超声引导下双侧胸椎旁神经节阻滞对行腹腔镜下胰十二指肠切除术患者应激反应的影响

Effect of bilateral paravertebral nerve block guided by ultrasound on stress response in patients undergoing laparoscopic pancreaticoduodenectomy

摘要:

目的 探讨超声引导下双侧胸椎旁神经节阻滞（TPVB）联合全身麻醉（GA）对行腹腔镜下胰十二 指肠切除术患者应激反应的影响。方法 选取2017年6月—2018年6月大连大学附属中山医院择期拟行腹腔镜下 胰十二指肠切除术的患者90例，采用随机数字表法将其分为双侧胸椎旁神经节阻滞组（TPVB+GA组）和全身麻 醉组（GA组），每组45例。两组患者术前均行常规监护、麻醉诱导及气管插管，TPVB+GA组在超声引导下于胸 椎T8、T9间隙行TPVB。在入室时（T0）、GA诱导后5 min （T1）、手术开始时（T2）、手术开始后30 min （T3）、 手术结束时（T4）时采集患者外周静脉血2 ml，采用ELISA法测定皮质醇、血糖及促肾上腺皮质激素的浓度；计 录麻醉药用量，术后2 h、4 h、12 h和24 h的VAS评分及术后不良反应。结果 TPVB+GA组的瑞芬太尼与丙泊 酚用量低于GA组（P<0.05）；不同时间点的平均动脉压（MAP）、心率（HR）比较无差异，T3和T4时的TPVB+ GA组的MAP低于GA组，（P<0.05）；在T2、T3和T4时TPVB+GA组的HR低于GA组，（P<0.05）；术后不同时 间点的VAS评分两组无差异，TPVB+GA组术后2 h、4 h、12 h和24 h的VAS评分低于GA组（P<0.05）；不同时 间点的Cor浓度、ACTH浓度及Glu水平有差异（P<0.05），T2、T3和T4时TPVB+GA组的Cor浓度低于GA组 （P<0.05）；T2、T3和T4时TPVB+GA组的ACTH浓度低于GA组（P<0.05）；T3和T4时的TPVB+GA组的Glu水 平低于GA组（P<0.05）；TPVB+GA组恶心呕吐发生率低于GA组（P<0.05）。结论 相对于单纯采用GA，GA 联合双侧TPVB能够在腹腔镜下胰十二指肠切除术中维持血流动力学稳定性，减轻患者围术期发生的应激反应， 且能降低不良反应的发生。

Abstract:

Objective To investigate the effect of bilateral paravertebral nerve block combined with general anesthesia on stress response during laparoscopic pancreaticoduodenectomy. Methods From June 2017 to June 2018, 90 patients undergoing laparoscopic cholecystectomy under general anesthesia were selected. The patients were randomly divided into two groups: bilateral paravertebral nerve block group (TPVB+GA group) and general anesthesia group (GA group), 45 patients in each group. Patients were given routine monitoring, anesthesia induction, and intubation before operation. In TPVB+GA group, paravertebral nerve block was performed between T8 and T9 under ultrasound guidance. The time at entering the room (T0), after induction of general anesthesia 5 min (T1), at the beginning of surgery (T2), at the beginning of operation 30 min (T3), and at the end of operation (T4) was collected, as well as the peripheral venous blood to determine the concentration of cortisol, blood glucose, and corticotropin. VAS scores were measured at 2 h, 4 h, 12 h and 24 h after operation, and postoperative side effects were observed. Results The dosage of remifentanil and propofol in TPVB GA group was lower than that in GA group (P < 0.05). There was no difference in MAP and HR at different time points. MAP in TPVB GA group at T3 and T4 was lower than that in GA group (P < 0.05). HR at T2, T3 and T4 in TPVB GA group was lower than that in GA group (P < 0.05). There was no significant difference in VAS score between the two groups at different time points after operation. At 2 h, 4 h, 12 h and 24 h after operation, the postoperative VAS scores in TPVB GA group were lower than that in GA group (P < 0.05). The concentrations of Cor, ACTH and Glu at different time points were lower than those in GA group. The concentration of Cor in GA group was higher than that in TPVB GA group (P < 0.05), the concentration of ACTH in GA group was higher than that in TPVB GA group (P < 0.05), and the levels of Glu at T3 and T4 in GA group were higher than those in TPVB GA group. The incidences of nausea and vomiting in GA group were higher than those in TPVB GA group. Conclusion The application of general anesthesia combined with bilateral thoracic paravertebral block in laparoscopic cholecystectomy can effectively maintain the hemodynamic stability, reduce the perioperative stress response, and effectively reduce the occurrence of adverse reactions.