压及心血管疾病；穿刺部位合并严重感染。

1．3  方法  (1)对照组行全麻复合静脉自控镇痛：①麻醉诱导：给予1.5～2 mg/kg丙泊酚＋2 mg咪达唑仑＋0.5～0.8 μg/kg舒芬太尼＋0.1 mg/kg维库溴铵麻醉诱导；②术中维持：丙泊酚恒速持续泵入＋维库溴铵联合舒芬太尼静脉滴注，脑电双频指数(bispectral index，BIS)维持在45～60，并根据BIS值对丙泊酚剂量进行调整，切皮后，血压、心率明显升高者，每次追加0.2 μg/kg舒芬太尼，术毕15 min前停止输注丙泊酚；③术后镇痛：术后给予100 μg/kg舒芬太尼＋0.6 mg雷莫司琼＋150 mg氟比洛芬酯＋250 mL生理盐水，以自控镇痛泵泵注，锁定时间15 min，背景流量5 mL/h，自控剂量1 mL。(2)观察组行全麻复合CTPVB：①麻醉诱导：麻醉诱导前先行面罩吸氧，并给予5 μg舒芬太尼＋1～2 mg咪达唑仑镇静，患者取患侧朝上侧卧位，于胸3椎间隙中点延线外侧3 cm左右处进行穿刺，穿刺针针尖触及横突后继续进针约1 cm，针尖进入椎旁间隙回抽无出血，注入2～2.5 mg/kg 0.5%罗哌卡因，对穿刺针进行固定，注入局麻药后置入导管，椎旁间隙内留置＜3 cm，以手术贴膜固定，起效 15 min后进行麻醉诱导，方法同对照组；②术中维持同对照组；③术后镇痛：手术结束前30 min，经椎旁留置导管注射15 mL 0.375%罗哌卡因，并连接电子输注泵输注250 mL 0.25%罗哌卡因，锁定时间15 min，背景流量5 mL/h，自控剂量5 mL。

1．4  观察指标  (1)记录T0、T1、T2不同时段HR、MAP变化情况；(2)对比2组丙泊酚、舒芬太尼用量及术后清醒、拔管时间；(3)采用视觉模拟评分法(visual analogue scale，VAS)^[8]对术后不同时段(4 h、8 h、12 h、24 h、48 h)疼痛程度进行评估，得分越高则疼痛越明显；(4)统计2组术后24 h不良反应发生率。

1．5  统计学分析  采用SPSS 20.0统计学软件分析数据，计量资料以均数±标准差(x±s)表示，采用t检验，计数资料以百分率(%)表示，采用χ²检验，P＜0.05为差异有统计学意义。

 

2．1  2组不同时段HR、MAP水平比较  T0时段2组HR、MAP水平差异无统计学意义(P＜0.05)，T1、T2时段观察组HR、MAP水平均低于对照组，差异有统计学意义(P＜0.05)。见表1。

2．2  2组麻醉药物用量及清醒、拔管时间比较  观察组丙泊酚、舒芬太尼用量少于对照组，清醒时间及拔管时间短于对照组，差异有统计学意义(P＜0.05)。见表2。

2．3  2组术后不同时段VAS评分比较  观察组术后不同时段VAS评分均低于对照组，差异有统计学意义(P＜0.05)。见表3。

2．4  2组术后24 h不良反应发生率比较  观察组不良反应发生率低于对照组，差异有统计学意义(P＜0.05)。见表4。

表1  2组不同时段HR、MAP水平比较  (x±s)

Table 1  Comparison of HR and MAP levels in 2 groups  (x±s)

时间	组别	n	HR(次/min)	MAP(mmHg)
T0	观察组	43	78.25±10.32	112.36±11.58
	对照组	43	78.31±10.15	113.02±10.79
	t值		0.027	0.273
	P值		＞0.05	＞0.05
T1	观察组	43	87.25±11.36	115.24±11.27
	对照组	43	92.23±11.02	120.67±12.54
	t值		2.063	2.112
	P值		＜0.05	＜0.05
T2	观察组	43	83.21±10.23	113.36±11.12
	对照组	43	88.63±10.01	118.25±10.32
	t值		2.483	2.114
	P值		＜0.05	＜0.05

