不同镇痛方式在胸腔镜肺叶切除术患者术后镇痛效果的比较  

Comparison of effects of different analgesia regimens in patients after thoracoscopic lobectomy

作　　者：张高峰[1] 孙立新[1] 陈怀龙[1] 孙晓鹏[1] 林旭[1] 时飞[1] 

机构地区：[1]青岛市市立医院东院麻醉科,266071

出　　处：《临床麻醉学杂志》2014年第10期984-988,共5页Journal of Clinical Anesthesiology

摘　　要：目的比较不同镇痛方式在胸腔镜肺叶切除术患者术后镇痛的效果。方法择期行单侧胸腔镜肺叶切除术患者60例,ASAⅠ或Ⅱ级,随机均分为三组：自控椎旁神经镇痛组（PVB组）、自控硬膜外镇痛组（PCEA组）和自控静脉镇痛组（PCIA组）。PVB组在神经刺激仪引导下行术侧T4~5椎旁间隙穿刺插管,PCEA组行T4~5硬膜外穿刺插管。手术结束前30min停用瑞芬太尼;PVB组经椎旁间隙导管注射0.2%罗哌卡因15ml负荷量;PCEA组硬膜外注射0.125%罗哌卡因5ml,PCIA组静脉注射舒芬太尼0.1μg/kg。之后连接镇痛泵PVB组0.2%罗哌卡因,5ml/h,PCA量5ml,锁定时间15min;PCEA组0.125%罗哌卡因,5ml/h,PCA量5ml,锁定时间15min;PCIA组舒芬太尼1.0μg/ml,2ml/h,PCA量2ml,锁定时间15min。记录入室后（T0）、拔出气管导管30min（T1）、术后24h（T2）、48h（T3）、72h（T4）HR、MAP、PaO2、PaCO2;及T1~T4时静息和咳嗽时VAS评分。测定T0、T2~T4时用力肺活量占预计值的百分比（FVC%）、用力1秒呼气量占预计值的百分比（FEV1%）,并计算FEV1/FVC;记录镇痛期间不良反应的发生情况。结果与T0时比较,T1时PVB组和PCEA组MAP明显降低、PCIA组MAP明显升高,PCEA组HR明显减慢、而T2时三组HR明显增快（P〈0.05）。与PCIA组比较,T1时PVB组、PCEA组和T2时PCEA组MAP明显降低,T1时PCEA组HR明显减慢（P〈0.05）。与PCEA组比较,T1、T2时PVB组MAP明显升高,T1时PVB组HR明显增快（P〈0.05）。与T0时比较,T1时三组患者PaO2和T1、T2时PCIA组PaCO2明显升高（P〈0.05）。与PCIA组比较,T1、T2时PVB组和PCEA组PaCO2明显降低（P〈0.05）。与T0时比较,T2~T4时三组FVC%、FEV1%明显降低（P〈0.05）。与PCIA组比较,T2~T4时PVB和PCEA组FVC%和FEV1%明显升高（P〈0.05）。三组FEV1/FVC组间组内差异无统计学意义。与PCIA组比较,T1~T4时PVB组和PCEA组咳嗽时VAS评分明显降低（P〈0.05）。PVB组和PCEA组患者无一例发生嗜睡,明显低于PCIA组14例�Objective To compare the efficacy of different analgesia ways in patients after lobectomy performed via video-assisted thoracoscope（VAT）.Methods Sixty patients of ASA Ⅰ orⅡ,aged 43-65 yr,weigh 56-81 kg,undergoing elective lobectomy via VAT,were randomly divided into 3groups（n=20each）;group patients-controlled paravertebral block（group PVB）,group patient-controlled epidural analgesia（group PCEA）,and group patient-controlled intravenous analgesia（group PCIA）.Cathetering into paravertebral space（T4-5）guided by nerve stimulator was performed in group PVB,and epidural catheterization（T4-5）in group PCEA.Visual analogue scale（VAS）were recorded when the patient was resting and coughing at the following time points：30min after extubation（T1）,24h（T2）,48h（T3）,72h（T4）after operation.Side effects were recorded during the analgesia.MAP and HR,PaO2 and PaCO2were recorded at baseline time（T0）,T1-T4.Pulmonary function indicatrix were measured at T0,T2-T4.Results There was significant diffenerce in VAS scale at coughing and forced vital capacity（the percentages of predicted value,FVC%）,forced expiratory volume first second（the percentages of predicted value,FEV1%）at the monitor point after operation between group PCIA and group PVB,group PCEA（P〈0.05）.Compared to group PCIA and group PCEA,MAP in group PVB was significantly different at T1,T2.The incidence of drowsiness in PVB and group PCEA were significicantly lower than that in group PCIA.Conclusion Both patient-controlled paravertebral block can provide an adequate,continuous and effective means for postoperative pain,profit recovery of postoperative lung function,with more stable haemodynamics and less side effects.

关 键 词：自控椎旁神经镇痛 自控硬膜外镇痛 自控静脉镇痛 胸腔镜肺叶切除术 

分 类 号：R614[医药卫生—麻醉学]