胸椎旁神经阻滞对冠脉搭桥术患者麻醉诱导期血流动力学及术后恢复的影响

刘磊; 李海慧; 冯涛; 吴障; 陶静; 梁启胜

doi:10.16766/j.cnki.issn.1674-4152.002316

胸椎旁神经阻滞对冠脉搭桥术患者麻醉诱导期血流动力学及术后恢复的影响

doi: 10.16766/j.cnki.issn.1674-4152.002316

刘磊¹,
李海慧²,
冯涛¹,
吴障¹,
陶静¹,
梁启胜^1, ,

1.
蚌埠医学院第一附属医院麻醉科，安徽蚌埠 233004
2.
蚌埠医学院第一附属医院心脏外科，安徽蚌埠 233004

基金项目:

安徽省教育厅高校自然科学研究重点项目 KJ2019A0362

详细信息

通讯作者:
梁启胜, E-mail: bbyemenlqs@126.com

中图分类号: R614.4 R654.2
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- 被引次数: 0
出版历程
- 收稿日期: 2021-09-18
- 网络出版日期: 2022-03-04

Effects of thoracic paravertebral nerve block on hemodynamics during induction of anesthesia and postoperative recovery in patients undergoing coronary artery bypass grafting

1.
Department of Anesthesiology, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China

摘要

摘要: 目的探讨胸椎旁神经阻滞对冠脉搭桥术患者麻醉诱导期血流动力学及术后恢复的影响。方法选择2020年8月—2021年8月于蚌埠医学院第一附属医院择期行冠脉搭桥手术的患者50例。根据随机数字表法将患者分为胸椎旁神经阻滞联合全麻组(P组)和常规全麻组(G组)，每组25例。记录2组患者麻醉诱导前(T0)、插管前(T1)、插管即刻(T2)、插管后1 min(T3)及5 min(T4)的平均动脉压(MAP)和心率(HR)；术中舒芬太尼用量；术后机械通气时间；拔管后、术后12、24 h的VAS评分；术后24 h补救镇痛例数；留置心脏外科重症监护室时间、术后住院时间；术后不良反应。结果 P组T2~T4时点的MAP分别为(74.84±10.05)mm Hg(1 mm Hg=0.133 kPa)、(74.96±10.03)mm Hg、(74.72±9.18)mm Hg，均低于G组[(85.08±10.57)mm Hg、(89.16±10.00)mm Hg、(81.04±8.92)mm Hg，均P < 0.05]；P组T2~T4时点的HR均低于G组(均P < 0.05)。P组术中舒芬太尼用量、术后机械通气时间、留置心脏外科重症监护室时间均少于G组(均P < 0.05)；P组术后各时间点的VAS评分均低于G组(均P < 0.05)；P组术后24 h补救镇痛例数少于G组(P < 0.05)；2组恶心呕吐、肺部感染的发生率比较差异无统计学意义(均P > 0.05)。结论胸椎旁神经阻滞可维持冠脉搭桥术患者麻醉诱导期血流动力学平稳，减轻术后疼痛，减少镇痛药物用量，有利于患者术后早期恢复。
- 胸椎旁神经阻滞 /
- 冠脉搭桥 /
- 血流动力学 /
- 术后恢复
Abstract: Objective To investigate the effects of thoracic paravertebral nerve block (TPVB) on hemodynamics during induction of anesthesia and postoperative recovery in patients undergoing coronary artery bypass grafting (CABG). Methods Fifty patients were selected for elective CABG at the First Affiliated Hospital of Bengbu Medical College from August 2020 to August 2021. The patients were divided into two groups using the random number table method: TPVB combined with general anesthesia group (group P) and conventional general anesthesia group (group G), each group contained 25 patients. The mean arterial pressure (MAP) and heart rate (HR) before induction of anesthesia (T0), before tracheal intubation (T1), immediately after tracheal intubation (T2), 1 min (T3) and 5 min (T4) after tracheal intubation, intraoperative sufentanil dosage, postoperative mechanical ventilation time, the visual analogue scale (VAS) scores after extubation, 12 and 24 h postoperatively, 24 h postoperative remedial analgesia cases, length of stay in the cardiac surgical intensive care unit (CSICU), postoperative hospital stay, and postoperative adverse effects were all recorded and analyzed accordingly. Results MAP at T2-T4 in group P were (74.84±10.05) mm Hg (1 mm Hg = 0.133 kPa), (74.96±10.03) mm Hg, (74.72±9.18) mm Hg, which were lower than those of group G [(85.08±10.57) mm Hg, (89.16±10.00) mm Hg, (81.04±8.92)mm Hg, all P < 0.05]; HR at T2-T4 in group P were lower than those in group G (all P < 0.05). Intraoperative sufentanil dosage, postoperative mechanical ventilation time, and length of stay in the CSICU in the group P were less than those in group G (all P < 0.05). The VAS scores at all postoperative time points in the group P were lower than those in the group G (all P < 0.05). The number of cases of remedial analgesia at 24 h postoperatively in the group P was less than that in the group G (P < 0.05). There was no statistically significant difference in the incidence of nausea and vomiting and pulmonary infection between the two groups (all P > 0.05). Conclusion TPVB can maintain stable hemodynamics during the induction period of anesthesia in patients undergoing coronary artery bypass grafting. It also alleviates postoperative pain, reduces the amount of analgesic drugs, and facilitates the early postoperative recovery of patients.
- Thoracic paravertebral nerve block /
- Coronary artery bypass grafting /
- Hemodynamics /
- Postoperative recovery

