不同浓度罗哌卡因竖脊肌平面阻滞对胸腔镜肺叶切除术患者的影响

doi:10.11958/20252134

摘要/Abstract

摘要：

目的探讨不同浓度罗哌卡因竖脊肌平面阻滞（ESPB）对胸腔镜肺叶切除术患者疼痛情况及应激反应的影响，并评估其对术后肺功能及早期恢复的影响。方法将最终纳入的114例拟行胸腔镜肺叶切除术患者通过随机数字表法分为A组（0.375%罗哌卡因，57例）和B组（0.5%罗哌卡因，57例）。记录2组患者术中相关指标，术后监测静脉自控镇痛（PCIA）使用情况，采用疼痛视觉模拟量表（VAS）评分评估术后2、6、12、24和48 h疼痛程度。检测术前及术后6、24、48 h应激指标[促肾上腺皮质激素（ACTH）、去甲肾上腺素（NE）及皮质醇（Cor）]和术后1周肺功能指标[用力肺活量（FVC）、第1秒用力呼气容积（FEV₁），第1秒用力呼气容积与用力肺活量比值（FEV₁/FVC）]，统计苏醒时间、麻醉恢复室滞留时间及围手术期不良事件发生率。结果与A组比较，B组术后PCIA首次按压时间较晚，48 h内按压次数减少（P<0.05）。与术后2 h比较，2组术后12、24、48 h疼痛VAS评分均升高（P<0.05）；B组术后24、48 h疼痛VAS评分显著低于A组（P<0.05）。术后6、24及48 h的ACTH、NE及Cor水平均较术前升高（P<0.05），但B组各时间点指标均低于A组（P<0.05）。与术前比较，2组术后1周FVC、FEV₁、FEV₁/FVC水平升高（P<0.05），但组间差异无统计学意义（P>0.05）。B组苏醒时间和麻醉恢复室滞留时间显著长于A组（P<0.05）。2组围手术期不良事件发生率比较，差异无统计学意义（14.0% vs. 22.8%，P>0.05）。结论 0.5%罗哌卡因ESPB能够缓解胸腔镜肺叶切除术患者24 h后的疼痛及应激反应，而0.375%罗哌卡因更有利于患者术后早期苏醒，均具有良好的安全性，临床需根据患者个体化需求选择。

关键词: 罗哌卡因, 胸腔镜检查, 肺切除术, 麻醉，局部, 镇痛, 竖脊肌

Abstract:

Objective To investigate the effects of different concentrations of ropivacaine in erector spinae plane block (ESPB) on postoperative pain and stress response in patients undergoing thoracoscopic lobectomy, and to evaluate their impact on postoperative pulmonary function and early recovery. Methods A total of 114 patients scheduled for thoracoscopic lobectomy were finally included and were randomly divided into the group A (0.375% ropivacaine, 57 cases) and the group B (0.5% ropivacaine, 57 cases) using a random number table method. Intraoperative surgical indicators were recorded, and postoperative patient-controlled intravenous analgesia (PCIA) usage was monitored in the two groups of patients. Pain intensity was assessed using the Visual Analog Scale (VAS) at 2, 6, 12, 24 and 48 hours postoperatively. Stress markers [adrenocorticotropic hormone (ACTH), norepinephrine (NE) and cortisol (Cor)] were measured preoperatively and at 6, 24 and 48 hours postoperatively. Pulmonary function parameters [forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁) and FEV₁/FVC ratio] were evaluated one week after surgery. Recovery time, post-anesthesia care unit (PACU) stay duration and perioperative adverse event rates were also recorded. Results Compared with the group A, the group B exhibited a longer time to first PCIA demand and fewer PCIA presses within 48 hours (P<0.05). VAS scores increased at 12, 24 and 48 hours compared to 2 hours postoperatively in both groups (P<0.05), but the VAS scores of pain were significantly lower at 24 and 48 hours after surgery in the group B than those of the group A (P<0.05). ACTH, NE and Cor levels increased at 6, 24 and 48 hours postoperatively (P<0.05), but each time point index was lower in the group B than that of the group A (P<0.05). Compared with preoperative values, the FVC, FEV₁ and FEV₁/FVC levels were increased one week after surgery in both groups (P<0.05), but there were no significant differences between the two groups (P>0.05). The recovery time and the PACU stay time were significantly longer in the group B than those of the group A (P<0.05). There were no significant differences in perioperative adverse event rates between the two groups (14.04% vs. 22.81%, P>0.05). Conclusion The 0.5% ropivacaine ESPB can better alleviate pain and stress response of patients undergoing thoracoscopic lobectomy beyond 24 hours postoperatively, whereas 0.375% ropivacaine facilitates earlier recovery. Both concentrations demonstrate good safety, and clinical selection should be individualized.

