本文選題：全身麻醉 + 硬膜外阻滯��； 參考：《內(nèi)蒙古大學》2014年碩士論文

【摘要】：目的：通過比較全身麻醉復合硬膜外麻醉,術后行患者自控硬膜外鎮(zhèn)痛與單純?nèi)砺樽?術后行患者自控靜脈鎮(zhèn)痛行乳腺癌根治術對患者術中血液動力學、麻醉效果、相關應激激素水平的變化(催乳素、白細胞介素-8、生長素、皮質醇、腎上腺素)以及術后恢復的影響。 方法：選擇擇期行乳腺癌改良根治手術病人80例,ASA I-II級,無硬膜外麻醉穿刺禁忌癥。隨機分為二組,每組40例。A組：全身麻醉復合硬膜外麻醉,術后行患者自控硬膜外鎮(zhèn)痛；B組：單純?nèi)砺樽?術后行患者自控靜脈鎮(zhèn)痛。各組患者年齡、體重、身高無顯著性差異。所有病人入室前30min分別給予0.5mmg阿托品進行肌肉注射,入室后常規(guī)監(jiān)測心電圖(ECG)、心率(HR)、血壓(NIBP)、脈搏血氧飽和度(Sp02)；面罩吸氧,開放靜脈通道按6m1/kg/h的速度輸注林格氏液,A組在全麻誘導前經(jīng)第2-3胸椎或第3-4胸椎椎間隙穿刺,成功后硬膜外腔注入試驗量5m1(1%利多卡因),5分鐘后經(jīng)硬膜外導管注入1%利多卡因5-8m1,使麻醉平面維持在胸2至胸9,維持量每隔1h自硬膜外導管注入1%利多卡因5-7m1,或連續(xù)硬膜外泵入5-7m11%利多卡因。兩組全麻誘導均采用：咪唑安定0.05-0.2m.g/kg,丙泊酚1.5-2.5mg/kg,維庫溴銨0.07-0.15mg/kg,芬太尼0.2-0.4mg,3分鐘后行氣管插管,術中維持用丙泊酚3-9mg/kg.h,瑞芬太尼0.1-0.3μ g/kg.min。術中依據(jù)心率血壓變化調(diào)整丙泊酚和瑞芬太尼的輸注量,間斷給予維庫溴銨維持肌肉松馳。 鎮(zhèn)痛方法：A組術畢保留硬膜外導管,連接鎮(zhèn)痛泵行自控硬膜外鎮(zhèn)痛。鎮(zhèn)痛液配方：0.77%布比卡因20m1+芬太尼0.4mg+氟哌利多5m1加生理鹽水至總量100m1,2ml/h泵入,自控追加劑量0.5m1,鎖定時間15minn B組手術結束前20min靜脈給予0.05nmg芬太尼,術畢行靜脈自控鎮(zhèn)痛,鎮(zhèn)痛藥配方：芬太尼0.015-0.020mg/kg+生理鹽水稀釋至100ml。鎮(zhèn)痛泵設定方法,負荷量5m1,2m1/h泵入,自控追加劑量1.6m1,鎖定時間16min。 記錄術后鎮(zhèn)痛的效果。同時用流式細胞儀研究了不同麻醉及術后鎮(zhèn)痛方式對惡性腫瘤患者圍麻醉期T淋巴細胞亞群,NK細胞和相關應激激素水平的影響。 結果：1.兩組患者中的血流學動力學變化為,B組的MAP和HR升高事件明顯高于A組(P0.05)。 2.在A,B各組中,每組患者的PRL的含量均為TO最低,T1最高。在T1時兩組患者中PRL的含量B組顯著高于A組(P0.05)。 3.A組患者血清中的GH的含量T1和T2的大于T0,T3和T4的(P0.05),B組患者血清中的GH的含量T2,T3大于T0,T1和T4,TO大于T1和T4(P0.05)。A組患者血清中的GH的含量小于B組。 4.A組患者血清中的IL-8的含量T0最大(P0.05)；B組沒有明顯差異。A組小于B組(P0.05)。 5.在A,B兩組之間及在A,B各組患者血清中的COR的含量也均無明顯差異(P0.05)。 6.A組患者血清中的IFN-γ的含量T3和T4的大于T0(P0.05)；B組患者血清中的IFN-γ的含量同樣為T3和T4的大于TO(P0.05)。在A,B兩組之間無明顯差異(P0.05)。 7.在A組中T1和T2時的CD3+顯著低于其它三組(P0.05)。而在B組中T1時的CD3+顯著低于其它四組(P0.05)。在A組中T各組的CD4+均沒有顯著差異(P0.05)。而在B組中,CD4+逐漸升高(P0.05)。B組顯著低于A組(P0.05)。通過檢測兩組患者中CD8+發(fā)現(xiàn)在A,B各組中,及在A,B兩組之間均沒有顯著差異(P0.05)。通過檢測兩組患者中CD4+/CD8+發(fā)現(xiàn),其中在A組中各組的CD4+/CD8+均沒有顯著差異(P0.05)。而在B組中,CD4+/CD8+在各個時間點逐漸降低(P0.05)。在T2,T3,T4時A組顯著高于B組(P0.05)。 8.其中在A組患者中NK細胞在各個時間沒有顯著差異(P0.05)。而在B組中,T2,T3,T4時間的NK細胞顯著高于T0和T1時間(P0.05)。而T3和T4時A組顯著高于B組(P0.05)。 結論：1.乳腺癌患者在麻醉前已處于應激狀態(tài)。用全麻復合硬膜外麻醉能夠更好的抑制乳腺癌改良根治手術術中的應激反應,同時減少麻醉藥的用量。 2.術后自控硬膜外鎮(zhèn)痛較靜脈自控鎮(zhèn)痛效果好,且利于患者術后早期恢發(fā)復,前者鎮(zhèn)痛方式并發(fā)癥少于后者。 3.全麻復合硬膜外麻可以更好的激發(fā)T淋巴細胞亞群和NK細胞數(shù)量的活性。
[Abstract]:Objective: To compare the hemodynamics, anesthetic effect and changes of stress hormone levels (prolactin, interleukin -8, auxin, cortisol, cortisol, cortisol, cortisol, cortisol, cortisol, cortisol, corticosteroid, corticosteroids, and on the kidney. Adenine) and the effect of postoperative recovery.
Methods: 80 patients with modified radical mastectomy for breast cancer were selected, ASA I-II grade and no contraindication to epidural anesthesia. They were randomly divided into two groups, 40.A groups in each group: general anesthesia combined with epidural anesthesia, postoperative patient controlled epidural analgesia; group B: simple general anesthesia, postoperative patient controlled intravenous analgesia. The age of the patients in each group, There was no significant difference in body weight and height. All patients were injected with 0.5mmg atropine at 30min before entering the room, followed by routine monitoring of electrocardiogram (ECG), heart rate (HR), blood pressure (NIBP), pulse oxygen saturation (Sp02), mask oxygen inhalation, open vein channel infusion at the rate of 6m1/kg/h, and group A in 2-3 chest before induction of general anesthesia. Vertebra or 3-4 thoracic vertebral space puncture, after successful epidural injection of 5m1 (1% lidocaine), 5 minutes after 5 minutes by epidural catheter injection of 1% lidocaine 5-8m1, to maintain the anesthesia level in the chest 2 to the chest 9, maintenance every 1H from epidural catheter injection 1% lidocaine 5-7m1, or continuous epidural pump into 5-7m11% lidocaine. Two general anesthesia. Two general anesthesia Induction with midazolam 0.05-0.2m.g/kg, propofol 1.5-2.5mg/kg, vecuronium 0.07-0.15mg/kg, fentanyl 0.2-0.4mg, 3 minutes after tracheal intubation, maintenance of propofol 3-9mg/kg.h, remifentanil 0.1-0.3 mu g/kg.min. to adjust the infusion of propopool and remifentanil according to the changes of heart rate and blood pressure in the operation, and give vecuronium intermittently Ammonium maintains muscle relaxation.
