超声引导下胸椎旁神经阻滞复合全身麻醉用于乳腺癌根治术及术后镇痛的临床效果

吕秀博 尚游

[摘要] 目的 觀察超声引导下胸椎旁神经阻滞复合全身麻醉用于乳腺癌根治术及术后镇痛的临床效果。 方法 选择2019年8月至2020年6月在我院拟行乳腺癌根治术的患者88例，按照随机数字表法分为两组，E组行气管插管静吸复合全身麻醉，T组在超声引导下实施胸椎旁神经阻滞后行喉罩静吸复合全身麻醉，患者术后镇痛方式均采用静脉自控镇痛。分别记录两组患者不同时刻血流动力学指标变化、术中舒芬太尼用量、丙泊酚用量及术后镇痛泵按压次数、术后不同时间点疼痛视觉模拟评分、术后不良反应发生情况。 结果 在麻醉后的各时间点E组的心率（HR）、平均动脉压（MAP）均显著高于T组（P<0.05）。E组在麻醉后的各时间点HR、MAP较入室时略有增加（P<0.05）。T组在麻醉后的各时间点HR、MAP较入室时显著降低（P<0.05）。切皮时、腋窝清扫时E组较T组脑电双频指数（BIS）波动较大（P<0.05）。E组术中舒芬太尼使用总量、丙泊酚用量及术后镇痛泵按压次数多于T组（P<0.05）。T组患者在术后24 h内疼痛视觉模拟评分显著低于E组（P<0.05）。E组术后不良反应总发生率显著高于T组（P<0.05）。 结论 超声引导下胸椎旁神经阻滞后行喉罩静吸复合全身麻醉可安全有效地应用于乳腺癌根治术，且能够提供较好的术后镇痛效果，不良反应总发生率显著降低。

[关键词] 超声引导;胸椎旁神经阻滞;乳腺癌根治术;术后镇痛

[Abstract] Objective To observe the clinical effect of ultrasound-guided paraspinal nerve block combined with general anesthesia for radical mastectomy and postoperative analgesia. Methods A total of 88 patients who were to undergo radical mastectomy for breast cancer in our hospital from August 2019 to June 2020 were selected. The patients were divided into two groups by random number table method. Group E was received endotracheal intubation combined with general anesthesia. Group T was received laryngeal mask combined general anesthesia after thoracic paravertebral nerve block under ultrasound guidance. The postoperative analgesia of the patients were all controlled intravenous analgesia. The changes in hemodynamic indicators at different times， the amount of sufentanil and propofol during the operation， the number of postoperative analgesia pump compressions， the visual analog score of pain at different time points after the operation， and the occurrence of postoperative adverse reactions of two groups were recorded. Results The heart rate（HR） and mean arterial pressure（MAP） of group E were significantly higher than those of group T at each time point after anesthesia（P<0.05）. In group E， HR and MAP at each time point after anesthesia were slightly higher than when entering the room（P<0.05）. The HR and MAP of the group T at each time point after anesthesia were significantly lower than when entering the room（P<0.05）. The EEG bispectral index（BIS） of the group E fluctuated more significantly during skin incision and axillary dissection than in group T（P<0.05）. The total amount of sufentanil， the amount of propofol during the operation and the number of postoperative analgesia pump compressions were more in group E than in group T（P<0.05）. The visual analog score of pain in the group T was significantly lower than that in group E within 24 hours after surgery（P<0.05）. The total incidence of postoperative adverse reactions in group E was significantly higher than in group T（P<0.05）. Conclusion Ultrasound-guided thoracic paravertebral nerve block with laryngeal mask intravenous inhalation combined with general anesthesia can be safely and effectively applied to radical mastectomy for breast cancer and can provide better postoperative analgesia. The total incidence of adverse reactions is significantly reduced.

[Key words] Ultrasound guidance; Thoracic paravertebral nerve block; Radical mastectomy; Postoperative analgesia

据临床资料统计，乳腺癌是威胁中国妇女健康最常见的恶性肿瘤之一，是中国肿瘤防治的重点，其严重危害患者的身心健康，乳腺癌的发病与遗传、环境、饮食等多种因素有关[1]。每年约有46万女性因乳腺癌去世，占癌症死亡率的25%和癌症相关死亡率的15%，部分大城市报告乳腺癌占女性恶性肿瘤之首位[2]。现在主张采用以手术为主的综合治疗，乳腺癌根治术仍然是首选方法，但其对患者创伤大，且可能导致患者术后出现慢性疼痛及顽固性疼痛，严重影响患者术后康复[3]。据相关研究报道，约40%以上接受传统全身麻醉乳腺癌根治术的患者会出现明显的急性术后疼痛[4]。目前乳腺癌根治术的麻醉多采用气管插管全麻，术后疼痛发生率高，且恶心呕吐等不良反应增加了患者的平均住院时间，阻碍了舒适化医疗及加速康复外科（Enhanced recovery after surgery，ERAS）的发展进程。……