超声引导胸椎旁神经阻滞对多发肋骨骨折术后镇痛和炎症反应的影响  

Effects of ultrasound-guided thoracic paravertebral block on postoperative analgesia and inflammatory response in patients with multiple rib fractures

作　　者：刘建东 陈建华 王伟立 陈松林[2] 陈检明[2] 焦昌结[2] 易云峰[2] Liu Jiandong;Chen Jianhua;Wang Weili;Chen Songlin;Chen Jianming;Jiao Changjie;Yi Yunfeng(Department of Anesthesiology,909th Hospital of Joint Logistics Support Force(Affiliated Dongnan Hospital of Xiamen University),Zhangzhou 363000,China;Department of Cardiothoracic Surgery,909th Hospital of Joint Logistics Support Force(Affiliated Dongnan Hospital of Xiamen University),Zhangzhou 363000,China)

机构地区：[1]解放军联勤保障部队第909医院(厦门大学附属东南医院)麻醉科,漳州363000 [2]解放军联勤保障部队第909医院(厦门大学附属东南医院)心胸外科,漳州363000

出　　处：《中华创伤杂志》2020年第7期608-613,共6页Chinese Journal of Trauma

基　　金：全军后勤科研项目(CWH17J030,CNJ14C007)。

摘　　要：目的探讨超声引导胸椎旁神经阻滞对多发肋骨骨折患者术后镇痛和炎症反应的影响。方法采用回顾性病例对照研究分析2016年7月—2018年12月解放军联勤保障部队第909医院收治的48例单侧多发肋骨骨折患者临床资料,其中男30例,女18例;年龄18~69岁[(41.1±10.4)岁]。肋骨骨折3~9根[(5.7±1.9)根]。患者均行记忆合金环抱器内固定手术。24例采用超声引导下胸椎旁阻滞镇痛(椎旁阻滞组),24例采用静脉自控镇痛(静脉镇痛组)。分别于麻醉诱导前(T1)、术后1 h(T2)、术后6 h(T3)、术后24 h(T4)、术后48 h(T5)记录静息和咳嗽咳痰时疼痛视觉模拟评分(VAS)。抽取静脉血,采用ELISA法测定血浆中性粒细胞弹性蛋白酶(NE)、肿瘤坏死因子-α(TNF-α)和白细胞介素-6(IL-6)水平。结果静息状态下,两组间T1时VAS差异无统计学意义(P>0.05),两组术后各时相点VAS较T1明显下降(P<0.01),椎旁阻滞组术后T2~T4时VAS[(3.4±0.7)分、(3.2±0.8)分、(3.1±0.7)分]明显低于静脉镇痛组[(4.8±0.9)分、(4.4±0.7)分、(3.9±0.8)分](P<0.01),两组间T5时VAS差异无统计学意义(P>0.05);在咳嗽咳痰时,两组间T1时VAS差异无统计学意义(P>0.05),静脉镇痛组术后各时相点VAS均超过6分[分别为(7.7±1.0)分、(7.6±1.3)分、(7.4±1.2)分、(7.1±0.9)分],明显高于椎旁阻滞组[(3.6±0.7)分、(3.3±0.7)分、(3.2±0.6)分、(2.9±0.7)分](P<0.01)。两组NE、TNF-α和IL-6水平在T2时与T1比较均明显增加(P<0.01),在T5时与T1比较均明显降低(P<0.01);术后各时相点椎旁阻滞组NE水平[分别为(65.5±19.0)ng/ml、(42.5±12.5)ng/ml、(26.3±9.3)ng/ml、(20.9±7.9)ng/ml]明显低于静脉镇痛组[(76.7±18.2)ng/ml、(51.4±15.1)ng/ml、(35.5±10.0)ng/ml、(28.6±9.0)ng/ml](P<0.05),TNF-α水平[分别为(8.7±1.9)pg/ml、(6.0±1.3)pg/ml、(3.9±0.9)pg/ml、(2.8±0.8)pg/ml]明显低于静脉镇痛组[(10.0±2.1)pg/ml、(6.8±1.5)pg/ml、(4.7±1.1)pg/ml、(3.6±1.0)pg/ml](P<0.05),IL-6水平[分别为(11.5�Objective To investigate the effects of ultrasound-guided thoracic paravertebral block on the changes of analgesic efficacy and inflammatory response in patients with multiple rib fractures.Methods A retrospective case-control study was performed in 48 patients with multiple rib fractures admitted to 909th Hospital of Joint Logistics Support Force from July 2016 to December 2018.There were 30 males and 18 females,with the age range of 18-69 years[(41.1±10.4)years].The number of fractured ribs was 3-9(5.7±1.9).All patients were stabilized with the memory alloy embracing fixator.Thoracic paravertebral block group received ultrasound-guided thoracic paravertebral block and intravenous analgesia group received patient controlled intravenous analgesia,with 24 patients in each group.The visual analogue scale(VAS)was observed and recorded in the resting/cough state before induction of anesthesia(T1),and 1 h(T2),6 h(T3),24 h(T4)and 48 h(T5)after surgery.Blood samples were taken simultaneously from the vein for determination of plasma neutrophil elastase(NE),tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)concentrations by ELISA method.Results In the resting state,there was no significant difference between two groups in VAS at T1(P>0.05);the VAS in two groups at T2-T5 decreased significantly compared with T1(P<0.01);the VAS at T2-T4 in thoracic paravertebral block group[(3.4±0.7)points,(3.2±0.8)points,(3.1±0.7)points]was significantly lower than that in intravenous analgesia group[(4.8±0.9)points,(4.4±0.7)points,(3.9±0.8)points](P<0.01).In the cough state,there was no significant difference between two groups in VAS at T1(P>0.05);the VAS at T2-T5 in intravenous analgesia group was all higher than 6 points[(7.7±1.0)points,(7.6±1.3)points,(7.4±1.2)points,(7.1±0.9)point],and was significantly higher than those in thoracic paravertebral block group[(3.6±0.7)points,(3.3±0.7)points,(3.2±0.6)points,(2.9±0.7)points](P<0.01).There was no significant difference between two groups in plasma levels of NE,TNF-

关 键 词：肋骨骨折 超声检查 自主神经传导阻滞 镇痛 细胞因子类 

分 类 号：R614[医药卫生—麻醉学]