非气管插管胸腔镜肺叶切除术前TPVB及EB的术后镇痛效果及对血清炎症因子、疼痛介质水平影响

Postoperative analgesic efficacy of TPVB and EB before non-intubated thoracoscopic lobectomy and their effects on serum inflammatory factors and pain mediators

摘要:

目的 探讨非气管插管胸腔镜肺叶切除术前胸椎旁神经阻滞（TPVB）及硬膜外阻滞（EB）的术后镇痛效果及对血清炎症因子、疼痛介质水平影响。方法 选取2020年10月—2022年10月胜利油田中心医院收治198例行非气管插管胸腔镜肺叶切除术的患者，采用单纯随机抽样法分为TPVB组、EB组和对照组，每组66例。对照组采用保留自主呼吸的非气管插管麻醉，TPVB组采用TPVB复合保留自主呼吸的非气管插管麻醉，EB组采用EB复合保留自主呼吸的非气管插管麻醉。比较3组围手术期指标、心率（HR）、平均动脉压（MAP）、视觉模拟评分法（VAS）评分、Ramsay镇静评分、血清疼痛介质［5-羟色胺（5-HT）、P物质（SP）、去甲肾上腺素（NE）、多巴胺（DA）］、炎症因子［超敏C反应蛋白（hs-CRP）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）］，体液免疫功能［免疫球蛋白A（IgA）、免疫球蛋白G（IgG）、免疫球蛋白M（IgM）］，记录围手术期不良反应。结果 3组麻醉时间、手术时间、右美托咪定用量、丙泊酚用量比较，差异均无统计学意义（P >0.05）。TPVB组、EB组芬太尼用量低于对照组（P <0.05）。3组T₁、T₂、T₃、T₄时HR、MAP水平比较，结果 ①3组不同时间点HR、MAP水平比较，差异均有统计学意义（P <0.05）；②3组HR、MAP水平比较，差异均有统计学意义（P <0.05）；③3组HR、MAP水平变化趋势水平比较，差异均有统计学意义（P <0.05）。3组术后6、12、24和48 h的VAS评分、Ramsay镇静评分比较，结果 ①3组不同时间点VAS评分、Ramsay镇静评分比较，差异均有统计学意义（P <0.05）；②3组VAS评分、Ramsay镇静评分比较，差异均有统计学意义（P <0.05）；③3组VAS评分、Ramsay镇静评分变化趋势比较，差异均有统计学意义（P <0.05）。3组术后1、3 d的5-HT、SP、NE、DA水平比较，结果 ①3组不同时间点5-HT、SP、NE、DA水平比较，差异均有统计学意义（P <0.05）；②3组5-HT、SP、NE、DA水平比较，差异均有统计学意义（P <0.05）；③3组5-HT、SP、NE、DA水平变化趋势比较，差异均有统计学意义（P <0.05）。3组术后1、3 d的hs-CRP、TNF-α、IL-6水平比较，结果 ①3组不同时间点hs-CRP、TNF-α、IL-6水平比较，差异均有统计学意义（P <0.05）；②3组hs-CRP、TNF-α、IL-6水平比较，差异均有统计学意义（P <0.05）；③3组hs-CRP、TNF-α、IL-6水平变化趋势比较，差异均有统计学意义（P <0.05）。3组术后1、3 d的IgA、IgG、IgM水平比较，结果 ①不同时间点IgA、IgG、IgM水平比较，差异均有统计学意义（P <0.05）；②3组IgA、IgG、IgM水平比较，差异均无统计学意义（P >0.05）；③3组IgA、IgG、IgM水平变化趋势比较，差异均无统计学意义（P >0.05）。3组心律失常、肺不张、低氧血症发生率比较，差异均无统计学意义（P >0.05）。3组低血压发生率比较，差异有统计学意义（P <0.05）。结论 TPVB用于非气管插管胸腔镜肺叶切除术的镇痛镇静效果与EB相当，并且两者均能减轻对患者MAP、HR等生命体征的影响，但TPVB在抑制疼痛介质和炎症因子方面优于EB，安全性高，具有推广价值。

Abstract:

Objective To explore the postoperative analgesic efficacy of thoracic paravertebral block (TPVB) and epidural block (EB) before non-intubated thoracoscopic lobectomy, and their effects on serum inflammatory factors and pain mediators.Methods A total of 198 patients who underwent non-intubated thoracoscopic lobectomy from October 2020 to October 2022 in Shengli Oilfield Central Hospital were selected and randomly divided into TPVB group, EB group and control group via simple sampling, with 66 patients in each group. The control group received non-intubated anesthesia with spontaneous breathing, the TPVB group received TPVB combined with non-intubated anesthesia with spontaneous breathing, and the EB group received EB combined with non-intubated anesthesia with spontaneous breathing. Perioperative indicators, heart rate (HR), mean arterial pressure (MAP), Visual Analogue Scale (VAS) score, Ramsay Sedation Scale score, serum pain mediators [5-hydroxytryptamine (5-HT), substance P (SP), norepinephrine (NE), dopamine (DA) ], inflammatory factors [high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) ], and humoral immune function (IgA, IgG, IgM) were compared among the three groups, and perioperative adverse reactions were recorded.Results There was no difference in duration of anesthesia, operative duration, dosage of dexmedetomidine or dosage of propofol (P > 0.05). The dosage of fentanyl in the TPVB group and the EB group was lower than that in the control group (P < 0.05). HR and MAP in the three groups at T₁, T₂, T₃ and T₄ were compared via repeated measures analysis of variance, and the results demonstrated that HR and MAP were different among the time points (P < 0.05) and the groups (P < 0.05), and that the change trends of HR and MAP differed among the groups (P < 0.05). VAS scores and Ramsay Sedation Scale scores 6 h, 12 h, 24 h and 48 h after the surgery were compared via repeated measures analysis of variance, which exhibited that VAS scores and Ramsay Sedation Scale scores were different among the time points (P < 0.05) and the groups (P < 0.05), and that the change trends of VAS scores and Ramsay Sedation Scale scores were different among the groups (P < 0.05). The levels of 5-HT, SP, NE and DA in the three groups 1 d and 3 d after the surgery were compared via repeated measures analysis of variance, and the results showed that they were different among the time points (P <0.05) and the groups (P < 0.05), and that the change trends of these indicators were also different among the groups (P < 0.05). The levels of hs-CRP, TNF-α and IL-6 in the three groups 1 d and 3 d after the surgery were compared via repeated measures analysis of variance, and the results indicated that they were different among the time points (P < 0.05) and the groups (P < 0.05), and that the change trends of them were different among the groups (P < 0.05). The levels of IgA, IgG and IgM in the three groups 1 d and 3 d after the surgery were compared via repeated measures analysis of variance, and the results suggested that they were different among the time points (P < 0.05). In contrast, there was no significant difference in levels of IgA, IgG and IgM and the change trends thereof among different groups (P > 0.05). The incidence of cardiac arrhythmias, pulmonary atelectasis and hypoxemia was not different among the three groups (P > 0.05), while the incidence of hypotension was different among the three groups (P < 0.05).Conclusions The analgesic and sedative efficacy of TPVB is comparable to that of EB applied in non-intubated thoracoscopic lobectomy, and both of TPVB and EB may mitigate the impact on MAP, HR and other vital signs of patients. However, TPVB is superior to EB in inhibiting pain mediators and inflammatory factors, and is safe and of value for being widely applied.