【摘要】 目的 探讨胸段硬膜外阻滞（TEA）和术后镇痛对开胸术后肺功能和心电图ST段的影响。方法 选取2006年9月至2014年5月在山东省青岛市中心医院择期行开胸小切口肺叶切除术肺癌合并冠状动脉粥样硬化性心脏病（冠心病）患者46例,完全随机分为全身麻醉复合TEA组和全身麻醉组,各23例。全身麻醉复合TEA组术中采用T_5-6硬膜外穿刺,术后自控硬膜外镇痛（PCEA）采用0.125%左旋布比卡因+2μ/ml芬太尼加人0.9%、氯化钠注射液至150 ml;全身麻醉组术中采用全身麻醉,术后自控静脉镇痛（PCIA）采用1μg/ml舒芬太尼加入0.9%氯化钠注射液至150 ml。比较2组术前2 d和术后6、24、48、72 h的用力肺活量（FVC）、第1秒用力呼气容积（FEV₁）、FEV₁占预计值百分比（FEV₁%）,FEV₁占FVC百分比和最大呼气中段流率、动脉血氧饱和度（SaO₂）以及术前2 d,硬膜外麻醉后30 min和术后6、24、48、72 h时的心电图肢导联ST段改变。比较2组患者术后6、24、48、72 h安静和咳嗽时的疼痛视觉模拟量表（VAS）评分、Ramsay镇静评分和患者满意度调查（PSS）评分。记录2组不良反应发生情况。结果 术前2 d,2组肺功能、心电图ST段改变及SaO₂比较,差异均无统计学意义（均P>0.05）。全身麻醉复合TEA组术后6、24、48、72 h的FVC、FEV₁和术后24、48 h的FEV₁%和SaO₂均明显高于全身麻醉组同时点[FVC:（1.8±0.7）L比（1.4±0.6）L、（2.0±0.8）L比（1.4±0.6）L、（2.1±0.8）L比（1.5±0.6）L、（2.2±0.8）L比（1.8±0.7）L,FEV.:（1.4±0.6）L/s比（1.1±0.5）L/s、（1.6±0.6）L/s比（1.2±0.6）L/s、（1.8±0.7）L/s比（1.3±0.6）L/s、（1.8±0.7）L/s比（1.4±0.6）L/s;FEV₁%:（58±9）%比（52±8）%、（61±9）%比（55±9）%;SaO₂:（95.0±1.9）%比（93.4±2.0）%、（96.0±1.7）%比（94.7±1.6）%].差异均有统计学意义（均P<0.05）。全身麻醉复合TEA组硬膜外麻醉30 min后心电图ST段改变明显优于术前2 d.术后6、24、48、72 h的心电图ST段改变均明显优于全身麻醉组同时点[（-0.046±0.01 1）mV比（-0.058±0.013）mV、（-0.047±0.013）mV比（-0.058±0.014）mV、（-0.047±0.013）mV比（-0.058±0.013）mV、（-0.047±0.012）mV比（-0.057±0.012）mV、（-0.046±0.012）mV比（-0.056±0.011）mV],差异均有统计学意义（均P<0.05）。安静时,全身麻醉复合TEA组术后24 h的VAS评分明显低于全身麻醉组,咳嗽时.全身麻醉复合TEA组术后6、24、48 h的VAS评分明显低于全身麻醉组;全身麻醉复合TEA组术后6、24、48 h的PSS评分均明显高于全身麻醉组,差异均有统计学意义（均P<0.05）。2组术后均无硬膜外血肿表现。结论 行开胸小切口肺叶切除术肺癌合并冠心病患者TEA和术后PCEA比术后PCIA可降低呼吸道阻力,改善肺功能和心肌血供,有更好的镇痛效果和患者满意度,并能减少并发症发生。更多还原

【Abstract】 Objective To evaluate the influence of thoracic epidural anesthesia（TEA） and postoperative analgesia on the lung function and ST segment in electrocanliogram（ECG） after thoracotomy.Methods Forty-six patients with lung cancer complicated with coronary heart disease who underwent elective thoracic lobectomy from September 2006 to May 2014 were randomly divided into general anesthesia combined with TEA group and general anesthesia group（23 cases in each group）.In general anesthesia combined with TEA group,the epidural space T_5-6was selected for puncture and 0.125%bupivacaine ±2 μg/ml fentanyl ±0.9%sodium chloride（totally 150 ml）were used in patient-controlled epidural analgesia（PCEA）;in general anesthesia group,1 μg/ml sufentanil ±0.9%sodium chloride（totally 150 ml） were used in patient controlled intravenous analgesia（PCIA）.The lung function[forced vital capacity（FVC）,percentage of FEV₁ and predict value（FEV₁%）,ratio of FEV₁ and FVC in percentage,maximal mid-expiratory flow curve]and oxygen saturation of arterial blood（SaO₂） 2 d before operation,6,24,48 and 72 h after operation,the changes of ST segment in ECG 2 d before operation,30 min after epidural anesthesia,6,24,48 and 72 h after operation were compai’ed between groups;the visual analogue scale（VAS） score at rest and cough,the Ramsay sedation score and patient satisfaction score（PSS） were assessed;the adverse reactions.Results Two days before operation,the lung function,ST segment and SaO₂ two days before operation were not significantly different between groups（P >0.05）.The FVC,FEV₁ 6,24,48,72 h after operation,the FEV₁%and SaO₂ 24 and 48 h after operation in general anesthesia combined with TEA group were significantly higher than those in general anesthesia group[FVC:（1.8±0.7） Lvs（1.4±0.6） L,（2.0±0.8） Lvs（1.4±0.6） L,（2.1 ±0.8） L vs（1.5 ±0.6） L,（2.2 ±0.8） L vs（1.8 ±0.7） L,FEV,:（1.4 ±0.6） L/s vs（1.1 ±0.5） L/s,（1.6±0.6） L/s vs（1.2±0.6） L/s,（1.8±0.7） L/s vs（1.3 ±0.6） L/s,（1.8±0.7） L/s vs（1.4±0.6） L/s,FEV₁%:（58 ±9）%vs（52 ±8）%,（61 ±9）%vs（55 ±9）%,SaO₂:（95.0 ± 1.9）%vs（93.4 ±2.0）%,（96.0 ± 1.7）%vs（94.7 ± 1.6）%]（all P < 0.05）.The change of ST segment 30 min after epidural anesthesia,6,24,48 and 72 h after operation in general anesthesia combined with TEA group were significantly better than those in general anesthesia group[（- 0.047 ± 0.013） mV vs（- 0.058 ± 0.014） mV,（- 0.047 ±0.013） mV vs（-0.058 ±0.013） mV,（-0.047 ±0.012） mV vs（-0.057 ±0.012） mV,（-0.046 ±0.012） mV vs（-0.056 ±0.011） mV]（all P < 0.05）.The VAS scores at rest 6 h after operation,the VAS scores at cough 6,24 and 48 h in general anesthesia combined with TEA group were significantly lower than those in general anesthesia group（all P < 0.05）.The PSS scores 6,24,48 h after operation in general anesthesia combined with TEA group was significantly higher than those in general anesthesia group（P<0.05）,and was not significantly different 72 h after operation between groups（P > 0.05）.Conclusion TEA and postoperative PCEA can effectively reduce the airway resistance,improve the lung function and myocardial blood supply,reduce the complications,and has better analgesia and higher PSS compared with PCIA in patients with lung cancer complicated with coronary heart disease undergoing thoracic lobectomy更多还原