腹横肌平面阻滞与胸段硬膜外阻滞在结直肠癌根治术患者中的临床应用  

Transversus abdominis plane block versus thoracic epidural analgesia in patients undergoing colorectal cancer radical surgery

作　　者：伊利亚尔·买买提力 张振英[1] 葛春林[1] 张欣欣 Ilyar MAMTILI;ZHANG Zhenying;GE Chunlin;ZHANG Xinxin(Department of Anesthesiolgy,Shanghai Xuhui Hospital,Shanghai 200030,China)

机构地区：[1]上海市徐汇区中心医院麻醉科,上海200030

出　　处：《上海医学》2020年第10期595-599,共5页Shanghai Medical Journal

摘　　要：目的评价硬膜外阻滞与腹横肌平面阻滞在结直肠癌根治术患者中的应用效果。方法选取于2015年12月—2017年10月在上海市徐汇区中心医院择期行结直肠癌根治术的患者144例,将患者随机分为2组:腹横肌平面阻滞组(腹横肌平面组)和胸段硬膜外阻滞组(胸段硬膜外组),每组各72例。排除中途退出的患者,最终腹横肌平面组患者数为71例,胸段硬膜外组患者数为70例。记录两组患者麻醉前(T 0)、切皮即刻(T 1)、手术开始后1 h(T 2)、手术结束时(T 3)、气管拔管后(T 4)各时间点的收缩压(SBP)、舒张压(DBP)、心率(HR)。于T 0和T 3时间点抽取外周静脉血检测皮质醇、肾上腺素、去甲肾上腺素水平;检测外周血CD3+、CD4+、CD8+T细胞比例,CD4+/CD8+T细胞比值和自然杀伤细胞(NK细胞)比例。记录两组患者术中舒芬太尼、麻黄素、阿托品等药物的使用剂量。记录患者气管插管拔管时间、苏醒期躁动和术后24 h内发生术后恶心呕吐(PONV)的例数、术后首次排气时间。结果两组患者T 1至T 4各时间点SBP、DBP、HR的差异均无统计学意义(P值均>0.05)。在T 3时间点,腹横肌平面组患者的血CD4+T细胞比例、CD4+/CD8+T细胞比值均显著高于胸段硬膜外组患者(P值均<0.05),两组间血皮质醇、肾上腺素、去甲肾上腺素水平,血CD3+、CD8+T细胞比例和NK细胞比例的差异均无统计学意义(P值均>0.05)。在T 3时间点,两组患者的血皮质醇、肾上腺素、去甲肾上腺素水平均显著高于T 0时间点(P值均<0.05),两组患者的血CD3+、CD4+T细胞比例,CD4+/CD8+T细胞比值和NK细胞比例均显著低于T 0时间点(P值均<0.05)。腹横肌平面组术中使用麻黄素、阿托品的患者例数和发生PONV的患者例数均显著少于胸段硬膜外组(P值均<0.05)。结论与胸段硬膜外阻滞相比,腹横肌平面阻滞联合全身麻醉能够减少行结直肠癌根治术的患者术中血管活性药物的使用,维持术后Objective To evaluate the clinical effect of transversus abdominis plane(TAP)block versus thoracic epidural analgesia(TEA)in patients undergoing colorectal cancer radical surgery.Methods A total of 144 patients scheduled for colorectal cancer radical surgery in our hospital between December 2015 and October 2017 were enrolled in this study.They were randomly divided into two groups(n=72):TAP group and TEA group.One patient in the TAP group and two patients in the TEA group withdrew from this trail.Systolic blood pressure(SBP),diastolic blood pressure(DBP),and heart rate(HR)were measured before anesthesia(T 0),at the beginning of the operation(T 1),on 1 h of the operation(T 2),at the end of the operation(T 3)and immediately after tracheal extubation(T 4).The levels of CD3+,CD4+,CD8+,CD4+/CD8+T lymphocyte subsets,natural killer(NK)cell,cortisol,adrenaline and norepinephrine were tested at T 0 and T 3.Intraoperative drug dose(sufentanil,ephedrine,atropine),extubation time,emergence agitation,postoperative nausea and vomiting(PONV)and the first evacuation time were recorded.Results There were no significant difference in the SBP,DBP or HR at any time point between two groups(all P>0.05).Neither were the level of blood cortisol,adrenaline or norepinephrine,or the ratio of CD3+,CD8+T lymphocyte subsets,NK cells(all P>0.05).CD4+T lymphocyte subsets ratio and CD4+/CD8+T lymphocyte subsets in the TAP group were significantly higher than those in the TEA group at T 3(all P<0.05).The serum levels of cortisol,epinephrine and norepinephrine at T 3 were significantly higher than those at T 0 in both groups(all P<0.05),while CD3+,CD4+T lymphocyte subsets and NK cell ratios,and CD4+/CD8+T lymphocyte subsets at T 3 were significantly lower than those at T 0(all P<0.05).The patient proportion of intraoperative use of ephedrine and atropine and the incidence of PONV in TAP group were significantly lower than those in TEA group(all P<0.05).Conclusion Compared with thoracic epidural analgesia,transversus abdominis plane block combine

关 键 词：腹横肌平面阻滞 胸段硬膜外阻滞 结直肠癌根治术 血流动力学 免疫功能 

分 类 号：R614[医药卫生—麻醉学] R735.34[医药卫生—外科学]