Key words: ropivacaine, thoracoscopy, pneumonectomy, anesthesia, local, analgesia, erector spinae

中图分类号:

R971.2，R655.3

图/表 7

参考文献 22

[1]	SUN L, MU J, YU L, et al. Continuous erector spinae plane block for postoperative analgesia in elderly patients after thoracoscopic lobectomy[J]. J Perianesth Nurs, 2024, 39(5):887-891. doi:10.1016/j.jopan.2024.01.001.
[2]	BELLANTONIO D, BOLONDI G, CULTRERA F, et al. Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion:a single-centre prospective randomised controlled trial[J]. BMC Anesthesiol, 2023, 23(1):187. doi:10.1186/s12871-023-02130-z.
[3]	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 Y, ZHANG L L, ZHANG Y. 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 Med J, 2023, 51(10):1126-1130. doi:10.11958/20222027.
[4]	ZHANG Y, LI W, WEI A, et al. Comparing liposomal bupivacaine and ropivacaine in serratus anterior plane block for thoracoscopic lobectomy:a randomized controlled trial[J]. Drug Des Devel Ther, 2025, 4(19):4717-4726. doi:10.2147/DDDT.S513287.
[5]	ZHANG J, ZHANG F, ZHANG H, et al. Effect of ropivacaine combined with nalbuphine in erector spinae plane block on postoperative analgesia in lumbar trauma surgery:a single-center randomized controlled trial[J]. J Pain Res, 2025, 3(18):11-19. doi:10.2147/JPR.S493518.
[6]	JIAN C, SHEN Y, FU H, et al. Effects of ultrasound-guided erector spinae plane block with dexmedetomidine combined with ropivacaine of the same dose and different concentrations on analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung: a prospective, randomized, controlled trial[J]. BMC Anesthesiol, 2022, 22(1):225. doi:10.1186/s12871-022-01768-5.
[7]	CHUNG H W, CHANG H, HONG D, et al. Optimal ropivacaine concentration for ultrasound-guided erector spinae plane block in patients who underwent video-assisted thoracoscopic lobectomy surgery[J]. Niger J Clin Pract, 2023, 26(8):1139-1146. doi:10.4103/njcp.njcp_63_23.
[8]	高娜, 贺涛, 薛娜. 超声引导下罗哌卡因腹横肌平面阻滞辅助椎管内麻醉在超体质量产妇剖宫产术中的应用[J]. 中国基层医药, 2025, 32(6):801-805.
	GAO N, HE T, XUE N. Application of ultrasound-guided transversus abdominis plane block with ropivacaine as an adjunct to intrathecal anesthesia in obese parturients undergoing cesarean section[J]. Chin J Prim Med Pharm, 2025, 32(6):801-805. doi:10.3760/cma.j.cn341190-20240820-01070.
[9]	APFELBAUM J L, HAGBERG C A, CONNIS R T, et al. 2022 American society of anesthesiologists practice guidelines for management of the difficult airway[J]. Anesthesiology,2022, 36(1):31-81. doi:10.1097/ALN.0000000000004002.
[10]	HELLER G Z, MANUGUERRA M, CHOW R. How to analyze the Visual Analogue Scale:Myths,truths and clinical relevance[J]. Scand J Pain, 2016, 10(13):67-75. doi:10.1016/j.sjpain.2016.06.012.
[11]	BANG Y J, KWON J H, KANG R, et al. Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection:study protocol for a randomized controlled trial[J]. Trials, 2023, 24(1):332. doi:10.1186/s13063-023-07341-w.
[12]	TANG W, HAO Y, WU G, et al. Comparison of the effectiveness of two different concentrations of ropivacaine for intrapleural analgesia in reducing stimulatory pain caused by chest tubes after uniportal video-assisted thoracoscopic surgery:a randomised controlled study[J]. BMC Anesthesiol, 2025, 25(1):119. doi:10.1186/s12871-025-02992-5.
