超声引导下竖脊肌平面阻滞和胸椎旁神经阻滞对胸腔镜手术患者应激反应和镇痛效果的比较

doi:10.11958/20222027

天津医药 ›› 2023, Vol. 51 ›› Issue (10): 1126-1130.doi: 10.11958/20222027

超声引导下竖脊肌平面阻滞和胸椎旁神经阻滞对胸腔镜手术患者应激反应和镇痛效果的比较

胡阳(), 张丽丽, 张野^△()

安徽医科大学第二附属医院麻醉与围术期医学科（邮编230601）

收稿日期:2022-12-08 修回日期:2023-02-15 出版日期:2023-10-15 发布日期:2023-10-18
通讯作者: ^∆E-mail：zhangye_hassan@sina.com
作者简介:胡阳（1998），女，硕士研究生在读，主要从事临床麻醉与疼痛诊疗方面研究。E-mail：709116348@qq.com

Comparison of stress response and postoperative analgesia of ultrasound-guided paravertebral block and erect spinae plane block in patients undergoing video-assisted thoracic surgery

HU Yang(), ZHANG Lili, ZHANG Ye^△()

Department of Anesthesiology and Perioperative Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China

Received:2022-12-08 Revised:2023-02-15 Published:2023-10-15 Online:2023-10-18
Contact: ^∆E-mail：zhangye_hassan@sina.com

胡阳, 张丽丽, 张野. 超声引导下竖脊肌平面阻滞和胸椎旁神经阻滞对胸腔镜手术患者应激反应和镇痛效果的比较[J]. 天津医药, 2023, 51(10): 1126-1130.

HU Yang, ZHANG Lili, ZHANG Ye. Comparison of stress response and postoperative analgesia of ultrasound-guided paravertebral block and erect spinae plane block in patients undergoing video-assisted thoracic surgery[J]. Tianjin Medical Journal, 2023, 51(10): 1126-1130.

摘要/Abstract

摘要：

目的评价超声引导下胸椎旁神经阻滞（TPVB）和竖脊肌平面阻滞（ESPB）对胸腔镜手术患者围手术期应激反应和镇痛效果的影响。方法选择择期全麻下行胸腔镜手术患者90例，采用随机数字表法分为对照组（C组）、ESPB组（E组）和TPVB组（T组），每组30例。麻醉诱导前C组不做任何处理，E组和T组分别行超声引导下患侧ESPB和TPVB，注入0.5%罗哌卡因20 mL。术毕患者自控镇痛（PCIA）。于术前即刻（T₀）、手术开始后30 min（T₁）、拔除气管导管时（T₂）采集静脉血检验血糖（Glu）和血清皮质醇（Cor）水平；记录手术类型、手术时间、术中因低血压需要使用去氧肾上腺素人数、瑞芬太尼药物用量；患者T₂、术后12 h（T₃）、术后24 h（T₄）、术后48 h（T₅）的静息和咳嗽状态疼痛视觉模拟评分（VAS），术后48 h内患者PCIA按压总次数及PCIA舒芬太尼输注总量，补救镇痛使用情况和不良反应发生情况。结果与T₀相比，患者T₁、T₂时Cor和Glu浓度均升高（P<0.05）；与C组相比，T组Glu明显降低。与C组相比，T组和E组患者T₂~T₅的静息状态疼痛VAS评分降低，T₂、T₄的咳嗽状态疼痛VAS评分降低，术中瑞芬太尼用量、PCIA按压次数及舒芬太尼输注总量均降低，T组补救镇痛率降低（P<0.05）。与T组相比，E组T₂、T₃、T₄静息状态疼痛VAS升高，T₃咳嗽状态疼痛VAS升高，PCIA按压次数、瑞芬太尼使用量及PCIA舒芬太尼输注总量升高，术中因低血压使用去氧肾上腺素比例降低（P<0.05）。结论 TPVB能抑制胸腔镜手术患者的应激反应，术后早期镇痛效果优于ESPB，对术中血压有明显抑制作用。

关键词: 镇痛, 胸腔镜, 应激, 生理学, 竖脊肌平面阻滞, 胸椎旁阻滞

Abstract:

