不同麻醉及镇痛方法对乳腺癌手术患者细胞免疫功能及激素水平的影响

发布时间：2018-06-05 14:42

本文选题：全身麻醉 + 硬膜外阻滞　；参考：《内蒙古大学》2014年硕士论文

【摘要】：目的：通过比较全身麻醉复合硬膜外麻醉,术后行患者自控硬膜外镇痛与单纯全身麻醉,术后行患者自控静脉镇痛行乳腺癌根治术对患者术中血液动力学、麻醉效果、相关应激激素水平的变化(催乳素、白细胞介素-8、生长素、皮质醇、肾上腺素)以及术后恢复的影响。方法：选择择期行乳腺癌改良根治手术病人80例,ASA I-II级,无硬膜外麻醉穿刺禁忌症。随机分为二组,每组40例。A组：全身麻醉复合硬膜外麻醉,术后行患者自控硬膜外镇痛；B组：单纯全身麻醉,术后行患者自控静脉镇痛。各组患者年龄、体重、身高无显著性差异。所有病人入室前30min分别给予0.5mmg阿托品进行肌肉注射,入室后常规监测心电图(ECG)、心率(HR)、血压(NIBP)、脉搏血氧饱和度(Sp02)；面罩吸氧,开放静脉通道按6m1/kg/h的速度输注林格氏液,A组在全麻诱导前经第2-3胸椎或第3-4胸椎椎间隙穿刺,成功后硬膜外腔注入试验量5m1(1%利多卡因),5分钟后经硬膜外导管注入1%利多卡因5-8m1,使麻醉平面维持在胸2至胸9,维持量每隔1h自硬膜外导管注入1%利多卡因5-7m1,或连续硬膜外泵入5-7m11%利多卡因。两组全麻诱导均采用：咪唑安定0.05-0.2m.g/kg,丙泊酚1.5-2.5mg/kg,维库溴铵0.07-0.15mg/kg,芬太尼0.2-0.4mg,3分钟后行气管插管,术中维持用丙泊酚3-9mg/kg.h,瑞芬太尼0.1-0.3μ g/kg.min。术中依据心率血压变化调整丙泊酚和瑞芬太尼的输注量,间断给予维库溴铵维持肌肉松驰。镇痛方法：A组术毕保留硬膜外导管,连接镇痛泵行自控硬膜外镇痛。镇痛液配方：0.77%布比卡因20m1+芬太尼0.4mg+氟哌利多5m1加生理盐水至总量100m1,2ml/h泵入,自控追加剂量0.5m1,锁定时间15minn B组手术结束前20min静脉给予0.05nmg芬太尼,术毕行静脉自控镇痛,镇痛药配方：芬太尼0.015-0.020mg/kg+生理盐水稀释至100ml。镇痛泵设定方法,负荷量5m1,2m1/h泵入,自控追加剂量1.6m1,锁定时间16min。记录术后镇痛的效果。同时用流式细胞仪研究了不同麻醉及术后镇痛方式对恶性肿瘤患者围麻醉期T淋巴细胞亚群,NK细胞和相关应激激素水平的影响。结果：1.两组患者中的血流学动力学变化为,B组的MAP和HR升高事件明显高于A组(P0.05)。 2.在A,B各组中,每组患者的PRL的含量均为TO最低,T1最高。在T1时两组患者中PRL的含量B组显著高于A组(P0.05)。 3.A组患者血清中的GH的含量T1和T2的大于T0,T3和T4的(P0.05),B组患者血清中的GH的含量T2,T3大于T0,T1和T4,TO大于T1和T4(P0.05)。A组患者血清中的GH的含量小于B组。 4.A组患者血清中的IL-8的含量T0最大(P0.05)；B组没有明显差异。A组小于B组(P0.05)。 5.在A,B两组之间及在A,B各组患者血清中的COR的含量也均无明显差异(P0.05)。 6.A组患者血清中的IFN-γ的含量T3和T4的大于T0(P0.05)；B组患者血清中的IFN-γ的含量同样为T3和T4的大于TO(P0.05)。在A,B两组之间无明显差异(P0.05)。 7.在A组中T1和T2时的CD3+显著低于其它三组(P0.05)。而在B组中T1时的CD3+显著低于其它四组(P0.05)。在A组中T各组的CD4+均没有显著差异(P0.05)。而在B组中,CD4+逐渐升高(P0.05)。B组显著低于A组(P0.05)。通过检测两组患者中CD8+发现在A,B各组中,及在A,B两组之间均没有显著差异(P0.05)。通过检测两组患者中CD4+/CD8+发现,其中在A组中各组的CD4+/CD8+均没有显著差异(P0.05)。而在B组中,CD4+/CD8+在各个时间点逐渐降低(P0.05)。在T2,T3,T4时A组显著高于B组(P0.05)。 8.其中在A组患者中NK细胞在各个时间没有显著差异(P0.05)。而在B组中,T2,T3,T4时间的NK细胞显著高于T0和T1时间(P0.05)。而T3和T4时A组显著高于B组(P0.05)。结论：1.乳腺癌患者在麻醉前已处于应激状态。用全麻复合硬膜外麻醉能够更好的抑制乳腺癌改良根治手术术中的应激反应,同时减少麻醉药的用量。 2.术后自控硬膜外镇痛较静脉自控镇痛效果好,且利于患者术后早期恢发复,前者镇痛方式并发症少于后者。 3.全麻复合硬膜外麻可以更好的激发T淋巴细胞亚群和NK细胞数量的活性。
[Abstract]:Objective: To compare the hemodynamics, anesthetic effect and changes of stress hormone levels (prolactin, interleukin -8, auxin, cortisol, cortisol, cortisol, cortisol, cortisol, cortisol, cortisol, corticosteroid, corticosteroids, and on the kidney. Adenine) and the effect of postoperative recovery.
Methods: 80 patients with modified radical mastectomy for breast cancer were selected, ASA I-II grade and no contraindication to epidural anesthesia. They were randomly divided into two groups, 40.A groups in each group: general anesthesia combined with epidural anesthesia, postoperative patient controlled epidural analgesia; group B: simple general anesthesia, postoperative patient controlled intravenous analgesia. The age of the patients in each group, There was no significant difference in body weight and height. All patients were injected with 0.5mmg atropine at 30min before entering the room, followed by routine monitoring of electrocardiogram (ECG), heart rate (HR), blood pressure (NIBP), pulse oxygen saturation (Sp02), mask oxygen inhalation, open vein channel infusion at the rate of 6m1/kg/h, and group A in 2-3 chest before induction of general anesthesia. Vertebra or 3-4 thoracic vertebral space puncture, after successful epidural injection of 5m1 (1% lidocaine), 5 minutes after 5 minutes by epidural catheter injection of 1% lidocaine 5-8m1, to maintain the anesthesia level in the chest 2 to the chest 9, maintenance every 1H from epidural catheter injection 1% lidocaine 5-7m1, or continuous epidural pump into 5-7m11% lidocaine. Two general anesthesia. Two general anesthesia Induction with midazolam 0.05-0.2m.g/kg, propofol 1.5-2.5mg/kg, vecuronium 0.07-0.15mg/kg, fentanyl 0.2-0.4mg, 3 minutes after tracheal intubation, maintenance of propofol 3-9mg/kg.h, remifentanil 0.1-0.3 mu g/kg.min. to adjust the infusion of propopool and remifentanil according to the changes of heart rate and blood pressure in the operation, and give vecuronium intermittently Ammonium maintains muscle relaxation.
