超声引导下椎旁神经阻滞在心脏瓣膜置换术围术期的应用效果  

The effect of ultrasound-guided paravertebral nerve block in the perioperative period of heart valve replacement

作　　者：刘雪印 杜守峰[1] 周威[1] LIU Xueyin;DU Shoufeng;ZHOU Wei(Department of Anesthesiology,Nanyang Central Hospital,Nanyang 473005,China)

机构地区：[1]南阳市中心医院麻醉科,473005

出　　处：《心肺血管病杂志》2025年第2期167-173,共7页Journal of Cardiovascular and Pulmonary Diseases

基　　金：2023年度南阳市科技发展计划项目(23KJGG098)。

摘　　要：目的:分析超声引导下椎旁神经阻滞(thoracic paravertebral nerve block,TPVB)在心脏瓣膜置换术(heart valve replacement,HVR)围术期的应用效果。方法:选择2022年1月至2024年1月,南阳市中心医院收治的182例HVR患者,依据神经阻滞方式不同将患者分为A组(超声引导下TPVB,49例)、B组(无超声引导的TPVB,46例)、C组(硬膜外技术,42例)及D组(超声引导下行胸横肌平面阻滞,45例)。比较四组术后恢复指标,气管插管(T1)、分开胸骨(T2)、显露心脏(T3)、关闭胸腔(T4)血流动力学,术前、术后即刻应激、炎症、心肌损伤指标,术后12、24、48 h疼痛,术后1 d四组安全性。结果:A组、C组拔管时间、苏醒时间、机械通气时间短于B组、D组(P<0.05),B组拔管时间、苏醒时间、机械通气时间短于D组(P<0.05)。T1、T2、T3、T4四组心率、平均动脉压、血氧饱和度呈降低趋势(P<0.05),但T2、T3、T4,A组、C组高于B、D组,B组高于D组(P<0.05)。术后即刻,四组血清皮质醇、血糖、去甲肾上腺素、细胞间黏附分子-1、IL-6、乳酸脱氢酶、心型脂肪酸结合蛋白及心肌肌钙蛋白I水平提高,但A组、C组低于B、D组,B组低于D组(P<0.05)。静息状态下,术后12~48 h,四组视觉模拟评分(visual analog scale,VAS)评分呈先升高后降低趋势,且术后12 h,静息状态下VAS评分,组间比较A组、C组、B组、D组呈升高趋势(P<0.05);动态下,术后12~48 h,四组VAS评分呈逐渐降低趋势,且术后12 h、24 h动态下VAS评分,组间比较A组、C组、B组、D组呈升高趋势(P<0.05)。术后1 d A组不良反应发生率低于B组、C组、D组(P<0.05)。结论:相较无超声引导的TPVB、超声引导下行胸横肌平面阻滞,超声引导下TPVB、硬膜外技术在HVR患者中应用,可提高HVR患者的镇痛效果,改善血流动力学,抑制应激、炎症反应,缓解心肌损伤,促进术后康复,超声引导下TPVB对镇痛效果、安全性的改善效果更明显。Objective:To analyze the effect of ultrasound guided thoracic paravertebral nerve block(TPVB)in the perioperative period of heart valve replacement(HVR).Methods:A total of 182 patients with HVR treated in Nanyang Central Hospital from January 2022 to January 2024 were selected and divided into the A group(ultrasound guided TPVB,49 cases),the B group(TPVB without ultrasound guidance,46 cases),the C group(epidural technology,42 cases),and the D group(transversal thoracic plane block under ultrasound guidance,45 cases).according to different nerve block methods.Postoperative recovery indexes,hemodynamics during endotracheal intubation(T1),thoracotomy(T2),pericardium incision(T3),thoracotomy(T4),stress,inflammation,myocardial damage indexes before and immediately after surgery,pain 12,24,48 h after surgery,and safety 1 d after surgery were compared between the four groups.Results:The extubation time,recovery time and mechanical ventilation time of the A group and the C group were shorter than those of the B group and the D group(P<0.05),and the extubation time,recovery time and mechanical ventilation time of the B group were shorter than those of the D group(P<0.05).Levels of heart rate,mean arterial pressure and blood oxygen saturation in four groups T1,T2,T3 and T4 showed a decreased trend(P<0.05),but T2,T3,T4,the A group and the C group were higher than the B group and the D group,and the B group was higher than the D group(P<0.05).Immediately after operation,serum levels of cortisol,blood glucose,noadrenaline,intercellular adhesion molecule 1,IL-6,lactate dehydrogenas,cardiac fatty acid-binding protein and cardiac troponin I(cTnI)in the four groups were increased,however,the A group,the C group were lower than the B group and the D group,and the B group was lower than the D group(P<0.05).At rest,from 12 h to 48 h after surgery,the score of visual analog scale(VAS)of the four groups showed a trend of first increasing and then decreasing,and at 12 h after surgery,the score of VAS of the four groups showed a trend o

关 键 词：超声引导 椎旁神经阻滞 心脏瓣膜置换术 镇痛效果 血流动力学 心肌损伤 应激反应 炎症 

分 类 号：R54[医药卫生—心血管疾病]