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表 1 2组冠脉搭桥术患者一般资料比较

组别	例数	年龄(x±s，岁)	性别(例)		体重(x±s，kg)	射血分数(x±s，%)	ASA分级(例)		搭桥数(x±s，支)	手术时间(x±s，min)
组别	例数	年龄(x±s，岁)	男性	女性	体重(x±s，kg)	射血分数(x±s，%)	Ⅱ级	Ⅲ级	搭桥数(x±s，支)	手术时间(x±s，min)
P组	25	65.60±4.66	14	11	64.36±9.50	55.72±2.56	10	15	3.08±0.49	408.24±26.96
G组	25	62.96±4.76	16	9	62.84±7.87	55.64±3.63	12	13	3.04±0.54	414.44±32.42
统计量		-1.982^a	0.333^b		-0.616^a	-0.090^a	0.325^b		-0.274^a	0.735^a
P值		0.053	0.564		0.541	0.929	0.569		0.785	0.466
注：^a为t值，^b为χ²值。

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表 2 2组冠脉搭桥术患者麻醉诱导期不同时间点MAP和HR比较(x ±s)

组别	例数	MAP(mm Hg)
组别	例数	T0	T1	T2	T3	T4
P组	25	91.64±10.53	73.56±10.26^a	74.84±10.05^a	74.96±10.03^a	74.72±9.18^a
G组	25	95.32±12.39	74.64±11.77^a	85.08±10.57^ab	89.16±10.00^abc	81.04±8.92^abcd
t值		1.132	0.346	3.510	5.014	2.469
P值		0.263	0.731	0.001	< 0.001	0.017

组别	例数	HR(次/min)
组别	例数	T0	T1	T2	T3	T4
P组	25	77.60±8.18	61.24±6.66^a	63.04±7.74^a	64.12±6.54^a	62.48±7.08^a
G组	25	79.84±7.50	62.16±8.31^a	72.40±7.21^ab	75.96±8.22^abc	68.96±8.73^abcd
t值		1.009	0.432	4.423	5.636	2.882
P值		0.318	0.668	< 0.001	< 0.001	0.006
注: 与T0比较，^aP < 0.05；与T1比较，^bP < 0.05；与T2比较，^cP < 0.001；与T3比较，^dP < 0.001。

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表 3 2组冠脉搭桥术患者术后不同时间点VAS评分比较(x ±s，分)

组别	例数	安静VAS评分			运动VAS评分
组别	例数	拔管后	术后12 h	术后24 h	拔管后	术后12 h	术后24 h
P组	25	2.80±0.71	3.04±0.73	2.20±0.76^ab	3.80±0.71	4.04±0.79	3.08±0.81^ab
G组	25	3.72±0.74	3.52±0.65	2.88±0.78^ab	4.84±0.85	4.52±0.77	4.04±0.89^a
t值		4.503	2.441	3.112	4.701	2.176	3.986
P值		< 0.001	0.018	0.003	< 0.001	0.035	< 0.001
注: 与拔管后比较，^aP < 0.05；与术后12 h比较，^bP < 0.001。

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表 4 2组冠脉搭桥术患者术中舒芬太尼用量、术后机械通气时间、CSICU时间、术后住院时间比较(x ±s)

组别	例数	术中舒芬太尼用量(μg)	术后机械通气时间(h)	CSICU时间(h)	术后住院时间(d)
P组	25	385.60±64.25	8.02±1.24	17.70±3.41	15.52±3.15
G组	25	452.20±61.51	9.42±1.26	20.70±3.70	16.68±3.33
t值		3.744	3.976	2.976	1.266
P值		< 0.001	< 0.001	0.005	0.212
注: CSICU为心脏外科重症监护室。

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表 5 2组冠脉搭桥术患者术后补救镇痛和术后不良反应的比较[例(%)]

组别	例数	术后补救镇痛	恶心呕吐	肺部感染
P组	25	3(12.0)	2(8.0)	0(0.0)
G组	25	11(44.0)	4(16.0)	2(8.0)
χ²值		6.349	0.189	0.521
P值		0.012	0.663	0.471

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参考文献(20)

