国际麻醉学与复苏杂志   2018, Issue (10): 11-11
    
多模式镇痛在胸腔镜下肺叶切除术中的应用
张琰, 刘婕婷1()
1.兰州大学第二医院
Application of multimodal analgesia in video-assisted thoracoscopic lobectomy
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摘要:

目的 探讨罗哌卡因胸椎旁阻滞联合氟比洛芬酯用于胸腔镜下肺叶切除术是否可以提高镇痛效果,抑制机体应激反应,降低阿片类药物用量及副作用,并进一步证实,研究结果是否与盐酸罗哌卡因浓度呈正相关。 方法 采用随机数字表法将60例胸腔镜下肺叶切除患者分为3组(每组20例):对照组,诱导前、缝皮前30 min各给予氟比洛芬酯注射液50 mg;低浓度联合组,0.375%罗哌卡因椎旁阻滞+诱导前、缝皮前30 min各给予凯纷50 mg;高浓度联合组,0.5%罗哌卡因椎旁阻滞+诱导前、缝皮前30 min各给予凯纷50 mg。术后常规患者自控静脉镇痛(patient-controlled intravenous analgesia, PCIA)。观察苏醒情况、术后静息疼痛数字评分法(Numerical Rating Scale, NRS)评分及咳嗽NRS评分、镇痛不良反应;记录术中瑞芬太尼总用量及术后PCIA按压总次数;测定血清皮质醇(cortisol, Cor)及β?蛳内啡肽(β-endorphin, β-EP)浓度。 结果 对照组苏醒期躁动发生率、躁动评分较其他两组明显增高(P<0.05)。与对照组比较,其他两组在术后2、6 h静息和咳嗽NRS评分均明显降低(P<0.05),术后12、24、48 h差异无统计学意义(P>0.05);与低浓度联合组比较,高浓度联合组在术后24 h静息及咳嗽NRS评分降低(P<0.05),其余各时间点差异无统计学意义(P>0.05)。对照组恶心呕吐发生率高于其他两组,但差异没有统计学意义(P>0.05)。3组患者术前及术毕Cor和β-EP水平差异无统计学意义(P>0.05);与对照组比较,其余两组Cor和β?-EP水平仅在术后6 h及12 h明显降低(P<0.05),其余时间点差异无统计学意义(P>0.05);低浓度联合组和高浓度联合组在术后6、12、24、48 h的Cor和β?蛳EP水平差异无统计学意义(P>0.05);与术前比较,仅对照组在术后6、12 h Cor和β-EP水平明显升高(P<0.05)。 结论 0.5%罗哌卡因胸椎旁阻滞联合氟比洛芬酯用于胸腔镜下肺叶切除术可提供更完善的镇痛效果,延长镇痛时间,减少阿片类药物用量及副作用,抑制机体应激反应,从而达到加速该类手术术后康复的目的。

关键词: 多模式镇痛; 氟比洛芬酯; 超声; 罗哌卡因; 胸腔镜下肺叶切除术
Abstract:

Objective To investigate whether the use of flurbiprofen axe combined with B-ultrasound guided paravertebral nerve block in thoracoscopic lobectomy can improve the analgesic effect, inhibit the body's stress response, reduce the dosage and side effects of opioids. To further test whether the results of the study are related to ropivacaine hydrochloride concentration. Methods Sixty patients undergoing thoracoscopic lobectomy were randomly divided into 3 groups(n=20). Control group was given Flurbiprofen axetil 50 mg 30 min before induction and also give same dose 30 min before sewing, low concentration combined group was given 0.375% ropivacaine paravertebral block+Flurbiprofen axetil (in the same way as the control group), high?蛳concentration combination group was given 0.5% ropivacaine paravertebral block+Flurbiprofen axetil (in the same way as the control group). All patients were given to patient?蛳controlled intravenous analgesia(PCIA) after operative. Observing the recovery situation, Numerical Rating Scale (NRS) scores at rest time and during cough after postoperative , analgesia adverse reactions; recording remifentanil dosage and the total number of compressions PCIA after operative, the determination of cortisol (Cor) and β?蛳endorphin (β?蛳EP) concentrations. Results The incidence of restlessness and restlessness scores in the control group were significantly higher than other two groups (P<0.05). Compared with the control group, the NRS scores at rest and during coughing at 2 h and 6 h were significantly lower in the other two groups (P<0.05), there was no significant difference between 12, 24 h and 48 h (P>0.05). Compared with the low-dose group, the NRS score at rest and the time of coughing in the high-dose group were significantly lower at the 24 h after operation (P<0.05), there was no significant difference at other time points. The incidence of nausea and vomiting was higher in the control group than the other two groups, but the difference was not statistically significant (P>0.05). There was no significant difference of the Cor and β-EP concentration in the preoperative and postoperative between the three groups (P>0.05). Compared with the control group, the concentration of Cor and β-EP were significantly low at 6 and 12 hours in the other two groups (P<0.05). The incidence of nausea and vomiting was higher in the control group than the incidence in the other two groups, but the difference was not statistically significant (P>0.05). There was no significant difference in the preoperative and postoperative Cor and β?蛳EP levels among the three groups (P>0.05). Compared with the control group, the Cor and β-EP levels in the other two groups were significantly low at 6 h and 12 h (P<0.05). There was no statistical difference at the other time points. Also, there was no significant difference in the concentrations of Cor and β-EP between the low-concentration group and the high-concentration group at each time point (P>0.05). The concentration of Cor and β-EP was increased significantly at 6 h and 12 h after surgery in the control group (P<0.05). Conclusions Thoracic paravertebral block with 0.5% ropivacaine combined with flurbiprofen axetil for thoracoscopic lobectomy provides more effective analgesia, prolongs analgesia time, reduces opioid use and side effects, and inhibits body stress response. As a result, thoracic paraveterbral block achieves the purpose of accelerating post-operative rehabilitation of this type of surgery.

Key words: Multimodal analgesia; Flurbiprofen Axetil; Ultrasound; Ropivacaine; Thoracoscopic lobectomy