全身麻醉联合椎旁神经阻滞少阿片化方案在胸腔镜肺段切除术中的临床应用效果研究

Efficacy of opioid-sparing general anesthesia combined with paravertebral nerve block for thoracoscopic segmentectomy

摘要:

目的 探讨全身麻醉联合椎旁神经阻滞少阿片化方案在胸腔镜肺段切除术中的临床应用效果。方法 选取2020年6月—2024年6月在南通市中医院行胸腔镜肺段切除术的82例患者。依据麻醉方式不同分为对照组（接受全身麻醉）和试验组（接受全身麻醉联合椎旁神经阻滞），各41例。比较两组血流动力学、瑞芬太尼用量、苏醒时间、自主呼吸恢复时间、疼痛状况、应激反应、并发症。结果 试验组与对照组术后麻醉前、诱导插管时（T₁）、切皮时（T₂）、拔管时（T₃）时平均动脉压（MAP）、心率（HR）比较，结果 ①不同时间点MAP、HR比较，差异均有统计学意义（P <0.05）；②两组MAP、HR比较，差异均有统计学意义（P <0.05），试验组T₁～T₃时MAP、HR均低于对照组（P <0.05）；③两组MAP、HR变化趋势比较，差异均有统计学意义（P <0.05）。试验组瑞芬太尼用量、苏醒时间和自主呼吸恢复时间均低于对照组（P <0.05）。两组术后4、24、48 h静息和咳嗽状态视觉模拟评分法（VAS）评分比较，结果 ①不同时间点静息、咳嗽状态VAS评分比较，差异均有统计学意义（P <0.05）；②两组静息、咳嗽状态VAS评分比较，差异均有统计学意义（P <0.05），试验组术后4 h静息、咳嗽状态VAS评分均低于对照组（P <0.05），试验组术后24 h咳嗽状态VAS评分低于对照组（P <0.05）；③两组静息、咳嗽状态VAS评分变化趋势比较，差异均有统计学意义（P <0.05）。试验组术后24 h内镇痛泵按压次数少于对照组（P <0.05）。试验组与对照组术前、术后1和3 d的甲肾上腺素（NE）、肾上腺素（E）、胰岛素（INS）、皮质醇（Cor）水平比较，结果 ①不同时间点NE、E、INS、Cor水平比较，差异均有统计学意义（P <0.05）；②两组NE、E、INS、Cor水平比较，差异均有统计学意义（P <0.05），试验组术后1、3 d的NE、E、INS、Cor水平均低于对照组（P <0.05）；③两组NE、E、INS、Cor变化趋势比较，差异均有统计学意义（P <0.05）。试验组并发症总发生率低于对照组（P <0.05）。结论 全身麻醉联合椎旁神经阻滞在胸腔镜肺段切除手术中可维持稳定的血流动力学、减少麻醉药物使用剂量、优化疼痛管理、从而减少生理应激和并发症的发生风险。

Abstract:

Objective To investigate the clinical efficacy of opioid-sparing general anesthesia combined with paravertebral nerve block for thoracoscopic segmentectomy.Methods Eighty-two patients undergoing thoracoscopic segmentectomy at Nantong Traditional Chinese Medicine Hospital between June 2020 and June 2024 were enrolled. Patients were divided into a control group (undergoing general anesthesia) and an experimental group (undergoing general anesthesia combined with paravertebral nerve block), with 41 patients in each group. The two groups were compared in terms of hemodynamic parameters, remifentanil dosage, time to recovery, time to spontaneous breathing recovery, pain status, stress response, and complications.Results Comparisons of mean arterial pressure (MAP) and heart rate (HR) between the experimental and control groups before anesthesia and at induction and intubation (T₁), skin incision (T₂), and extubation (T₃) revealed that they were different among the time points (P < 0.05) and between the groups (P < 0.05), where MAP and HR in the experimental group were lower than those in the control group at T₁ to T₃ (P < 0.05). The change trends of MAP and HR were also different between the two groups (P < 0.05). The experimental group exhibited lower remifentanil dosage, shorter time to recovery, and earlier recovery of spontaneous breathing compared with the control group (P < 0.05). Comparisons of visual analogue scale (VAS) scores at rest and during coughing at 4, 24, and 48 hours postoperatively revealed that they were different across the time points (P < 0.05) and between the two groups (P < 0.05), and that the experimental group exhibited lower VAS scores at rest and during coughing than the control group at 4 hours postoperatively, and lower VAS scores during coughing at 24 hours postoperatively (P < 0.05). Besides, the change trends of VAS scores at rest and during coughing were different between the groups (P < 0.05). The experimental group exhibited fewer analgesic pump presses within 24 hours postoperatively than the control group (P < 0.05). Comparisons of levels of noradrenaline (NE), adrenaline (E), insulin (INS), and cortisol (Cor) before surgery, and 1 day and 3 days after surgery in the experimental and control groups revealed that they were different across the time points (P < 0.05) and between the two groups (P < 0.05), where NE, E, INS, and Cor levels 1 day and 3 days after surgery in the experimental group were lower than those in the control group (P < 0.05). The change trends of NE, E, INS, and Cor levels were also different between the groups (P < 0.05). The overall complication rate was lower in the experimental group than in the control group (P < 0.05).Conclusion Combined general anesthesia with paravertebral nerve block during thoracoscopic segmentectomy maintains stable hemodynamics, reduces anesthetic drug dosage, and optimizes pain management, thereby decreasing physiological stress and the risk of complications.