Objective To evaluate the effects of ultrasus-guided thoracic paravertebral nerve block (TPVB) and erectile spinal-plane block (ESPB) on perioperative stress response and analgesia in patients undergoing thoracoscopic surgery. Methods Ninety patients underwent thoracoscopic surgery under elective general anesthesia were included and randomly divided into the control group (group C), the ESPB group (group E) and the TPVB group (group T), with 30 cases in each group. Before anesthesia induction, no treatment was given to the group C, and the group E and the group T were treated with ultrasound guided ESPB and TPVB on the affected side, and injected with 20 mL of 0.5% ropivacaine. Patient controlled analgesia (PCIA) was connected after operation. The venous blood samples were collected immediately before operation (T₀), 30 minutes after operation (T₁) and at the time of tracheal catheter removal (T₂) to test the concentration of blood glucose (Glu) and serum cortisol (Cor). The type of surgery, the duration time of surgery, the number of patients who needed to use phenylephrine and the amount of remifentanil for hypotension during operation were recorded. Visual analog scores (VAS) of patients at rest and coughing status at T₂, 12 hours after operation (T₃), 24 hours after operation (T₄), 48 hours after operation (T₅), the total number of PCIA compression and the total amount of PCIA sufentanil infusion within 48 hours after operation, the use of rescue analgesia, and the occurrence of adverse reactions were recorded. Results Compared with T₀, concentrations of Cor and Glu at T₁ and T₂, were increased in patients (P<0.05). Compared with the group C, Glu was significantly decreased in the group T, the resting VAS pain scores of T₂, T₃, T₄ and T₅ were decreased in the group T and the group E. The coughing VAS pain scores of T₂ and T₄ were decreased, and the intraoperative dosage of reifentanil, the number of PCIA compression and the total infusion of sufentanil were decreased. The remedial analgesic rate was decreased in the T group (P<0.05). Compared with the group T, the resting VAS scores of T₂, T₃ and T₄ were increased in the group E, and the coughing VAS scores of T₃ were increased, the number of PCIA compression, remifentanil usage and the total infusion of PCIA sufentanil were increased. The percentage of intraoperative use of norepinephrine for hypotension was decreased (P<0.05). Conclusion TPVB can inhibit the stress response of patients undergoing thoracoscopic surgery. TPVB could provide better postoperative analgesia than ESPB, and has a significant inhibitory effect on intraoperative blood pressure.

Key words: analgesia, thoracoscopes, stress, physiological, erector spinae plane block, thoracic paravertebral block

中图分类号:

