超声引导竖脊肌平面阻滞对胸腔镜肺叶切除患者术后镇痛和细胞免疫功能的影响

Effect of ultrasound-guided erector spinae plane block on postoperative analgesia and cellular immunity in patients undergoing video-assisted thoracoscopic lobectomy

摘要:

目的 观察超声引导下竖脊肌平面（ESP）阻滞对胸腔镜下肺叶切除患者术后镇痛和细胞免疫功能的影响。方法 选择择期胸腔镜下肺叶切除术患者90例，美国麻醉医师协会（ASA）分级Ⅰ～Ⅲ级。随机分为单纯静脉全麻组（C组）、椎旁神经阻滞+静脉全麻组（P组）和ESP阻滞+静脉全麻组（E组）。E组和P组分别在全麻诱导前行超声引导下ESP阻滞和椎旁神经阻滞，20 min后测定阻滞范围和效果，术毕3组均采用静脉自控镇痛（PCIA）。记录入手术室（T₀）、麻醉诱导前（T₁）、切皮即刻（T₂）和术毕（T₃）3组患者平均动脉压（MAP）和心率（HR）；记录术后2 h（T₄）、8 h（T₅）、12 h（T₆）、24 h（T₇）和48 h（T₈）静态数字疼痛评分［NRS（R）］和动态NRS评分［NRS（M）］；并于T₀、T₃、T₇和T₈抽取静脉血5 mL，检测血液自然杀伤（NK）细胞数目和Th1/Th2比值；记录术后镇痛泵按压次数、药物输注总量、曲马多给药次数和术后不良反应发生情况。结果 与T₀比较，P组患者在T₁时点MAP降低、HR增快（P < 0.05），C组患者T₂和T₃时点MAP增高、HR增快（P < 0.05）；P组和E组患者T₂和T₃时点MAP低于C组、HR慢于C组（P < 0.05）；C组和E组患者T₁时点MAP高于P组、HR慢于P组（P < 0.05）；P组和E组患者术后T₄～T₆时点的NRS（R）低于C组（P < 0.05），E组患者术后T₇时点NRS（R）低于C组（P < 0.05）；P组和E组患者术后T₄～T₆时点的NRS（M）低于C组（P < 0.05）；P组和E组各时点NRS比较，差异无统计学意义（P > 0.05）。各组患者在T₃、T₇和T₈时点NK细胞数目、Th1/Th2比值均较T₀降低，E组和P组在T₃、T₇和T₈时点NK细胞数目、Th1/Th2比值高于C组（P < 0.05），E组和P组比较，差异无统计学意义（P > 0.05）；E组和P组术中瑞芬太尼用量、镇痛泵按压次数、药物输注总量和曲马多给药次数均明显少于C组（P < 0.05），E组与P组比较，差异无统计学意义。P组术后低血压发生率高于C组和E组（P < 0.05）、C组术后恶心呕吐发生率高于P组和E组（P < 0.05）。结论 超声引导下ESP阻滞，对胸腔镜下肺叶切除患者术后疼痛和免疫功能的影响与椎旁神经阻滞相当，但对患者循环影响更小。

Abstract:

Objective To observe the effect of ultrasound-guided erector spinae plane(ESP) block on postoperative analgesia and cellular immunity in patients undergoing lobectomy performed via video-assisted thoracoscope.Methods Ninety patients (ASA physical status Ⅰ~Ⅲ), scheduled for elective video-assisted thoracoscopic labectomy, were randomly assigned into three groups, intravenous anesthesia group (group C), paravertebral block combined with intravenous anesthesia group (group P) and ESP block combined with intravenous anesthesia group (group E). The group P and E were given the paravertebral block and ESP block by ultrasound-guided in the T₅ before general anesthesia, and the effect was evaluated by testing the area of block, the patients of three groups were given PCIA. The mean arterial pressure (MAP) and HR were recorded at the time of entering operating room (T₀), before induction of anaesthesia (T₁), the instant of skin incision (T₂) and the end of the surgery (T₃). NRS (R) (rest NRS score) and NRS (M) (movement NRS) were recorded at 2 h (T₄), 8 h (T₅), 12 h (T₆), 24 h (T₇) and 48 h (T₈) after operation. 5 mL venous blood samples were collected at T₀, T₃, T₇, T₈ respectively, flow cytometry was used to detect the number of NK cells and the ratio of Th1/Th2. Recorded the frequency for compress PCIA, the total volume of analgesic drugs, the consumption of tramadol, and the postoperative adverse reactions.Results Compared with T₀, the patients of group P showed a decrease in MAP and increase of HR at T₁ (P < 0.05), and the HR and MAP of group C was higher in the time of T₂ , T₃ (P < 0.05); Compared with group C, The MAP and HR of group P and E was lower than the group C in the time of T₂ , T₃ (P < 0.05), compared with group P, the MAP of group C and group E was higher than the group P and the HR was lower in the time of T₁ , (P < 0.05). The score of NRS (R) in the groups of P and E were lower than goup C at the time of T₄～T₆ (P < 0.05), the score of NRS (R) in the group of E was lower than group C at the time of T₇ (P < 0.05); The score of NRS(M) in the groups of P and E were lower than group C at the time of T₄～T₆ (P < 0.05); There was no significant different in pain scores between the group P and group E at the timeT₄～T_8, Compare with T₀ , the number of NK cells and the ratio of Th1/Th2 were significantly lower in the time of T₃, T₇, T₈ (P < 0.05), the number of NK cells and the ratio of Th1/Th2 in group E and P were significantly higher than the group C (P < 0.05), there was no significant difference between the group E and P (P > 0.05). The dose of remifentanil in the operation, compress PCA numbers, volume of analgesic drugs and the consumption of tramadol in the groups of P and E were significantly less than group C (P < 0.05), and there was no statistically difference between group E and P (P > 0.05). The incidence of postoperative hypotension was higher in the group P than the groups E and group C (P < 0.05); The incidence of postoperative nausea and vomiting of group E and group P were lower than group C (P < 0.05).Conclusion Ultrasound-guided erector spinae plane block was similar to that of paravertebral nerve block on postoperative pain and cellular immunity fuction in patients with lobectomy under thoracoscope, but less influence of the blood pressure to the patients.