前锯肌平面阻滞对胸腔镜肺癌根治术患者物质能量代谢和胰岛素抵抗的影响

Effect of serratus anterior plane block on substance and energy metabolism and insulin resistance in patients undergoing thoracoscopic radical resection for lung cancer

摘要:

目的 探讨前锯肌平面阻滞对胸腔镜肺癌根治术患者物质能量代谢和胰岛素抵抗的影响。方法 选取2018年6月—2020年6月在日照市人民医院全身麻醉下行胸腔镜肺癌根治手术的60例患者。采用随机数字表法分为对照组和阻滞组，每组30例。对照组行全身麻醉，阻滞组先在超声引导下行前锯肌平面阻滞，后行全身麻醉。记录两组患者入手术室后5 min（T₀）、麻醉诱导前（T₁）、手术切皮时（T₂）、手术结束时（T₃）平均血压（BP）和心率（HR）。记录两组患者术后6 h（T₄）、12 h（T₅）、24 h（T₆）、48 h（T₇）时静止状态及咳嗽状态下行视觉模拟量表评分。两组患者T₀、T₃、T₆、T₇时检测C反应蛋白、静息能量消耗、呼吸商、甘油三酯、血糖、胰岛素。采用间接测热法测定静息能量消耗和呼吸商，稳态模型评价胰岛素抵抗指数，全自动生化分析仪测定甘油三酯水平，酶联免疫吸附试验试剂盒检测C反应蛋白。结果 两组性别比例、年龄、体质量指数、美国麻醉医生协会分级、手术时间和术中出血量比较，差异均无统计学意义（P >0.05）。阻滞组术中瑞芬太尼用量较对照组少，自主呼吸恢复时间、拔管时间较对照组短（P <0.05）。两组患者T₀、T₁、T₂、T₃时BP比较，结果 ①不同时间点BP比较，差异有统计学意义（P <0.05）；②两组BP比较，差异无统计学意义（P >0.05）；③两组BP变化趋势比较，差异有统计学意义（P <0.05）。两组T₀、T₁、T₂、T₃时HR比较，结果 ①不同时间点HR比较，差异有统计学意义（P <0.05）；②两组HR比较，差异有统计学意义（P <0.05），阻滞组T₂、T₃时较对照组低（P <0.05）；③两组HR变化趋势比较，差异有统计学意义（P <0.05）。两组T₄、T₅、T₆、T₇时静息状态下VAS比较，结果 ①不同时间点VAS比较，差异有统计学意义（P <0.05）；②两组VAS比较，差异有统计学意义（P <0.05），阻滞组T₄、T₅时较对照组低（P <0.05）；③两组VAS变化趋势比较，差异无统计学意义（P >0.05）。两组T₄、T₅、T₆、T₇时咳嗽状态下VAS比较，结果 ①不同时间点VAS比较，差异有统计学意义（P <0.05）；②两组VAS比较，差异有统计学意义（P <0.05），阻滞组T₄、T₅时较对照组低（P <0.05）；③两组VAS变化趋势比较，差异有统计学意义（P <0.05）。两组患者T₀、T₃、T₆、T₇时C反应蛋白、REE、RQ、甘油三酯、IRI比较，结果 ①不同时间点C反应蛋白、REE、RQ、甘油三酯、IRI比较，差异均有统计学意义（P <0.05）；②两组C反应蛋白、REE、RQ、甘油三酯、IRI比较，差异均有统计学意义（P <0.05）；③两组C反应蛋白、REE、RQ、甘油三酯、IRI变化趋势比较，差异均有统计学意义（P <0.05）。结论 前锯肌平面阻滞可减轻胸腔镜肺癌根治术患者炎症反应，改善物质代谢和静息能量消耗，减轻胰岛素抵抗。

Abstract:

Objective To investigate the effect of serratus anterior plane block on substance and energy metabolism and insulin resistance in patients undergoing thoracoscopic radical resection for lung cancer.Methods Sixty patients undergoing thoracoscopic radical resection for lung cancer under general anesthesia in our hospital from June 2018 to June 2020 were selected, and were randomly divided into the control group and the serratus anterior plane block group with the random number table method, with 30 patients in each group. The patients in the control group received general anesthesia, and the patients in the serratus anterior plane block group received ultrasound-guided serratus anterior plane block followed by general anesthesia. The mean blood pressure (BP) and the heart rate (HR) were recorded 5 minutes after admission (T₀), before anesthesia induction (T₁), at the time of skin incision making (T₂) and at the end of the operation (T₃). Visual Analogue Scale (VAS) scores at rest and during coughing were measured 6 h (T₄), 12 h (T₅), 24 h (T₆) and 48 h (T7) after the operation. The level of C-reactive protein, resting energy expenditure (REE), respiratory quotient (RQ), and levels of triglyceride, blood glucose and insulin of patients in the two groups were detected at T₀, T₃, T₆, and T₇. The REE and RQ were measured by indirect calorimetry. The insulin resistance index (IRI) was calculated with the homeostatic model assessment. The level of triglyceride was detected via fully automated chemistry analyzer, while the level of C-reactive protein was measured via ELISA kits.Results There was no difference in sex composition, age, body mass index, the grade of American Society of Anesthesiologists, operative duration or intraoperative blood loss between the two groups (P > 0.05). Compared with the control group, the dosage of remifentanil was higher and the time to recovery of spontaneous breathing and extubation were shorter in the serratus anterior plane block group (P < 0.05). The BP at T₀, T₁, T₂ and T₃ in the two groups of patients were compared via repeated measures analysis of variance, which exhibited that BP was different among the time points (P < 0.05) and between the groups (P < 0.05), and that the change trends of BP were different between the two groups (P < 0.05). The HR at T₀, T₁, T₂ and T₃ in the two groups of patients were also compared via repeated measures analysis of variance, and the results demonstrated that HR was different among the time points (P < 0.05) and between the groups (P < 0.05). Specifically, HR at T₂ and T₃ in the serratus anterior plane block group was lower than that in the control group (P < 0.05). Besides, the change trends of HR were different between the two groups (P < 0.05). The VAS scores at rest at T₄, T₅, T₆ and T₇ were compared via repeated measures analysis of variance, which showed that the VAS scores at rest were different among the time points (P < 0.05) and between the groups (P < 0.05), where VAS scores at rest at T₄ and T₅ in the serratus anterior plane block group were lower than those in the control group (P < 0.05). The change trends of VAS scores at rest were not different between the two groups (P > 0.05). The VAS scores during coughing at T₄, T₅, T₆ and T₇ in the two groups of patients were compared via repeated measures analysis of variance, and the results suggested that VAS scores during coughing were different among the time points (P < 0.05) and between the groups (P < 0.05), and that the VAS scores during coughing at T₄ and T₅ in the serratus anterior plane block group were lower than those in the control group (P < 0.05). The change trends of VAS scores during coughing were also different between the two groups (P < 0.05). The level of C-reactive protein, REE, RQ, the level of triglyceride, and IRI at T₀, T₃, T₆ and T₇ were compared via repeated measures analysis of variance, which indicated that these indicators were different among the time points (P < 0.05) and between the groups (P < 0.05), and that the change trends of these indicators were different between the groups (P < 0.05).Conclusions The serratus anterior plane block may mitigate the inflammation, improve the substance metabolism and REE, and alleviate the insulin resistance in patients undergoing thoracoscopic radical resection for lung cancer.