[13]	WU K W, DENG S Y, ZHANG X F, et al. Thoracoscopy-guided thoracic paravertebral block using dexmedetomidine in combination with ropivacaine for postoperative analgesia after thoracoscopic radical resection of lung cancer:a randomized controlled trial[J]. J Cancer Res Clin Oncol, 2025, 151(5):158. doi:10.1007/s00432-025-06218-6.
[14]	CHENG P, YING F, LI Y. Effects of different concentrations of ropivacaine lumbar plexus-sciatic nerve block on recovery from anesthesia,postoperative pain and cognitive function in elderly patients with femoral neck fracture[J]. Evid Based Complement Alternat Med, 2022, 8(25):4096005. doi:10.1155/2022/4096005.
[15]	SHI L, ZHANG D, YE P, et al. Clinical effect of different concentrations of ropivacaine in the labor analgesia of dural puncture epidural technique for obese puerperae[J]. Perioper Med(Lond), 2024, 13(1):7. doi:10.1186/s13741-024-00363-1.
[16]	LEE S C, JEONG J H, JEONG S Y, et al. Comparison between two different concentrations of a fixed dose of ropivacaine in interscalene brachial plexus block for pain management after arthroscopic shoulder surgery: a randomized clinical trial[J]. Korean J Anesthesiol, 2021, 74(3):226-233. doi:10.4097/kja.20353.
[17]	TANG W, HAO Y, WU G, et al. Comparison of the effectiveness of two different concentrations of ropivacaine for intrapleural analgesia in reducing stimulatory pain caused by chest tubes after uniportal video-assisted thoracoscopic surgery:a randomised controlled study[J]. BMC Anesthesiol, 2025, 25(1):119. doi:10.1136/bmjopen-2023-077876.
[18]	LI J, PAN J, XU Y, et al. Optimal concentration of ropivacaine for peripheral nerve blocks in adult patients:a protocol for systematic review and meta-analysis[J]. BMJ Open, 2023, 13(12):e077876. doi:10.1136/bmjopen-2023-077876.
[19]	杨奎, 俞红青. 腰硬联合麻醉中不同浓度罗哌卡因对GDM剖宫产产妇微循环及氧化应激反应的影响[J]. 中国计划生育学杂志, 2024, 32(10):2277-2282.
	YANG K, YU H Q. Effects of the different concentrations of ropivacaine used in the combined spinal epidural anesthesia during cesarean sec-tion of women with gestational iabetes mellitus on their microcirculation and oxidative stress response[J]. Chinese Journal of Family Planning, 2024, 32(10):2277-2282. doi:10.3969/j.issn.1004-8189.2024.10.011.
[20]	LI Q P, XUE F S, LI X T. Determining optimal ropivacaine concentration for erector spinae plane block in patients for thoracoscopic lobectomy[J]. Niger J Clin Pract, 2024, 27(7):929-930. doi:10.4103/njcp.njcp_660_23.
[21]	王菁. 不同浓度罗哌卡因腹横肌平面阻滞在剖宫产术后镇痛的效果及药代动力学研究[D]. 福州: 福建医科大学, 2025.
	WANG J. Effect and pharmacokinetics of different concentrations of ropivacaine on postoperative analgesia after cesarean section[D]. Fuzhou: Fujian Medical University, 2025.
[22]	LING J, XU C, TANG L, et al. Comparison of the pharmacokinetic variations of different concentrations of ropivacaine used for serratus anterior plane block in patients undergoing thoracoscopic lobectomy:a population pharmacokinetics analysis[J]. Front Pharmacol, 2025, 26(16):1540606. doi:10.3389/fphar.2025.1540606.

