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硬膜外阻滞复合全麻对胸科手术患者血浆内皮素、前列腺素和血栓素的影响
| 【Abstract】Objective To observe the effects of epidural block combined with general anesthesia on plasma levels of Endothelin(ET) and 6-keto-PGF1a (PGF1a)and TXB2 in patients undergoing thoracic surgery. Methods Twenty patients, ASA physical status ⅠorⅡ, undergoing thoracic surgery, were randomly divided into two groups: group I (n=10) were received total intravenous general anesthesia; group Ⅱ(n=10) were received epidural block combined with general anesthesia. ECG, HR, SBP, DBP, MAP, SpO2 and PetCO2 were continuously monitored. Venous samples were taken at five time points of before anesthesia, after induction, after open chest , one hour after incision and at the end of surgery to measure contents of ET , PGF1a and TXB2 by radioimmumoassay. Results (1) The levels of plasma ET had significantly increased at one hour after incision and the end of surgery in group Ⅰ (p<0.05 or 0.01), but significantly decreased (P<0.05) after intubation and no statistical difference after open chest in groupⅡ. (2) The levels of plasma PGF1a had increased markedly after induction in two groups and significantly greater in groupⅡ(P<0.05 or 0.01), but no statistical difference in group Ⅰand significantly higher in groupⅡafter incision. The levels of plasma TXB2 had decreased markedly after induction in two groups and significantly lower in groupⅡ(P<0.05 or <0.01), restored afterincision and increased at the end of surgery in groupⅠ, but significantly lower than before anesthesia in group Ⅱ. (3) Rates of PGF1a and TXB2 had increased markedly after induction in two groups and significantly greater in groupⅡ(P<0.05 or 0.01), but no statistical difference in group Ⅰand significantly greater than before anesthesia and groupⅠin groupⅡafter incision (P<0.05 or 0.01). Conclusions Epidural block combined with general anesthesia could better controlled plasma levels of ET,PGF1a and TXB2 than total intravenous general anesthesia in patients undergoing thoracic surgery. 【key words】Surgery, thoracic; Anesthesia, epidural/general; Endothelin; Prostaglandin; Thromboxane 胸部手术后肺部并发症是临床关注重点。有报道内皮素(ET)、前列腺素和血栓素在肺微血管收缩、白细胞局部扣押、血小板聚集等平衡方面起重要作用[1-4]。本研究拟观察硬膜外阻滞复合全麻对胸科手术患者血浆ET、6-酮-前列腺素1a(6-keto-PGF1a，PGF1a)和血栓素B2(TXB2)的影响。 1 资料与方法 1.1 研究对象 选择ASAI～II级择期胸科手术病人20例，其中食道根治术18例、肺叶切除术2例。术前无明显心血管疾病史及慢性阻塞性肺疾患史，肝肾功能均正常。随机分为两组，每组10例：Ⅰ组为静脉全麻组，年龄35～72岁（58.2±10.2岁），体重55～82 Kg（64.5±9.5 Kg），男4例，女6例；II组为硬膜外阻滞复合静脉全麻组，年龄36～73岁（59.1±11.5岁），体重54～85 Kg（63.6±6.5 Kg），男女各5例。术中输注羟乙基淀粉500ml和乳酸钠林格氏液5~10ml/(kg•h)，两组手术时间（200.2±21.3 min、215.1±27.8 min）、术中失血量（485.7±66.8ml、460.9±45.3 ml）相似，均未输血。 