全身麻醉联合区域神经阻滞对腹腔镜结直肠癌根治术患者术后恢复的影响

发布时间：2018-05-12 04:47

本文选题：区域神经阻滞 + 联合麻醉　；参考：《广西医科大学》2016年博士论文

【摘要】：第一部分全身麻醉联合区域神经阻滞对腹腔镜结直肠癌根治术患者术中的影响目的:探讨全身麻醉联合区域神经阻滞对腹腔镜辅助结直肠癌根治术患者术中麻醉药物的消耗量、应激反应及炎症反应等的影响。方法:择期行腹腔镜辅助结直肠癌根治术患者90例,ASA I~Ⅲ级,年龄32~65岁,体重46~82Kg。随机分为三组:对照组(单纯静脉麻醉组,G组)、全身麻醉联合硬膜外阻滞组(GE组)和全身麻醉联合腹横肌平面阻滞组(GT组)。三组患者全程监测BIS,记录麻醉前(T0,入室后平静10min时)、气管插管前即刻(T1)、插管后5min(T2)、切皮前即刻(T3)、切皮后5min(T4)、建立气腹后5min(T5)、术毕(T6)各时间点收缩压(SBP)、舒张压(DBP)、心率(HR),记录丙泊酚和瑞芬太尼术中的用量,ELISA法检测血浆中T0、T4、T6时间点的去甲肾上腺素(NE)、皮质醇(Cor)、白细胞介素6(IL-6)和肿瘤坏死因子-α(TNF-α)的浓度。结果:切皮后5min(T4)和术毕(T6)G组SBP、DBP、HR比GE组和GT组高(P0.05);三组患者麻醉诱导意识消失时的BIS值和丙泊酚的浓度差异无统计学意义(P0.05);与G组相比,GE组和GT组丙泊酚和瑞芬太尼总用量和单位时间消耗量减少(P0.05)。G组术中芬太尼的使用量最多(P0.05);GE组和GT组患者T4及T6时点血清NE、Cor浓度升高的幅度比G组小(P0.05);GE组、GT组病人术毕时血清IL-6、TNF-α的浓度的升高幅度明显低于G组(P0.05)。结论:全身麻醉联合区域神经阻滞可以维持较稳定的血流动力学,减少腹腔镜下结直肠癌根治术的全身麻醉药用量,减轻术中应激反应,炎症细胞因子释放减少。第二部分全身麻醉联合区域神经阻滞对腹腔镜结直肠癌根治术患者术后的影响目的:探讨全身麻醉联合区域神经阻滞对腹腔镜结直肠癌根治术患者术后应激反应、炎症反应、镇痛效果、疼痛评分以及对患者术后恢复的影响。方法:择期行腹腔镜下结直肠癌根治术患者90例,ASA I~Ⅲ级,年龄32~65岁,体重46~82Kg。随机分为三组:对照组(单纯静脉麻醉组,G组)、全身麻醉联合硬膜外阻滞组(GE组)和全身麻醉联合腹横肌平面阻滞组(GT组)。G组和GT组采用芬太尼0.5mg,氟比洛芬酯150mg,加生理盐水稀释至150ml,背景剂量3ml/h,PCA 3ml/次,锁定时间20min,进行术后镇痛;GE组采用芬太尼0.4mg,0.75%罗哌卡因30ml,加生理盐水稀释至150ml,背景剂量3ml/h,PCA 3ml/次,锁定时间20min,进行术后镇痛。观察三组患者术后自主呼吸恢复时间,苏醒时间,拔除气管导管时间,术后6h、术后24h和48h的BP、HR、VAS评分,首次按压镇痛泵时间,0~12h、12~24h、24~48h PCA的有效按压次数,术后出现恶心呕吐情况,首次肛门排气时间,下床活动时间,拔除尿管时间,随访患者术后住院时间,ELISA方法检测患者术后6h、24h、48h血浆中去甲肾上腺素(NE)、皮质醇(Cor)、白细胞介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)浓度。以及术后24h、48h血浆胃动素(MTL)浓度。结果:GT组和GE组自主呼吸恢复时间、苏醒时间和拔除气管导管时间比G组短(P0.05);与GE组和GT组相应时点比较,G组患者T6、T7、T8时点SBP、DBP、HR较GE组和GT组高(P0.05);G组术后拔管后30min、术后6h、术后12h、术后24h VAS评分较GE组和GT组高(P0.05);GE组和GT组术后镇痛泵首次按压时间较G组长,其中GE组最长(P0.05);G组术后24小时以内的PCA有效按压次数较GE组和GT组多(P0.05);GE组拔除尿管时间较G组和GT组迟(P0.05);T8、T9时点GE组和GT组NE、Cor、IL-6、TNF-α升高的幅度较G组低(P0.05)。结论:术中采用全身麻醉联合区域神经阻滞,可以改善患者术后镇痛效果,减少术后阿片类药物的用量,减少炎性细胞因子释放,抑制术后48小时以内的应激反应,对机体有积极保护作用,可以作为患者术后多模式镇痛的选择。
[Abstract]:Part one effect of general anesthesia combined with regional nerve block on laparoscopic radical resection of colorectal cancer: Objective To explore the effects of general anesthesia combined with regional nerve block on the consumption of narcotic drugs, stress response and inflammatory reaction in laparoscopic assisted radical resection of colorectal cancer. 90 patients with radical resection of colorectal cancer, ASA I~ III, age 32~65, and weight 46~82Kg. were randomly divided into three groups: control group (simple intravenous anesthesia group, G group), general anesthesia combined with epidural block group (group GE) and general anesthesia combined with abdominal transverse muscle block group (group GT). The three groups were monitored all the time, BIS before anesthesia (T0, the calm 10min after admission). Immediately after intubation (T1), 5min (T2) after intubation, immediate (T3) before cutting, 5min (T4) after skin cutting, 5min (T5) after pneumoperitoneum, systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR) at the end of operation (T6), and the dosage of propofol and remifentanil. Results: the concentrations of interleukin 6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha). Results: SBP, DBP, HR were higher in group 5min (T4) and G group than in group GE and GT group (P0.05) after skin incision. There was no statistically significant difference between the three groups and the concentration of propofol and