组别	n	性别（男/女）	年龄/ 岁	体质量指数/（kg/m²）		ASA分级
组别	n	性别（男/女）	年龄/ 岁	体质量指数/（kg/m²）		Ⅰ级	Ⅱ级
A组	57	32/25	53.95±5.26	22.65±1.35		21（36.8）	36（63.2）
B组	57	35/22	54.36±5.17	22.73±1.44		24（42.1）	33（57.9）
χ²或t		0.326	0.420	0.306		0.330
组别		疾病类型			切除范围
组别		早期非小细胞肺癌		多发性肺结节	单侧肺叶	双侧肺叶	楔形
A组		44（77.2）		13（22.8）	40（70.2）	5（8.8）	12（21.0）
B组		40（70.2）		17（29.8）	42（73.7）	6（10.5）	9（15.8）
χ²		0.724			0.568

组别	n	性别（男/女）	年龄/ 岁	体质量指数/（kg/m²）		ASA分级
组别	n	性别（男/女）	年龄/ 岁	体质量指数/（kg/m²）		Ⅰ级	Ⅱ级
A组	57	32/25	53.95±5.26	22.65±1.35		21（36.8）	36（63.2）
B组	57	35/22	54.36±5.17	22.73±1.44		24（42.1）	33（57.9）
χ²或t		0.326	0.420	0.306		0.330
组别		疾病类型			切除范围
组别		早期非小细胞肺癌		多发性肺结节	单侧肺叶	双侧肺叶	楔形
A组		44（77.2）		13（22.8）	40（70.2）	5（8.8）	12（21.0）
B组		40（70.2）		17（29.8）	42（73.7）	6（10.5）	9（15.8）
χ²		0.724			0.568

组别	麻醉时间/min		手术时间/min		术中出血量/mL		术中丙泊酚用量/mg
A组	151.46±37.54		88.95±25.33		108.26±19.59		831.06±15.43
B组	155.23±40.59		89.46±22.77		110.51±20.09		835.49±17.59
t	0.515		0.113		0.604		1.432
组别		术中瑞芬太尼用量/mg		术后PCIA首次按压时间/h		48 h内PCIA按压次数/次
A组		0.98±0.26		10.46±2.76		6.56±2.16
B组		1.07±0.35		12.33±3.02		4.95±1.34
t		1.401		3.461^＊＊		4.787^＊＊

组别	麻醉时间/min		手术时间/min		术中出血量/mL		术中丙泊酚用量/mg
A组	151.46±37.54		88.95±25.33		108.26±19.59		831.06±15.43
B组	155.23±40.59		89.46±22.77		110.51±20.09		835.49±17.59
t	0.515		0.113		0.604		1.432
组别		术中瑞芬太尼用量/mg		术后PCIA首次按压时间/h		48 h内PCIA按压次数/次
A组		0.98±0.26		10.46±2.76		6.56±2.16
B组		1.07±0.35		12.33±3.02		4.95±1.34
t		1.401		3.461^＊＊		4.787^＊＊

组别	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h
A组	1.42±0.50	1.68±0.51^a	2.05±0.58^ab	2.46±0.71^abc	2.89±0.56^abcd
B组	1.39±0.50	1.53±0.57	1.86±0.61^ab	2.18±0.63^abc	2.54±0.60^abcd
t	0.320	1.481	1.704	2.227^＊	3.220^＊＊