多模式镇痛在开胸食管癌根治术中的临床应用及其对术后认知功能的影响

发布时间：2018-05-12 13:16

本文选题：多模式镇痛 + 开胸　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:本研究以开胸手术食管癌患者为研究对象,采用多模式镇痛模式,观察其镇痛的效果及不良反应的种类、术后认知功能障碍发生率和多项炎症因子(IL-6,S100β)的变化.方法:选择自2015年1月至2016年8月间衡水市第二人民医院择期食管癌根治术患者50例,随机数字法分为两组多模式镇痛组(M组)和对照组(C组),每组25例。所有患者采用全凭静脉麻醉。依次给予舒芬太尼0.3μg/kg,丙泊酚1-1.5 mg/kg,依托咪酯0.2-0.3 mg/kg待患者意识消失后,静脉给予顺式阿曲库铵0.2 mg/kg。麻醉维持:丙泊酚持续4~8mg/(kg·h)泵入,瑞芬太尼0.02~0.2μg/(kg·min),同时间断推注顺式阿曲库铵0.05 mg/kg,使BIS值在45~60之间,术中输液以醋酸林格氏液和羟乙基淀粉130\0.4为主,术中血压在基础血压的±30%波动。关胸前静注氟比洛芬酯50 mg。术毕停用麻醉药。关胸前由外科医生进行肋间神经阻滞,选择切口及切口上下两个肋间,分别在腋前线、腋中线及腋后线等各注射3~5 ml。M组:0.75%罗哌卡因20ml+1μg/kg右美托咪定用生理盐水稀释至40 ml;C组:给予生理盐水40 ml在相应肋间相同注射点注射。后接静脉镇痛泵,M组:舒芬太尼2μg/kg+右美托咪定1.5μg/kg+托烷司琼5 mg,生理盐水稀释至150 ml,泵速2 ml/h,PCA3 ml,间隔时间15min,镇痛时间48 h;C组:舒芬太尼2μg/kg+托烷司琼5 mg,生理盐水稀释至150 ml,其它参数设置同M组。统计患者一般情况(性别、年龄、体重、ASA分级、受教育年限、病灶位置和病理分型),围术期指标(手术时间、术后苏醒时间、术中出血量、尿量、输液量)。苏醒后4h、8h、12h、24h、48h进行视觉模拟(VAS)疼痛评分和Ramsay镇静分级。记录术后48h内PCA有效自控按压次数。手术前1天,术后6h,术后3d检测IL-6、S100β水平。术前1d、术后1d、3d、7d运用简易精神状态量表(MMSE)为患者的精神状态评分。记录不良反应发生率。结果:M组和C组性别、年龄、体重、ASA分级、受教育年限、病灶位置和病理类型比较,差异均无统计学意义(P0.05)。M组和C组患者手术时间、术后苏醒时间、术中出血量、尿量、输液量比较,差异均无统计学意义(P0.05)。苏醒后4h、8h、12h、24h、48h M组和C组患者VAS评分比较,差异均无统计学意义(P0.05)。苏醒后4h、8h、12h、24h、48h M组和C组患者Ramsay镇静分级比较,差异均无统计学意义(P0.05)。手术前1天,M组和C组IL-6、S100β水平比较差异无统计学意义(P0.05);术后6h,术后3d,M组3d IL-6、S100β水平均显著低于C组(P0.05)。术前1d,M组和C组患者MMSE评分比较差异无统计学意义(P0.05);术后1 d、3 d、7 d M组MMSE评分显著高于C组(P0.05)。术后1 d、3 d、7 d,M组POCD发生率均显著低于C组(P0.05)。M组和C组患者术后不良反应发生率比较差异无统计学意义(P0.05)。结论:多模式镇痛有助于降低开胸食管癌根治术患者术后IL-6、S100β蛋白水平,改善术后认知功能,降低术后认知功能障碍的发生率。
[Abstract]:Objective: to observe the effect of analgesia and the types of adverse reactions, the incidence of cognitive dysfunction and the changes of multiple inflammatory cytokines (IL-6S100 尾) in patients with esophageal carcinoma undergoing thoracotomy. Methods: from January 2015 to August 2016, 50 patients with esophageal cancer were randomly divided into two groups: group M (n = 25) and group C (n = 25). All patients received total intravenous anesthesia. Sufentanil (0.3 渭 g / kg), propofol (1-1.5 mg / kg), etomidate (0.2-0.3 mg/kg) were given intravenously to atracurium (0.2 mg / kg) after consciousness disappeared. Anesthesia maintenance: propofol was continuously pumped into 4~8mg/(kg, remifentanil was injected with 0. 2 渭 g/(kg / min, and cis atracurium was injected at 0. 05 mg / kg. The BIS value was between 45 and 60. The intraoperative infusion consisted mainly of Ringer acetate and hydroxyethyl starch 130\ 0.4. The blood pressure fluctuated 卤30% of the baseline blood pressure during the operation. 