R614

图/表 4

参考文献 17

[1]	XIE D, ZHONG Y, DENG J, et al. Comparison of uniportal video-assisted thoracoscopic versus thoracotomy bronchial sleeve lobectomy with pulmonary arterioplasty for centrally located non-small-cell lung cancer[J]. Eur J Cardiothorac Surg, 2021, 59(5):978-986. doi:10.1093/ejcts/ezaa404.
[2]	BAYMAN E O, PAREKH K R, KEECH J, et al. Preoperative patient expectations of postoperative pain are associated with moderate to severe acute pain after VATS[J]. Pain Med, 2019, 20(3):543-554. doi:10.1093/pm/pny096.
[3]	D'ERCOLE F, ARORA H, KUMAR P A. Paravertebral block for thoracic surgery[J]. J Cardiothorac Vasc Anesth, 2018, 32(2):915-927. doi:10.1053/j.jvca.2017.10.003.
[4]	FORERO M, ADHIKARY S D, LOPEZ H, et al. The erector spinae plane block:A novel analgesic technique in thoracic neuropathic pain[J]. Reg Anesth Pain Med, 2016, 41(5):621-627. doi:10.1097/AAP.0000000000000451.
[5]	CHIN K J, ADHIKARY S, SARWANI N, et al. The analgesic efficacy of pre-operative bilateral erector spinae plane(ESP)blocks in patients having ventral hernia repair[J]. Anaesthesia, 2017, 72(4):452-460. doi:10.1111/anae.13814.
[6]	KREDIET A C, MOAYERI N, VAN GEFFEN G J, et al. Different approaches to ultrasound-guided thoracic paravertebral block:An illustrated review[J]. Anesthesiology, 2015, 123(2):459-474. doi:10.1097/ALN.0000000000000747.
[7]	FORERO M, RAJARATHINAM M, ADHIKARY S, et al. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure:A case report[J]. A A Case Rep, 2017, 8(10):254-256. doi:10.1213/XAA.0000000000000478.
[8]	MARSHALL K, MCLAUGHLIN K. Pain management in thoracic surgery[J]. Thorac Surg Clin, 2020, 30(3):339-346. doi:10.1016/j.thorsurg.2020.03.001.
[9]	VARDAS K, ILIA S, SERTEDAKI A, et al. Increased glucocorticoid receptor expression in sepsis is related to heat shock proteins, cytokines, and cortisol and is associated with increased mortality[J]. Intensive Care Med Exp, 2017, 5(1):10. doi:10.1186/s40635-017-0123-8.
[10]	ONYANGO A N. Cellular stresses and stress responses in the pathogenesis of insulin resistance[J]. Oxid Med Cell Longev, 2018, 2018:4321714. doi:10.1155/2018/4321714.
[11]	宋亚男, 赵艳, 郭向阳. 围术期应激反应监测指标的研究现状[J]. 中国微创外科杂志, 2017, 17(12):1129-1132.
	SONG Y N, ZHAO Y, GUO X Y. Research status of perioperative stress response monitoring indicators[J]. Chin J Min Inv Surg, 2017, 17(12):1129-1132. doi:10.3969/j.issn.1009-6604 2017.12.021.
[12]	ARDON A E, LEE J, FRANCO C D, et al. Paravertebral block:Anatomy and relevant safety issues[J]. Korean J Anesthesiol, 2020, 73(5):394-400. doi:10.4097/kja.20065.
[13]	LIU D, LIU H, WU J, et al. Effects of thoracic paravertebral blockon inflammatory response,stress response,hemodynamics and anesthesia resuscitation in gallbladder carcinoma[J]. Cell Mol Biol(Noisy-le-grand), 2022, 68(2):171-177. doi:10.14715/cmb/2022.68.2.24.
[14]	纪久雨, 鲁学文, 杨小亮, 等. 罗哌卡因联合地塞米松胸椎旁神经阻滞对全身麻醉下行胸腔镜手术患者术中升压及阿片类药物使用影响[J]. 临床军医杂志, 2021, 49(12):1394-1396,1399.
	JI J Y, LU X W, YANG X L, et al. Effects of ropivacaine combined with dexamethasone thoracic paravertebral nerve block on intraoperative pressure and opioid use in patients undergoing thoracoscopic surgery under general anesthesia[J]. Clin J Med Offic, 2021, 49(12):1394-1396,1399. doi:10.16680/j.1671-3826.2021.12.32.
[15]	张冉, 金佳, 田龙, 等. 胸椎旁神经阻滞对全麻胸腔镜肺部手术患者术中低血压的影响[J]. 中华麻醉学杂志, 2020, 40(5):528-532.
	ZHANG R, JIN J, TIAN L, et al. Effect of thoracic paravertebral block on intraoperative hypotension in patients undergoing thoracoscopic lung surgery under general anesthsia[J]. Chin J Anesthesiol, 2020, 40(5):528-532. doi:10.3760/cma.j.cn131073.20191020.00504.
[16]	TAKETA Y, IRISAWA Y, FUJITANI T. Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery:a randomized controlled non-inferiority clinical trial[J]. Reg Anesth Pain Med, 2019: rapm-2019-100827. doi:10.1136/rapm-2019-100827. [Epub ahead of print].
[17]	朱冠楠, 高景斌, 黄道礼, 等. B超引导下竖脊肌平面阻滞在腰椎间孔镜手术麻醉患者中的应用效果及对应激反应的影响研究[J]. 中国医学创新, 2020, 17(20):113-117.
	ZHU G N, GAO J B, HUANG D L, et al. Study on the application effect of B-ultrasound guided erector spinae plane block in anesthesia patients for lumbar intervertebral foramen surgery and its effect on stress response[J]. Medical Innovation of China, 2020, 17(20):113-117. doi:10.3969/j.issn.1674-4985.2020.20.029.