表2  2组麻醉药物用量及清醒、拔管时间比较  (x±s)

Table 2  Comparison of the amount of anesthetic drugs in 2 groups and the time of awake and extubation  (x±s)

表3  2组术后不同时段VAS评分比较  (x±s，分)

Table 3  Comparison of VAS scores at different time points in 2 groups  (x±s，score)

表4  2组术后24 h不良反应发生率比较  [n(%)]

Table 4  Comparison of the incidence of adverse reactions after 24 hours of two groups  [n(%)]

 

        随医疗科学技术迅速发展，手术成为乳腺癌治疗的主要有效手段之一，但乳腺癌根治术创面较大，若术中麻醉效果不理想极易增加围手术期生理及心理应激反应，不利于术后早期康复及预后改善^[23-31]，故乳腺癌手术中，选择何种麻醉方式以提高麻醉效果及术后镇痛效果、维持围手术期血流动力学稳定逐渐成为临床研究的重要课题^[32-39]。

        目前，椎旁神经阻滞术后镇痛已广泛运用于临床，并取得显著效果^[40-46]。孙立新等^[15]研究指出，在非体外循环冠脉搭桥手术中，给予患者全身麻醉复合双侧胸椎旁神经阻滞，可取得显著镇痛效果，且有利于维持患者血流动力学稳定，较为安全有效。张留福等^[16]在乳腺手术全身麻醉与胸椎旁神经阻滞Meta分析发现，胸椎旁神经阻滞可有效减少术中麻醉药物用量，可取得理想镇痛效果，进而有利于减少麻醉药物过量使用、术后疼痛等所致的一系列不良反应。本研究中，观察组采取全麻复合CTPVB，其HR、MAP及丙泊酚、舒芬太尼用量、术后苏醒时间、拔管时间、疼痛评分均优于对照组(P＜0.05)，与上述研究结果基本一致，充分佐证了全麻复合CTPVB在乳腺癌手术中的可行性与有效性。CTPVB镇痛机制是使局麻药物直接作用于椎间隙神经及其交感神经干、交通支与背侧支，药物扩散后进入硬膜外腔而对这一部位神经后根支配的体壁感觉产生抑制^[47-55]。同时，CTPVB可产生超前镇痛，将具有伤害性刺激的神经冲动阻断，避免其向中枢传导，进而防止中枢神经系统痛觉敏化，能够为乳腺癌手术提供有效的麻醉及镇痛，有利于减少静脉麻醉药物及阿片类镇痛药的使用，减轻患者心血管应激反应，使围手术期血流动力学更稳定^[56-60]，此外，良好的镇痛效果可减少术后急性疼痛及相关并发症的发生。本研究还显示，观察组术后24 h头晕、恶心、呕吐等不良反应发生率低于对照组(P＜0.05)。王芸等^[20]研究指出，术后恶心、呕吐等是全麻复合静脉镇痛最常见并发症，其发生机制主要与术中过量使用舒芬太尼等药物对抗手术伤害刺激及疼痛有关，且会对术后恢复产生不同程度影响。CTPVB能够提高麻醉及镇痛效果^[21-23]，且有利于减少舒芬太尼等药物使用剂量，对降低术后不良反应发生率具有重要意义。

 

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(收稿2018-08-25)

本文责编：关慧

本文引用信息：殷亚鹏，吴鹏，崔魁，李永强，李宪营．连续胸椎旁神经阻滞在乳腺癌全麻手术中的效果观察[J]．中国实用神经疾病杂志，2019，22(4)：406-412.DOI：10.12083/SYSJ.2019.04.127

Reference information：YIN Yapeng，WU Peng，CUI Kui，LI Yongqiang，LI Xianying.Application of continuous thoracic paravertebral nerve block in general anesthesia for breast cancer[J]．Chinese Journal of Practical Nervous Diseases，2019，22(4)：406-412.DOI：10.12083/SYSJ.2019.04.127