基于快速康复外科理念的超声引导胸椎旁阻滞在胸腔镜肺叶切除术中的应用价值评估

Application of ultrasound-guided thoracic paravertebral block in VATS lobectomy based on ERAS concept

摘要:

目的 基于快速康复外科（ERAS）理念探讨超声引导胸椎旁阻滞（TPVB）在胸腔镜（VATS）肺叶切除术中的应用价值。方法 选取2019年4月—2021年10月于长沙市第一医院接受VATS肺叶切除术的早期肺癌患者106例纳入研究。将患者分为TPVB组和EA组，各53例。TPVB组采用超声引导下TPVB+全身麻醉，EA组采用硬膜外阻滞+全麻。比较两组镇痛效果、生命体征、肺功能、术后恢复情况、术后并发症等。结果 两组患者术后6 h、12 h、24 h、48 h的静息状态下视觉模拟评分法（VAS）评分比较，经重复测量设计的方差分析，结果 ①不同时间点间的静息状态下VAS评分比较有差异（F =25.842，P <0.05）。②两组患者静息状态下VAS评分比较有差异（F =101.268，P <0.05），TPVB组静息状态下VAS评分比EA组低，相对镇痛效果好。③两组患者静息状态下VAS评分变化趋势比较有差异（F =42.638，P <0.05）。两组患者不同时间点的平均动脉压（MAP）、心率（HR）、血氧饱和度（SpO₂）比较，经重复测量设计的方差分析，结果 ①不同时间点的MAP、HR、SpO₂比较有差异（F =19.635、27.415、40.362，均P <0.05）。②两组患者MAP、HR、SpO₂比较有差异（F =12.845、24.632、31.486，均P <0.05），TPVB组切皮时高于EA组。③两组患者MAP、HR、SpO₂变化趋势比较有差异（F =89.563、102.542、117.635，均P <0.05）。两组患者拔管后第1秒用力呼气容积（FEV₁）、肺活量（VC）、每分钟最大通气量（MVV）比较，差异无统计学意义（P >0.05），TPVB组术后48 h的FEV₁、VC、MVV及拔管后与术后48 h的差值大于EA组（P <0.05）。两组患者术后拔管时间比较，差异无统计学意义（P >0.05），TPVB组首次排气时间、排便时间、下床活动时间、术后住院时间短于EA组（P <0.05）。TPVB组术后并发症总发生率低于EA组（P <0.05）。结论 超声引导下TPVB应用于VATS肺叶切除术的镇痛效果确切，有助于稳定患者血流动力学，保护肺功能，降低术后并发症风险，符合ERAS理念。

Abstract:

Objective To explore the value of ultrasound-guided thoracic paravertebral block (TPVB) in video-assisted thoracoscopic surgery (VATS) lobectomy based on the concept of enhanced recovery after surgery (ERAS).Methods A total of 106 patients with early lung cancer who underwent VATS lobectomy in our hospital from April 2019 to October 2021 were included in the study. They were randomly divided into TPVB group and EA group, with 53 cases in each group. The TPVB group was treated with ultrasound-guided TPVB and general anesthesia, while the EA group was treated with epidural anesthesia and general anesthesia. The analgesic effect, vital signs, pulmonary function, postoperative recovery and postoperative complications were compared between the two groups.Results The Visual Analogue Scale (VAS) scores at rest of the TPVB group were compared with those of EA group at 6 h, 12 h, 24 h and 48 h after operation. The repeated measures analysis of variance showed that there were significant differences in VAS scores at rest among the time points (F = 25.842, P <0.05) and between TPVB group and EA group (F = 101.268, P < 0.05). The VAS score at rest of TPVB group was lower than that of EA group, indicating a better analgesic effect. Besides, there were significant differences in the change trends of VAS scores at rest between TPVB group and EA group (F = 42.638, P = 0.000). The MAP, HR, and SpO₂ were also different among the time points (F = 19.635, 27.415 and 40.362, all P <0.05) and between the two groups (F = 12.845, 24.632 and 31.486, all P < 0.05). The MAP, HR and SpO₂ during skin incision in TPVB group were higher than those in EA group. There were significant differences in the change trends of MAP, HR and SpO₂ between the two groups (F = 89.563, 102.542 and 117.635, all P <0.05). There was no difference in forced expiratory volume in one second (FEV₁), vital capacity (VC) and minute ventilation volume (MVV) after the extubation between the two group (P >0.05), while FEV₁, VC, MVV at 48 h after operation and the differences of FEV₁, VC, MVV after the extubation and at 48 h after operation were higher in TPVB group than those in EA group (P < 0.05). There was no difference in the extubation time between the two groups (P >0.05). The time to first flatus, defecation, and off-bed activity and the length of hospital stay in TPVB group were shorter than those in EA group (P < 0.05). The overall incidence of postoperative complications in TPVB group was lower than that in EA group (P < 0.05).Conclusions The ultrasound-guided TPVB is effective for analgesia in VATS lobectomy, and is conducive to stabilizing the hemodynamics, protecting the lung function, and reducing the risk of postoperative complications, which is in line with the ERAS concept.