组别		年龄/岁		性别（男/女）	BMI/（kg/m²）
C组		52.9±10.9		14/16	22.0±1.2
T组		49.7±10.9		10/20	21.5±1.4
E组		51.6±11.2		12/18	21.7±1.5
F或χ²		0.642		1.111	1.513
组别	ASA分级（Ⅰ/Ⅱ）		手术时间/min			肺部分切除术/ 肺叶切除术
C组	9/21		83.0（72.3，93.3）			20/10
T组	10/20		84.5（68.7，105.8）			18/12
E组	11/19		76.5（61.5，107.5）			16/14
χ²	0.300		1.024			1.111

组别		年龄/岁		性别（男/女）	BMI/（kg/m²）
C组		52.9±10.9		14/16	22.0±1.2
T组		49.7±10.9		10/20	21.5±1.4
E组		51.6±11.2		12/18	21.7±1.5
F或χ²		0.642		1.111	1.513
组别	ASA分级（Ⅰ/Ⅱ）		手术时间/min			肺部分切除术/ 肺叶切除术
C组	9/21		83.0（72.3，93.3）			20/10
T组	10/20		84.5（68.7，105.8）			18/12
E组	11/19		76.5（61.5，107.5）			16/14
χ²	0.300		1.024			1.111

组别	Cor/（nmol/L）
组别	T₀		T₁		T₂
C组	209.5±60.3		279.8±90.3^a		314.2±150.9^a
T组	178.7±100.3		257.4±74.4		286.0±115.7^a
E组	207.0±80.9		267.1±98.2^a		299.5±107.4^a
组别		Glu/（mmol/L）
组别		T₀		T₁		T₂
C组		4.6±1.0		6.1±0.7^a		7.2±2.0^a
T组		4.8±0.4		5.3±0.7^b		6.4±1.5^a
E组		5.0±0.7		5.9±1.3^a		6.8±1.6^a

组别	Cor/（nmol/L）
组别	T₀		T₁		T₂
C组	209.5±60.3		279.8±90.3^a		314.2±150.9^a
T组	178.7±100.3		257.4±74.4		286.0±115.7^a
E组	207.0±80.9		267.1±98.2^a		299.5±107.4^a
组别		Glu/（mmol/L）
组别		T₀		T₁		T₂
C组		4.6±1.0		6.1±0.7^a		7.2±2.0^a
T组		4.8±0.4		5.3±0.7^b		6.4±1.5^a
E组		5.0±0.7		5.9±1.3^a		6.8±1.6^a

组别	静息VAS评分/分
组别	T₂			T₃	T₄		T₅		F
C组	4.3±0.6			4.5±0.9	4.2±0.8		4.0±0.6		2.595
T组	2.0±0.5^a			2.5±0.6^a	2.6±0.7^a		2.8±0.8^a		8.065^＊＊
E组	3.3±0.7^ab			3.7±0.6^ab	3.2±0.5^ab		3.1±0.7^a		7.148^＊＊
F	106.986^＊＊			68.817^＊＊	42.585^＊＊		22.858^＊＊
组别		咳嗽VAS评分/分
组别		T₂	T₃			T₄	T₅	F
C组		5.5±0.8	5.2±0.7			4.8±1.0	4.5±1.1	6.848^＊＊
T组		3.5±1.3^a	3.3±1.5^a			3.8±1.0^a	3.4±1.2^a	0.775
E组		3.8±1.5^a	4.5±1.4^b			4.0±1.2^a	3.8±1.2	1.315
F		24.894^＊＊	18.670^＊＊			6.602^＊＊	6.705^＊＊

超声引导下竖脊肌平面阻滞和胸椎旁神经阻滞对胸腔镜手术患者应激反应和镇痛效果的比较

Comparison of stress response and postoperative analgesia of ultrasound-guided paravertebral block and erect spinae plane block in patients undergoing video-assisted thoracic surgery

引用本文

RichHTML

PDF (PC)

