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全麻复合椎旁阻滞对食道手术围术期循环及术后镇痛的影响
Effects of general anesthesia combined with paravertebral block techniques on perioperative circulatory system and postoperative analgesia in patients undergoing thoracic esophagus surgery

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DOI:
作者:
裘毅敏
QIU Yimin, TANG Liang, WANG Zhengping , WANG Zha
作者单位:
上海交通大学附属第一人民医院
Department of Anesthesiology and Pain Management, Shanghai First People’s hospital, Shanghai Jiaotong University, Shanghai 200080, China
关键词:
胸椎旁阻滞; 开胸手术; 血流动力学; 每搏量变异度；术后镇痛
Thoracic Paravertebral block; Thoracic surgery; Hemodynamics; SVV; Postoperative analgesia
摘要:
摘要：目的：观察全麻复合椎旁阻滞、全麻复合硬膜外阻滞及单纯全麻三种麻醉方法在开胸手术平卧位、侧卧位、单肺通气时对血流动力学及术后镇痛的影响。方法：选择60例ASA Ⅰ～Ⅱ级择期行开胸手术的患者，手术切口在第4～5肋间，胸腔引流管在第7、8肋间。随机分为全麻组（组Ⅰ）、全麻复合硬膜外组（组Ⅱ）及全麻复合椎旁阻滞组（组Ⅲ）。每组各20例。分别于入室静息状态（T0）、全麻诱导插管后（T1）、侧卧位后（T2）、硬膜外加药后或胸椎旁阻滞后5min（T3）、开胸单肺通气后20min（T4）及术毕拔管前（T5）5个时间点，应用多功能监测仪连续监测心电图、心率（HR）、平均动脉压（MAP）、中心静脉压（CVP），采用Vigileo持续心排出量监测仪持续监测心排血量（CO）和每搏量变异度（SVV）。三组患者均于术毕缝皮时开启PCIA泵。观察记录术后2h、24h、48h的静息状态、咳嗽状态VAS评分、0～24h、24～48h的PCIA按压数及不良反应。结果：1、组内比较，三组患者T1时点SVV均值最高，均高于正常值高限13%，与T0时点相比，T1、T2时点三组的MAP、CO均值下降（P <0.05）。组间比较，组Ⅱ在T4时点SVV值高于组I 及组Ⅲ（P <0.05）。组Ⅲ在T4时点MAP值低于组Ⅱ（P <0.05）。但三组间的CO值差异无统计学意义。2、镇痛评分：组Ⅱ、组Ⅲ患者术后各时点VAS评分均低于组Ⅰ(P ＜0.05)；组Ⅲ术后2～48h内静态VAS评分低于组Ⅱ（P <0.05）。术后0h～24h、24h～48hPCA按压数，组Ⅲ明显少于组Ⅰ、组Ⅱ(P ＜0.05)。结论：全麻复合椎旁阻滞麻醉联合术后PCIA ，对开胸手术的患者术后镇痛效果最好；全麻复合硬膜外麻醉引起的循环波动表现为SVV显著高于全麻组及全麻复合椎旁阻滞组，不伴MAP下降；全麻复合椎旁阻滞对循环的抑制表现为MAP下降，不伴SVV增高。
【Abstract】: Objective To investigate the effects of general anesthesia combined with paravertebral block, general anesthesia combined with epidural block as well as general anesthesia alone on hemodynamic parameters and postoperative analgesia in patients undergoing thoracic surgery in the condition of supine position, lateral position, one-lung ventilation. Methods Sixty cases of ASA Ⅰ ~ Ⅱ patients undergoing surgery were randomly divided into groupⅠ( general anesthesia), group Ⅱ(general anesthesia combined with epidural block) and group Ⅲ (general anesthesia combined with paravertebral block) . All the patients had an incision in the 4th to 5th intercostal space and chest drainage tube in the 7th to 8th intercostal space . ECG, heart rate( HR) , mean artrial pression( MAP) , central venous pressure(CVP), cadiac output ( CO) and stroke volume variability (SVV) were continuously monitored each group and recorded immediately after intubation (T1), after lateral position (T2), 5 min after nerve block( T3) , 20 min after one-lung ventilation(T4) and before extubation (T5). Patient-controlled intravenous analgesia (PCIA) was started at the time of suture in all patients. Static and dynamic Visual analogue scales (VAS) were measured at 2h, 24h, 48h after surgery, while the pressing numbers of PCIA during 0-24h, 24h-48h and side effects were also recorded. Results 1. Compared within group, three groups of patients’ SVV was highest at T1, SVV means were higher than the normal limit values of 13%; Compared with T0, CO and MAP of three group were lower at T1 and T2( P < 0.05 ). Compared among groups, SVV values was higher in Group II than in Group Ⅰ and Group Ⅲ at T4 ( P < 0.05 ). In Group Ⅲ MAP was lower than in Group Ⅱ at T4 ( P < 0.05 ). However three groups showed no significant difference in CO. 2. Compared with Group Ⅰ, the postoperative VAS were lower in Group Ⅱ and Ⅲ(P <0.05). Meanwhile, the Static VAS during 2-48h after surgery in Group Ⅲ were lower than in Group Ⅱ(P<0.05). In comparison of GroupⅠand GroupⅡ, the pressing numbers of PCIA during 0-24h, 24h-48h in Group III were less than those in Group Ⅰand Ⅱ (P<0.05). Conclusion Paravertebral block combined with PCIA provided the most adequate postoperative analgesia in patients undergoing thoracic operation. Hemodynamic changes induced by general anesthesia combined with epidural anesthesia were characterized with significantly increased SVV without drop in MAP, while hemodynamic changes induced by general anesthesia combined with paravertebral block were characterized with significantly decreased MAP without increase in SVV.

 

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