1.2 麻醉方法 术前30min肌注苯巴比妥钠0.1g，阿托品0.5mg。入室后Ⅰ组行静脉全麻，诱导用咪唑安定0.1mg/kg、丙泊酚1mg/kg、芬太尼3-4g/kg、琥珀胆碱2mg/kg，肌松后插入气管导管，接麻醉机行机械通气，潮气量8~12ml/kg、呼吸频率10~12次/min。维持PETCO24.5～6.0kPa。持续输注丙泊酚60~70g/(kg•min)和维库溴铵1～2g/(kg•min)维持麻醉。间断追加芬太尼镇痛。Ⅱ组入室后先行T6-7硬膜外穿刺置管，注入1.5%利多卡因4ml试验量后行全麻诱导，诱导和维持同Ⅰ组，并按需追加硬膜外局麻药（0.8%利多卡因+0.30%布比卡因）。关胸后停肌松剂，缝皮时丙泊酚减量并停用。术毕有自主呼吸后静注新斯的明和阿托品拮抗，待通气满意、病人清醒、吞咽反射恢复后拔除气管导管。 1.3 监测指标 用惠普多功能监测仪连续监测ECG、HR、SBP、DBP、MAP、SpO2。于麻醉前(T1)、诱导后(T2)、 开胸后(T3)、手术1小时（T4）、术毕(T5)五个时点，在非输液侧肢体采静脉血5ml，2ml注入含 EDTA2Na和抑肽酶的试管，另3ml加入含有EDTA2Na和消炎痛的试管，4℃离心3000rpm，10min；取上清液，-26℃保存。用东雅免疫所的放免药盒测定血浆中ET、6-keto-PGF1a和TXB2的含量。 1.4 统计学处理 数据以 X±s表示，用SPSS10.0统计软件处理，组内比较采用两因素方差分析，组间比较采用成组设计的t 检验，P<0.05认为差异有统计学意义。 2 结 果 2.1 血浆ET、6-keto-PGF1a和TXB2含量变化 (表1) （1）ET在Ⅰ组开胸后逐渐升高，手术1小时和术毕明显升高(P<0.05或<0.01)，而Ⅱ组诱导后明显降低 (P<0.05)，开胸后无明显变化。（2）血浆6-keto-PGF1a在诱导后均升高，Ⅱ组升高更明显(P<0.05)，手术后I组无明显变化，但Ⅱ组仍较高(P<0.05)；TXB2在诱导后均下降，Ⅱ组下降更明显(P<0.05)，手术后I组渐恢复，且术毕明显升高，而Ⅱ组均低于术前（P<0.01或<0.05）；（3）6-keto-PGF1a 与TXB2比值（K/T值）：诱导后两组均升高，Ⅱ组显著增高(P <0.01)；手术后I组渐下降，而Ⅱ组术中术毕仍明显高于术前，与I组比较亦有显著差异(P<0.01或0.05)。
注：组内与T1比较：ET：I组q=3.19,* P<0.05, q≥4.90,**P<0.01, II组q=3.62, * P<0.05, PGF1a：I组q=3.51,*P<0.05, II组q=3.42, 3.31, 3.35 *P<0.05, q≥5.19, **P<0.01, TXB2：I组q=3.07, *P<0.05, q≥5.51,**P<0.01, II组q=3.52, 3.71 * P<0.05, q≥5.25,**P<0.01，K/T：I组q=3.83 ,* P<0.05, II组q=3.46, 3.91, * P<0.05, q≥5.58, ** P<0.01； 组间比较：ET：t=2.433,+ P<0.05, t=3.055,++ P<0.01, PGF1a：t=2.318,+ P<0.05, TXB2：t=2.482,+ P<0.05, t=2.988,++ P<0.01, K/T：t=2.483, 2.568, 2.553, + P<0.05, t=3.015,++ P<0.01 3讨 论 参 考 文 献 [1] KuklinV，Kirov M，Sovershaev M，et al .Tezosentan induced attenuation of lung injury in endotoxemic sheep is associated with reduced activation of protein kinase C.Crit Care，2005，9(3): R211-217. [2] KuklinV，Sovershaev M，Andreasen T，et al. Tezostan reduces the microvascular filtration coefficient in isolated lung from rats subjected to cecum ligation and puncture. Crit Care，2005, 9(6):R677-686. [3] 赵业婷,姚只巧,赵金恒.内皮素与急性呼吸窘迫综合征.中国职业医学,2005,32(6): 49-51. [4] 翁翠莲,汪建新,薛庆亮,等.美洛昔康对兔急性肺损伤保护作用的研究.中国急救医学, 2006, 26(11):822-824. [5] 沈通桃,傅诚章,刘存明,等.地氟醚、异氟醚和丙泊酚对上腹部手术患者血浆内皮素和心钠素的影响. 中华麻醉学杂志, 2002, 22(7):412-415. [6] Boldt J, Uphus D, Hempelmann G.. Changes in regulators of the circulation in the patients undergoing surgery. Br J Anaesth, 1997,79(6): 733-739. [7] 沈通桃,傅诚章,刘存明,等.不同麻醉方式对上腹部手术患者血浆前列腺素和血栓素的影响. 现代医学, 2002,30(2):80-82. [8] Fillinger MP，Yeager MP，Dodds MF，et a1．Epidural anesthesia and analgesia：effects on recovery from cardiac surgery. Cardiothorac Vasc Anesth,2002,16(1):15-20． [9] Flood P, Krasowski MD. Intravenous anesthetic differentially modulate ligand-gated ion channels. Anesthesiology,2000,92(5):1418-1425. |
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