propofol and propofol and remifentanil. The dosage and unit time consumption decreased (P0.05) in group.G with the maximum use of fentanyl (P0.05); the increase of serum NE in GE and GT patients was smaller than that in the G group (P0.05). Block can maintain stable hemodynamics, reduce the amount of general anesthetics in laparoscopic radical resection of colorectal cancer, reduce intraoperative stress response, and decrease the release of inflammatory cytokines. Second the effect of partial general anesthesia combined with regional nerve block on postoperative laparoscopic radical resection of colorectal cancer Stress response, inflammatory response, analgesic effect, pain score and effect on postoperative recovery of patients with laparoscopic radical resection of colorectal cancer. Methods: 90 patients with laparoscopic radical resection of colorectal cancer, ASA I~ III, age 32~65, and weight 46~82Kg. were randomly divided into three groups: a control group (simple vein) Anesthesia group, G group, general anesthesia combined with epidural block group (group GE) and general anesthesia combined with abdominal transverse muscle block group (group GT) group.G and GT group.G and fentanyl 0.5mg, flurbiprofen ester 150mg, saline diluted to 150ml, background dose 3ml/h, PCA 3ml/ time, locking time 20min, postoperative analgesia; group of fentanyl, 0.75% Luo Pipivacaine 30ml, diluted to 150ml with physiological saline, background dose 3ml/h, PCA 3ml/, lock time 20min, for postoperative analgesia. Observe the recovery time of spontaneous breathing after operation, recovery time, extraction of tracheal catheter time, 6h after operation, 24h and 48h after operation, HR, VAS score after operation in three groups of patients. The time of nausea and vomiting, the first time of anus and vomiting, the time of the first anus, the time of removal of the bed, the removal of the catheter time, the time of hospitalization after the patients were followed up, and the ELISA method was used to detect the concentration of norepinephrine (NE), cortisol (Cor), interleukin -6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha) in the plasma of 6h, 24h, 48h, and the concentration of the serum -6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha) after the operation. 24h, 48h plasma motilin (MTL) concentration. Results: the time of spontaneous breathing recovery in group GT and GE group was shorter than that of group G (P0.05). Compared with group GE and GT group, T6, T7, time points were higher than those of group GE and GT group. Compared with group GE and group GT (P0.05), group GE and GT group had longer compression time than G group, and GE group was the longest (P0.05), and PCA effective press times within 24 hours after operation in group G was more than that of GE group and GT group. Low (P0.05). Conclusion: the use of general anesthesia combined with regional nerve block can improve the postoperative analgesic effect, reduce the dosage of opioid drugs, reduce the release of inflammatory cytokines, inhibit the stress response within 48 hours after operation, and have a positive protective effect on the body, which can be used as a choice for postoperative multimodal analgesia.

【学位授予单位】：广西医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614;R735.34

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