目的 探讨多模式镇痛对胸腔镜下肺叶切除术患者围术期镇痛和免疫功能的影响。方法 胸腔镜下肺叶切除术患者90例,男51例,女39例,年龄18~65岁,随机分为3组(每组30例),对照组:静脉自控镇痛(patient controlled intravenous analgesia,PCIA);超前镇痛组:氟比洛芬酯+PCIA;多模式镇痛组:氟比洛芬酯+胸椎旁神经阻滞(thoracic paravertebral nerve block,TPVB)+PCIA。记录术中丙泊酚、瑞芬太尼用量及舒芬太尼追加量,术后6、24、48 h疼痛视觉模拟评分(visual analogue scale,VAS)、48 h内镇痛泵按压次数,采用流式细胞仪测量麻醉前(T0)、术毕(T1)、术后24 h(T2)、术后72 h(T3)T淋巴细胞亚群(CD3+、CD4+、CD8+)与NK细胞百分比,并计算CD4+/CD8+。结果 与对照组比较,超前镇痛组和多模式镇痛组瑞芬太尼用量和舒芬太尼追加量显著减少(P<0.05),超前镇痛组术后6 h的VAS评分明显降低(P<0.05)、T1时NK细胞百分比以及CD3+、CD4+、CD4+/CD8+水平明显升高(P<0.05);多模式镇痛组术后6 h、24 h VAS评分均较低(P<0.05),镇痛泵按压次数少(P<0.05),T1、T2时NK细胞百分比、CD3+、CD4+、CD4+/CD8+水平及T3时CD3+、CD4+较高(P<0.05),术后恶心呕吐发生率低(P<0.05)。结论 胸腔镜肺叶切除术中,多模式镇痛可增强术后镇痛效果,减少围术期阿片类药物使用量,减轻免疫抑制,且不增加术后恶心呕吐发生率。其中,氟比洛芬酯联合椎旁神经阻滞围术期镇痛更完善,对免疫功能影响小。
Abstract
Objective To investigate the effects of multimodal analgesia on perioperative analgesia and immune function in patients undergoing thoracoscopic lobectomy. Methods Ninety patients with lung resection under thoracoscope (51 males, 39 females, and aged 18 to 65) were randomly and evenly divided into three groups:the control group in which patient-controlled intravenous analgesia(PCIA)was adopted, Preemptive analgesia group that received flurbiprofen axetil +PCIA, and the multimodal analgesia group where flurbiprofen axetil+thoracic paravertebral nerve block (TPVB)+ PCIA was used. The usage of intraoperative propofol, remifentanil dosage and additional dosage of sufentanil were recorded. The VAS scores at postoperative 6, 24, 48 h and the number of times the analgesia pump was pressed within 48 h were calculated. Venous blood samples were collected before anesthesia (T0), at the end of the surgery(T1), and on the morning of one day(T2) and three days (T3) after operation. The levels of T lymphocyte subsets(CD3+ , CD4+ and CD8+ ) and NK cells were measured by flow cytometry, and the ratio of CD4+/CD8+ was calculated.Results Compared with control group, the dosage of remifentanil and sufentanil supplementation in preemptive analgesia group and multimodal analgesia group were significantly decreased (P<0.05); In preemptive analgesia group,the VAS score at 6 h after surgery was significantly decreased (P<0.05), the percentage of NK cells at T1 and the levels of CD3+, CD4+ and CD4+/CD8+ were significantly increased (P<0.05); In multimodal analgesia group, the VAS scores at 6 h and 24 h after surgery were significantly decreased (P<0.05), the analgesia pump was pressed less frequently(P<0.05), the percentage of NK cells and the levels of CD3+, CD4+,CD4+/CD8+ at T1 and T2, and the levels of CD3+ and CD4+ at T3 were increased(P<0.05), and the incidence of postoperative nausea and vomiting group was lower (P<0.05).Conclusions For thoracoscopic lobectomy, multimodal analgesia can enhance postoperative analgesia, reduce perioperative opioid dosage, alleviate immunosuppression, and increase no incidence of postoperative nausea and vomiting. Besides, flurbiprofen ester combined with paravertebral nerve block had can contribute more to perioperative analgesia and immune function.
关键词
多模式镇痛 /
椎旁神经阻滞 /
超前镇痛 /
肺癌 /
免疫功能
Key words
multimodal analgesia /
paravertebral nerve block /
preemptive analgesia /
lung cancer /
immune function
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] Hirsch F R, Scagliotti G V, Mulshine J L, et al. Lung cancer: current therapies and new targeted treatments[J]. Lancet, 2017, 389(10066):299-311.
[2] O'Brien S M, Klampatsa A, Thompson J C, et al. Function of human tumor-infiltrating lymphocytes in early-stage non-small cell lung cancer[J]. Cancer Immunol Res, 2019, 7(6): 896-909.
[3] 钱可宝, 张 勇, 雷 青, 等. 三孔胸腔镜与开胸肺癌根治术对老年患者近期免疫功能的影响[J]. 中国老年学杂志, 2020,40(18):3849-3851.
[4] Plein L M, Rittner H L. Opioids and the immune system - friend or foe[J]. Br J Pharmacol, 2018,175(14):2717-2725.
[5] Hung M H, Chan K C, Liu Y J, et al. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases[J]. Medicine (Baltimore), 2015, 94(13):e727.
[6] Hiller J G, Perry N J, Poulogiannis G, et al. Perioperative events influence cancer recurrence risk after surgery [J]. Nat Rev Clin Oncol, 2018, 15(4):205-218.
[7] Tucker E M, Thompson J A, Muckler V C. Implementation of a multimodal analgesia protocol among outpatient neurosurgical patients undergoing spine surgery to improve patient outcomes[J]. J Peri Anesthesia Nurs, 2021,36(1):8-13.
[8] Fabi D W. Multimodal analgesia in the hip fracture patient[J]. J Orthop Trauma, 2016, 30(Suppl 1):S6-S11.
[9] Majumder A, Fayezizadeh M, Neupane R, et al. Benefits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair[J]. J Am Coll Surg, 2016, 222(6): 1106-1115.
[10] 王 懿, 贾 忠, 吴龙风. 氟比洛芬酯对甲状腺癌手术患者血流动力学、术后疼痛、炎性因子的影响研究[J]. 全科医学临床与教育, 2018, 16(6): 652-654.
[11] 闫彩云, 徐惠青, 徐璟琦, 等. 氟比洛芬酯超前镇痛对下肢骨科手术老年患者术后认知功能及白细胞水平的影响[J]. 广东医学, 2017, 38(6):952-954.
[12] Brown E N, Pavone K J, Naranjo M. Multimodal general anesthesia: theory and practice[J]. Anesth Analg, 2018, 127(5):1246-1258.
[13] Gelman D, Gelmanas A, Urbanaite D, et al. Role of multimodal analgesia in the evolving enhanced recovery after surgery pathways [J]. Medicina (Kaunas), 2018, 54(2): 154-157.
[14] Pace M M, Sharma B, Anderson-Dam J, et al. Ultrasound-guided thoracic paravertebral blockade: a retrospective study of the incidence of complications[J]. Anesth Analg, 2016, 122(4):1186-1191.
[15] Sabouri A S, Crawford L, Bick S K, et al. Is a retrolaminar approach to the thoracic paravertebral space possible? A human cadaveric study[J]. Reg Anesth Pain Med, 2018, 43(8):864-868.
[16] Kim R. Effects of surgery and anesthetic choice on immunosuppression and cancer recurrence[J]. J Transl Med, 2018, 16(1):8.
PDF(644 KB)