可视化

摘要/Abstract

使用本文

图/表 4

参考文献 17

相关文章 15

编辑推荐

Metrics

本文评价

组别	瑞芬太尼用量/mg		去氧肾上腺素		PCIA按压次数/次
C组	1.73±0.29		4（13.3）		13.5±3.6
T组	0.81±0.30^a		15（50.0）^a		4.6±4.2^a
E组	1.09±0.32^ab		6（20.0）^b		7.4±5.1^ab
F或χ²	75.422^＊＊		11.409^＊＊		35.135^＊＊
组别		PCIA舒芬太尼输注总量/mL		补救镇痛		恶心呕吐
C组		83.1±6.3		10（33.3）		6（20.0）
T组		47.3±7.6^a		3（10.0）^a		5（16.7）
E组		56.2±6.2^ab		5（16.7）		4（13.3）
F或χ²		238.046^＊＊		5.417		3.315

[1]	王欣爽, 安亚娟, 管秀菊, 李娇, 刘玥, 魏丽萍, 齐新. 异甘草酸镁改善顺铂诱导的大鼠心肌损伤[J]. 天津医药, 2024, 52(8): 809-814.
[2]	钟敏, 施震, 周劲松, 李晋杰. GABA信号通路对脓毒症大鼠急性肺损伤内质网应激和线粒体自噬的影响[J]. 天津医药, 2024, 52(7): 733-737.
[3]	吴波, 朱卓农, 郑丽娟, 陈俊如. 苦参碱对特应性皮炎炎症、氧化应激和伤口愈合的影响[J]. 天津医药, 2024, 52(6): 566-571.
[4]	王俊懿, 李宸, 吴昕岳, 丁心语, 万春晓. 早期运动干预对脑缺血大鼠脑神经髓鞘的影响及机制研究[J]. 天津医药, 2024, 52(6): 589-594.
[5]	黎敏, 龚坚, 吴伟伟, 刘巧. Nrf2/HO-1通路在银屑病中作用的研究进展[J]. 天津医药, 2024, 52(5): 552-556.
[6]	解有成, 王菲, 徐进, 于晓辉. SIRT1在糖尿病心肌病发病中的研究进展[J]. 天津医药, 2024, 52(4): 443-448.
[7]	何颖, 张广华, 田立东, 于泳浩. 富氢液通过增加自噬治疗大鼠神经病理性疼痛[J]. 天津医药, 2024, 52(3): 261-265.
[8]	陈静, 魏运姣, 罗超, 黄利华, 陈橙, 段莎莎. 基于Nrf2/ARE抗氧化应激途径探究乌梅丸对溃疡性结肠炎小鼠的作用机制[J]. 天津医药, 2024, 52(3): 278-254.
[9]	陈慧敏, 贾洪峰, 江婷婷, 贾耀辉. 术中血糖波动和术后胰岛素抵抗对胸腔镜肺癌根治术后老年患者认知功能障碍的影响[J]. 天津医药, 2024, 52(2): 201-205.
[10]	缪春波, 许迎春, 常以芳. 根皮苷通过下调miR-125a-5p减轻缺氧/复氧诱导的H9C2细胞氧化应激和凋亡[J]. 天津医药, 2024, 52(12): 1233-1238.
[11]	杨阳, 何巧玉. 丹酚酸B对创伤后应激障碍模型大鼠认知功能和GSK-3β/β-Catenin信号通路的影响[J]. 天津医药, 2024, 52(1): 73-79.
[12]	田亚静, 杨雪, 汪静, 葛文杰, 何玉玲. 芒柄花素对妊娠期糖尿病大鼠氧化应激损伤的影响[J]. 天津医药, 2023, 51(7): 734-738.
[13]	李艳萍, 王协涛, 史立彬, 刘琼. 白藜芦醇调控Nrf2-GPX4通路对H₂O₂诱导肺泡上皮细胞铁死亡的影响[J]. 天津医药, 2023, 51(6): 568-572.
[14]	周梦竹, 张海凤, 张雪, 张跃, 程立君, 刘彤, 刘长乐. NLRP3-CAMKⅡ-IRE-1α通路激活诱导氧化应激增强对糖尿病大鼠心室重构的影响[J]. 天津医药, 2023, 51(6): 580-585.
[15]	吴克义, 黄勇, 许成浩, 马天鸣, 代飞彪, 李雪, 唐朝亮. 全麻联合胸椎旁神经阻滞对肺癌手术患者术后镇痛和肺部感染的影响[J]. 天津医药, 2023, 51(6): 648-652.