超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用

目的探讨超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用价值。方法选择ASA I~II级，年龄18~60岁择期行开胸手术肺结核患者90例，随机分为单纯全麻组（G组）、全麻复合超声引导下胸椎旁神经阻滞组（P组）和全麻复合硬膜外阻滞组（E组），每组各30例。P组患者麻醉诱导前在超声引导下行单次胸椎旁神经阻滞，E组患者麻醉诱导前行胸段硬膜外穿刺并留置硬膜外导管。3组患者均采用静吸复合全麻维持麻醉，术毕行静脉自控镇痛。记录患者入手术室时（T0）、诱导插管前（T1）、切皮前（T2）、切皮后5 min（T3）、拔管后（T4）及术后2 h (T5)的MAP及HR；记录患者术中舒芬太尼用量、手术时间及多巴胺使用例数；记录患者术后2、6、12、24、48、72 h安静状态下和咳嗽时VAS评分及镇痛泵的按压次数。结果P组患者MAP在T3、T4时间点较G组患者有下降（P<0.05），HR在T3、T4、T5时间点较G组患者有下降（P<0.05）；E组患者MAP、HR在T1、T2、T3、T4、T5时间点较G组、P组患者均有下降（P<0.05）；P组及E组患者术中舒芬太尼用量较G组患者少（P<0.05）；E组患者多巴胺使用例数多于G组、P组患者（P<0.05），而P组患者多巴胺使用例数多于G组患者（P<0.05）；在安静和咳嗽状态下，P组患者在术后2、6、12 h评分低于G组患者（P<0.05），E组患者在术后2、6 h评分低于G组患者（P<0.05）；P组、E组患者术后镇痛泵按压次数少于G组患者（P<0.05）。结论超声引导下胸椎旁神经阻滞操作成功率高，镇痛效果确切，围术期血流动力学平稳，可减少肺结核患者开胸手术术中阿片类药物用量，增强术后早期镇痛效果，可安全有效地应用于肺结核患者开胸手术麻醉。 

Application of ultrasound-guided thoracic paravertebral nerve block in thoracotomy for pulmonary tuberculosis patients

Objective To evaluate the value of ultrasound-guided thoracic paravertebral nerve block in thoracotomy for patients with pulmonary tuberculosis. Methods Ninety cases of tuberculosis patients with ASA grade I ~ II, aged 18 ~ 60, who underwent elective thoracotomy were randomly divided into the group of general anesthesia alone(group G), the group of general anesthesia combined with ultrasound-guided thoracic paravertebral nerve block(group P) and the group of general anesthesia combined with epidural block(group E), with 30 cases in each group.Patients in group P were subjected to single paravertebral nerve block under ultrasound guidance before anesthesia induction. The patients in group E were subjected to anaesthesia induction with anterior thoracic epidural puncture and indwelling epidural catheter.All the patients in 3 groups were treated with intravenous analgesia by static aspiration combined with general anesthesia. We recorded MAP and HR of patients entering the operating room(T0), before induction of intubation(T1), before skin cutting(T2), 5 min after skin cutting(T3), after extubation(T4) and 2 h after surgery(T5). Intraoperative sufentanil dosage, operative time and number of dopamine users were recorded. VAS score and the number of compressions of the analgesic pump were recorded at 2, 6, 12, 24, 48, 72 h after the operation. Results Compared with group G, MAP of group P decreased at time points T3 and T4(P<0.05), and HR decreased at time points T3, T4 and T5(P<0.05). MAP and HR in group E decreased at time points T1, T2, T3, T4 and T5 compared with that in group G and group P(P<0.05). The intraoperative sufentanil dosage in group P and group E were lower than that in group G(P<0.05).The number of dopamine users in group E was more than that in group G and group P(P<0.05),while the number of dopamine users in group P was more than that in group G(P<0.05). In the quiet and cough condition, the score of group P was lower than that of group G at 2, 6 and 12 h after surgery(P<0.05). The score of group E was lower than that of group G at 2, 6 h after surgery(P<0.05). The number of postoperative analgesic pump presses in group P and group E were less than that in group G(P<0.05). Conclusion Ultrasound-guided thoracic paravertebral nerve block operation has a high success rate, definite analgesic effect and stable perioperative hemodynamics. It can reduce opioid dosage during thoracotomy in patients with tuberculosis and enhance the early postoperative analgesic effect. It can be safely and effectively applied to thoracotomy anesthesia in patients with tuberculosis.