50 mg flurbiprofen ester was intravenously injected before closing the chest. The anesthetic was discontinued at the end of the operation. The intercostal nerve block was performed by a surgeon before closing the chest. The incision and the upper and lower intercostals were selected respectively at the axillary front. The midaxillary line and posterior axillary line were injected with 5 ml.M: 0.75% ropivacaine 20ml 1 渭 g/kg dexmetomidine diluted to 40 ml C group: 40 ml normal saline 40 ml injection at the corresponding intercostal injection point. Group M: sufentanil 2 渭 g/kg dexmetomidine 1.5 渭 g/kg tropisetron 5 mg, saline diluted to 150ml, pump speed 2 ml / h PCA3, interval 15 min, analgesia time 48 h: sufentanil 2 渭 g/kg tropisetron 5 mg, saline dilute Release to 150 ml, other parameters set the same as M group. The patients' general condition (sex, age, weight, ASA grade, years of education, location of lesion and pathological classification, perioperative time, postoperative recovery time, intraoperative bleeding volume, urine volume, transfusion volume) were statistically analyzed. The pain score and Ramsay sedation grade of visual analogue VAS were performed at 4 h, 8 h, 12 h, 24 h and 48 h after recovery. The number of effective automatic control pressing of PCA was recorded within 48 hours after operation. The level of IL 6 S 100 尾 was measured 1 day before operation, 6 hours after operation and 3 days after operation. MMSE was used to evaluate the mental state of the patients 1 day before operation and 3 days after operation. The incidence of adverse reactions was recorded. Results there were no significant differences in sex, age, body weight, ASA grade, education years, location of lesion and pathological type between the two groups. There was no significant difference in operation time, postoperative recovery time, intraoperative bleeding volume and urine volume between group M and group C. There was no significant difference in infusion volume (P 0.05). There was no significant difference in VAS score between group M and group C (P 0.05). There was no significant difference in Ramsay sedation grade between group M and group C at 12h, 12h, 12h and 48h after recovery. There was no significant difference in Ramsay sedation grade between group M and group C (P 0.05). There was no significant difference in the level of IL-6S100 尾 between group M and group C one day before operation, but the level of IL-6S100 尾 in group M was significantly lower than that in group C at 6 hours after operation and 3 days after operation. There was no significant difference in MMSE score between group M and group C 1 day before operation, but the MMSE score of group M was significantly higher than that of group C (P 0.05) 1 day after operation at 3 days and 7 days after operation. The incidence of POCD in group M was significantly lower than that in group C (P 0.05) and group C (P 0.05). There was no significant difference in the incidence of postoperative adverse reactions between group C and group C (P 0.05). Conclusion: Multi-mode analgesia is helpful to reduce the level of IL-6S100 尾, improve postoperative cognitive function and reduce the incidence of postoperative cognitive dysfunction in patients with open esophageal carcinoma after radical operation.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614;R735.1

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