Analgesic method: the A group retained the epidural catheter and connected the analgesic pump for self-control epidural analgesia. The analgesic solution formula: 0.77% bupivacaine 20m1+ fentanyl 0.4mg+ fluperidol 5m1 plus physiological saline to total 100m1,2ml/h pump, self-control additional dose 0.5m1, 15minn B group 15minn B group before the end of hand operation to 0.05nmg fentanyl. Intravenous self-control analgesia, analgesic formula: fentanyl 0.015-0.020mg/kg+ saline dilution to 100ml. analgesia pump setting method, load 5m1,2m1/h pump, auto-control additional dose 1.6m1, lock time 16min.
The effects of postoperative analgesia were recorded. Flow cytometry was used to study the effects of different anesthesia and postoperative analgesia on the T lymphocyte subsets, NK cells and related stress hormone levels in the peri anaesthesia of patients with malignant tumor.
Results: 1.. The hemodynamic changes in the two groups were higher than those in group A (P0.05). The MAP and HR events in group B were significantly higher than those in group A (P0.05).
2. in A, B groups, the PRL content of each group was lowest and T1 was the highest. In T1 group, the PRL content of the two groups was significantly higher than that of A group (P0.05) in B group (PRL).
The content of GH in serum of patients in group 3.A was larger than T0, T3 and T4 (P0.05). The content of GH in serum of patients with group B was T2.
The serum level of IL-8 in group 4.A was the largest (P0.05) in T0, while there was no significant difference between B group and.A group (P0.05).
5. there was no significant difference in serum COR levels between A, B two groups and A and B groups (P0.05).
The content of IFN- gamma in serum of patients in group 6.A was greater than T0 (P0.05), and the content of IFN- y in serum of B group was also greater than TO (P0.05). There was no significant difference between the two groups.
7. in group A, the CD3+ of T1 and T2 was significantly lower than that of the other three groups (P0.05). The CD3+ in B group was significantly lower than that of the other four groups (P0.05). There was no significant difference between the two groups (P0.05). By detecting CD4+/CD8+ in the two groups of patients, there was no significant difference in CD4+/CD8+ in group A (P0.05). In group B, CD4+/CD8+ decreased gradually at every time point (P0.05).
8. in group A, there was no significant difference in NK cells at every time (P0.05). In group B, T2, T3, and T4 time NK cells were significantly higher than T0 and T1 time (P0.05).
Conclusion: 1. patients with breast cancer have been stressed before anaesthesia. General anesthesia combined with epidural anesthesia can better inhibit the stress response in modified radical mastectomy and reduce the dosage of anesthetics.
2. postoperative patient-controlled epidural analgesia is better than patient-controlled intravenous analgesia, and is conducive to early recovery and postoperative complications.
3. general anesthesia combined with epidural anesthesia can better stimulate the activity of T lymphocyte subsets and NK cell numbers.
【学位授予单位】：内蒙古大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R737.9;R614

【参考文献】