胸椎旁神经阻滞联合全身麻醉用于腹腔镜根治性肾切除术患者的改良效果  

Modified efficacy of thoracic paravertebral block combined with general anesthesia in patients undergoing laparoscopic radical nephrectomy

作　　者：吕帅国 卢锡华 李长生 杨铁军 孙亚林 白玉 黄锦秀 李鑫涛 缪长虹 Lyu Shuaiguo;Lu Xihua;Li Changsheng;Yang Tiejun;Sun Yalin;Bai Yu;Huang Jinxiu;Li Xintao;Miao Changhong(Department of Anesthesiology and Perioperative Medicine,Affiliated Cancer Hospital of Zhengzhou University,Zhengzhou 450008,China;Department of Urology,Affiliated Cancer Hospital of Zhengzhou University,Zhengzhou 450008,China;Department of Anesthesiology,Zhongshan Hospital,Fudan University,Shanghai 200032,China)

机构地区：[1]郑州大学附属肿瘤医院麻醉与围术期医学科,450008 [2]郑州大学附属肿瘤医院泌尿外科,450008 [3]复旦大学附属中山医院麻醉科,上海200032

出　　处：《中华麻醉学杂志》2020年第7期817-820,共4页Chinese Journal of Anesthesiology

基　　金：河南省医学教育研究项目(wjlx2018087)。

摘　　要：目的评价胸椎旁神经阻滞联合全身麻醉用于腹腔镜根治性肾切除术患者的改良效果。方法择期行腹腔镜根治性肾切除术患者80例,年龄38~64岁,BMI 18~24 kg/m2,ASA分级Ⅰ或Ⅱ级,性别不限,采用随机数字表法分为2组(n=40):全身麻醉组(GA组)和胸椎旁神经阻滞联合全身麻醉组(TPVB+GA组)。TPVB+GA组于麻醉诱导前在超声引导下行T8和T10椎旁神经阻滞,各注入0.5%罗哌卡因10 ml。静脉注射丙泊酚、舒芬太尼、依托咪酯、罗库溴铵行麻醉诱导,静脉输注丙泊酚和瑞芬太尼行麻醉维持。术毕采用舒芬太尼、酮咯酸氨丁三醇和盐酸托烷司琼行PCIA,术后VAS评分≥4分时,静脉注射曲马多50 mg补救镇痛。分别于麻醉诱导前即刻(T0)、气腹5 min(T1)、气腹2 h(T2)、气腹结束即刻(T3)和术后24 h(T4)时采集静脉血样,采用ELISA法测定血浆去甲肾上腺素(NE)浓度,采用放射免疫法测定血浆皮质醇(Cor)水平,测定血糖浓度;记录术中舒芬太尼和瑞芬太尼用量,记录术中高血压、低血压和心动过缓的发生情况,记录术后24 h内恶心呕吐、皮肤瘙痒等发生情况和补救镇痛情况。结果与GA组比较,TPVB+GA组T1-4时血浆Cor、NE和血糖浓度降低,术中舒芬太尼和瑞芬太尼用量减少,术后补救镇痛率降低(P<0.05)。2组术中和术后不良反应发生率差异无统计学意义(P>0.05)。结论相对于单纯全身麻醉而言,胸椎旁神经阻滞联合全身麻醉用于腹腔镜根治性肾切除术患者,有助于实现低阿片类药物麻醉模式,更有利于术中、术后应激反应及术后痛敏反应的抑制。Objective To evaluate the modified efficacy of thoracic paravertebral block(TPVB)combined with general anesthesia in the patients undergoing laparoscopic radical nephrectomy.Methods Eighty patients,aged 38-64 yr,with body mass index of 18-24 kg/m2,of American Society of Anesthesiologists physical statusⅠorⅡ,scheduled for elective laparoscopic radical nephrectomy,were selected and randomly divided into 2 groups(n=40 each)using a random number table method:general anesthesia group(group GA)and TPVB combined with general anesthesia group(group TPVB+GA).A paravertebral catheter was placed at T8 and T10 under ultrasound guidance before induction of anesthesia,and 0.5%ropivacaine 10 ml was administered via the catheter in group TPVB+GA.Anesthesia was induced with propofol,sufentanil,etomidate and rocuronium and maintained by intravenous infusion of propofol and remifentanil.Patient-controlled intravenous analgesia was performed with sufentanil,ketorolac tromethamine and tropisetron at the end of surgery.When postoperative visual analog scale score≥4,tramadol 50 mg was intravenously injected as rescue analgesic.Immediately before anesthesia induction(T0),at 5 min after establishing pneumoperitoneum(T1),at 2 h of pneumoperitoneum(T2),and immediately after the end of pneumoperitoneum(T3),and at 24 h after operation(T4),venous blood samples were collected for determination of plasma norepinephrine concentrations(by enzyme-linked immunosorbent assay),plasma cortisol level(using radioimmunoassay),and blood glucose concentrations were measured.The intraoperative consumption of sufentanil and remifentanil was recorded.The intraoperative hypertension,hypotension,and bradycardia were recorded,and the nausea and vomiting,pruritus,and requirement for rescue analgesia occurred within 24 h after surgery were recorded.Results Compared with group GA,the plasma concentrations of norepinephrine,cortisol and blood glucose were significantly decreased at T1-4,the intraoperative consumption of sufentanil and remifentanil was reduced,

关 键 词：神经传导阻滞 胸椎 麻醉 全身 腹腔镜检查 肾肿瘤 

分 类 号：R614[医药卫生—麻醉学]