[1]	张俊杰, 李曼, 曹亚楠, 等. 罗哌卡因双侧胸椎旁神经阻滞对心肺转流心脏瓣膜手术后康复的影响[J]. 临床麻醉学杂志, 2017, 33(12): 1178-1180. doi: 10.3969/j.issn.1004-5805.2017.12.009
[2]	SINGH D, JAGANNATH S, PRIYE S, et al. The comparison of dexmedetomidine, esmolol, and combination of dexmedetomidine with esmolol for attenuation of sympathomimetic response to laryngoscopy and intubation in patients undergoing coronary artery bypass grafting[J]. Ann Card Anaesth, 2019, 22(4): 353-357. doi: 10.4103/aca.ACA_112_18
[3]	RAJ N. Regional anesthesia for sternotomy and bypass-beyond the epidural[J]. Paediatr Anaesth, 2019, 29(5): 519-529. doi: 10.1111/pan.13626
[4]	CHAKRAVARTHY M. Regional analgesia in cardiothoracic surgery: A changing paradigm toward opioid-free anesthesia?[J]. Ann Card Anaesth, 2018, 21(3): 225-227. doi: 10.4103/aca.ACA_56_18
[5]	NOSS C, PRUSINKIEWICZ C, NELSON G, et al. Enhanced recovery for cardiac surgery[J]. J Cardiothorac Vasc Anesth, 2018, 32(6): 2760-2770. doi: 10.1053/j.jvca.2018.01.045
[6]	MOLL V, MAFFEO C, MITCHELL M, et al. Association of serratus anterior plane block for minimally invasive direct coronary artery bypass surgery with higher opioid consumption: A retrospective observational study[J]. J Cardiothorac Vasc Anesth, 2018, 32(6): 2570-2577. doi: 10.1053/j.jvca.2018.04.043
[7]	EL SHORA H A, EL BELEEHY A A, ABDELWAHAB A A, et al. Bilateral paravertebral block versus thoracic epidural analgesia for pain control post-cardiac surgery: A randomized controlled trial[J]. Thorac Cardiovasc Surg, 2020, 68(5): 410-416. doi: 10.1055/s-0038-1668496
[8]	张瑜, 孙莹杰, 刁玉刚. 超声引导下双侧胸椎旁神经阻滞复合全麻在非体外循环冠状动脉搭桥术中的应用效果探讨[J]. 中国实用医药, 2021, 16(13): 48-51. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSSA202113012.htm
[9]	ARDON A E, LEE J, FRANCO C D, et al. Paravertebral block: Anatomy and relevant safety issues[J]. Korean J Anesthesiol, 2020, 73(5): 394-400. doi: 10.4097/kja.20065
[10]	D'ERCOLE F, ARORA H, KUMAR P A. Paravertebral block for thoracic surgery[J]. J Cardiothorac Vasc Anesth, 2018, 32(2): 915-927. doi: 10.1053/j.jvca.2017.10.003
[11]	吴佳, 陈龙, 陈悦, 等. 超声引导下胸椎旁神经阻滞对食管癌手术患者围术期应激反应的影响[J]. 中华全科医学, 2018, 16(11): 1826-1828, 1842. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201811018.htm
[12]	HORLOCKER T T, VANDERMEUELEN E, KOPP S L, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-based guidelines (fourth edition)[J]. Reg Anesth Pain Med, 2018, 43(3): 263-309. doi: 10.1097/AAP.0000000000000763
[13]	SANTONASTASO D P, DE CHIARA A, RISPOLI M, et al. Real-time view of anesthetic solution spread during an ultrasound-guided thoracic paravertebral block[J]. Tumori, 2018, 104(6): NP50-NP52. doi: 10.1177/0300891618763212
[14]	汤姗, 刘丹彦. 胸椎旁神经阻滞在胸科手术应用中的研究进展[J]. 山东医药, 2018, 58(30): 109-112. doi: 10.3969/j.issn.1002-266X.2018.30.032
[15]	罗太君, 李坤, 高广阔, 等. 超声引导下单点和两点胸椎旁神经阻滞对胸腔镜手术患者血流动力学和应激反应的影响[J]. 临床麻醉学杂志, 2019, 35(7): 680-684. https://www.cnki.com.cn/Article/CJFDTOTAL-LCMZ201907018.htm
[16]	SUN L, LI Q, WANG Q, et al. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: A feasibility study[J]. BMC Anesthesiol, 2019, 19(1): 101. doi: 10.1186/s12871-019-0768-9
[17]	高平, 闫晓燕, 高晓增. 右美托咪定复合罗哌卡因行胸椎旁神经阻滞在冠脉搭桥术中的应用及对术后镇痛的影响[J]. 中国临床研究, 2021, 34(7): 909-912. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCK202107010.htm
[18]	邓燕忠, 彭生, 刘佩蓉. 超声引导下椎旁神经阻滞复合全身麻醉对胸科手术血流动力学及恢复的影响[J]. 国际麻醉学与复苏杂志, 2019, 40(10): 927-930. doi: 10.3760/cma.j.issn.1673-4378.2019.10.007
[19]	吴丹, 雷李培, 张杰, 等. 连续胸椎旁神经阻滞复合全身麻醉对肺癌患者术后康复和免疫功能的影响[J]. 中华全科医学, 2019, 17(6): 1033-1036, 1041. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201906040.htm
[20]	王思嘉, 蔡宏伟. 椎旁神经阻滞和胸横肌平面阻滞在心脏换瓣手术中应用效果的对比[J]. 湖南师范大学学报(医学版), 2021, 18(2): 120-123. https://www.cnki.com.cn/Article/CJFDTOTAL-HNYG202102034.htm