氟比洛芬酯对食管癌根治术后芬太尼病人自控静脉镇痛时细胞免疫功能的影响

目的 探讨氟比洛芬酯对食管癌根治术后芬太尼病人自控静脉镇痛(PCIA)时细胞免疫功能的影响.方法 择期行食管癌根治术的病人45例,ASA Ⅰ或Ⅱ级,年龄40～64岁,体重50～80 kg,随机分为3组(n=15),Ⅰ组:PCLA药物为芬太尼20μg/kg;Ⅱ组:PCIA药物为芬太尼10μg/kg+氟比洛芬酯2 mg/kg;Ⅲ组:氟比洛芬酯1 mg/kg静脉超前镇痛联合PCIA芬太尼10 μg/kg+氟比洛芬酯1 mg/kg.手术结束前10 min时静脉注射芬太尼0.05 mg并连接PCIA泵,3组PCLA泵中均加入氟哌利多2.5 mg,用生理盐水稀释为100 ml,输注速率2 ml/h,PCA剂量0.5 ml,锁定时间5 min.分别于术前30 min(T_0)、术后1、24、72 h(T1～3)时测定血浆去甲肾上腺素(NE)、促肾上腺皮质激素(ACTH)和皮质醇(Cor)的浓度,采用流式细胞仪测定淋巴细胞CD3~+,CD4~+、CD8~+水平,计算CD4~+/ED8~+.记录术后48 h内有效按压次数.结果 Ⅲ组有效按压次数少于Ⅰ组和Ⅱ组(P<0.05).与T0时比较,各组术后血浆NE、ACTH和Cor的浓度均升高,Ⅰ组和Ⅱ组,T1时、Ⅲ组T1,3时淋巴细胞CD3~+水平降低,Ⅰ组和Ⅱ组淋巴细胞CD4~+水平和CD4+/CD8~+均降低(P<0.05),淋巴细胞CD8~+水平差异无统计学意义,Ⅲ组淋巴细胞CD4~+、CD8~+水平和CD4~+/CD8~+差异无统计学意义(P>0.05);与Ⅰ组比较,Ⅱ组术后血浆ACTH浓度降低,淋巴细胞CD3~+水平升高,Ⅲ组术后血浆NE、ACTH和Cor浓度降低,T1,3时淋巴细胞CD3~+水平升高,T1,2时淋巴细胞CD4~+水平和CD4~+/CD8~+升高(P<0.05);与Ⅱ组比较,Ⅲ组术后血浆NE浓度降低,淋巴细胞CD4~+水平和CD4+/CD8~+升高(P<0.05).结论 氟比洛芬酯既可降低芬太尼PCIA用量,又可抑制术后应激反应,从而改善食管癌根治术后病人细胞免疫功能,且术前和术后联合应用氟比洛芬酯的效果更好.

Effects of flurbiprofen on cellular immune function during patient-controlled intravenous analgesia with fentanyl in patients after esophagectomy

Objective To investigate the effects of flurbiprofen on cellular immune function during patient-controlled intravenous analgesia (PCIA) with fentanyl in the patients after esophagectomy. Methods Forty-five ASA Ⅰ or Ⅱ patients, aged 40-64 yr, weighing 50-80 kg, were randomly divided into 3 groups with 15 cases each: group Ⅰ PCIA with fentanyl 20 μg/kg; group Ⅱ PCIA with fentanyl 10 μg/kg + flurbiprofen 2 mg/kg and group Ⅲ preemptive analgesia with iv flurbiprofen 1 mg/kg + PCIA with fentanyl 10 μg/kg + flurbiprofen 1 mg/kg. The patients received iv injection of fentanyl 0.05 mg 10 min before the end of operation and then were attached to a PCIA pump. Droperidol 2.5 mg was added to normal saline 100 ml in all groups. PCIA was started with background infusion rate 2 ml/h, bolus dose 0.5 ml, lockout interval 5 min. Blood samples were obtained from peripheral vein at 30 min before operation (T_0, baseline), and at 1, 24 and 72 h after operation (T1-3) for determination of the plasma concentrations of norepinephrine (NE), adrenocorticotropic hormone (ACTH), cortisol (Cor) and levels of CD3~+, CD4~+ and CD8~+ in lymphocyte. CD4~+/CD8~+ ratio was calculated. The number of successful delivered doses was recorded. Results The number of successful delivered doses was significantly less in group Ⅲ than in group Ⅰ and Ⅱ (P<0.05) . Compared with the baseline value, the plasma concentrations of NE, ACTH and Cor were significantly increased after operation in each group, the CD3~+ level was significantly decreased at T1 in group Ⅰ and Ⅱ and at T1,3 in group Ⅲ, the CD4~+ level and CD4~+/CD8~+ ratio were significantly decreased in group Ⅰ and Ⅱ (P<0.05), while no significant change in CD8~+ level in group Ⅰ and Ⅱ , and CD4~+ and CD8~+ levels and CD4~+/CD8~+ ratio in group Ⅲ was found (P > 0.05). The plasma concentration of ACTH was significantly lower and CD3~+ level significantly higher after operation in group Ⅱ , the plasma concentrations of NE, ACTH and Cor were significantly lower, CD3+ level was significantly higher at T1,3, and CD4+ level and CD4~+/CD8~+ ratio at T1,2 were significantly higher after operation in group Ⅲ than in group Ⅰ (P<0.05). The plasma concentration of NE was significantly lower, and CD4~+ level and CD4~+/CD8~+ ratio were significantly higher in group Ⅲ than in group Ⅱ (P<0.05). Conclusion Flurbiprofen can improve the cellular immune function in the patients after esophagectomy through reducing the consumption of fentanyl for PCIA and inhibiting the postoperative stress, and the efficacy is better when flurbiprofen is used before and after operation.