Analgesic method: the A group retained the epidural catheter and connected the analgesic pump for self-control epidural analgesia. The analgesic solution formula: 0.77% bupivacaine 20m1+ fentanyl 0.4mg+ fluperidol 5m1 plus physiological saline to total 100m1,2ml/h pump, self-control additional dose 0.5m1, 15minn B group 15minn B group before the end of hand operation to 0.05nmg fentanyl. Intravenous self-control analgesia, analgesic formula: fentanyl 0.015-0.020mg/kg+ saline dilution to 100ml. analgesia pump setting method, load 5m1,2m1/h pump, auto-control additional dose 1.6m1, lock time 16min.
The effects of postoperative analgesia were recorded. Flow cytometry was used to study the effects of different anesthesia and postoperative analgesia on the T lymphocyte subsets, NK cells and related stress hormone levels in the peri anaesthesia of patients with malignant tumor.
Results: 1.. The hemodynamic changes in the two groups were higher than those in group A (P0.05). The MAP and HR events in group B were significantly higher than those in group A (P0.05).
2. in A, B groups, the PRL content of each group was lowest and T1 was the highest. In T1 group, the PRL content of the two groups was significantly higher than that of A group (P0.05) in B group (PRL).
The content of GH in serum of patients in group 3.A was larger than T0, T3 and T4 (P0.05). The content of GH in serum of patients with group B was T2.
The serum level of IL-8 in group 4.A was the largest (P0.05) in T0, while there was no significant difference between B group and.A group (P0.05).
5. there was no significant difference in serum COR levels between A, B two groups and A and B groups (P0.05).
The content of IFN- gamma in serum of patients in group 6.A was greater than T0 (P0.05), and the content of IFN- y in serum of B group was also greater than TO (P0.05). There was no significant difference between the two groups.
7. in group A, the CD3+ of T1 and T2 was significantly lower than that of the other three groups (P0.05). The CD3+ in B group was significantly lower than that of the other four groups (P0.05). There was no significant difference between the two groups (P0.05). By detecting CD4+/CD8+ in the two groups of patients, there was no significant difference in CD4+/CD8+ in group A (P0.05). In group B, CD4+/CD8+ decreased gradually at every time point (P0.05).
8. in group A, there was no significant difference in NK cells at every time (P0.05). In group B, T2, T3, and T4 time NK cells were significantly higher than T0 and T1 time (P0.05).
Conclusion: 1. patients with breast cancer have been stressed before anaesthesia. General anesthesia combined with epidural anesthesia can better inhibit the stress response in modified radical mastectomy and reduce the dosage of anesthetics.
2. postoperative patient-controlled epidural analgesia is better than patient-controlled intravenous analgesia, and is conducive to early recovery and postoperative complications.
3. general anesthesia combined with epidural anesthesia can better stimulate the activity of T lymphocyte subsets and NK cell numbers.
【學位授予單位】：內(nèi)蒙古大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R737.9;R614

【參考文獻】

相關期刊論文 前10條

1 陳學新;馬漢祥;熊利澤;孟盡海;王建珍;劉紅;施偉忠;;全憑靜脈麻醉的鎮(zhèn)靜程度與血流動力學及應激反應指標的相關性研究[J];第四軍醫(yī)大學學報;2008年01期

2 王磊,黃敬孚;生長激素對免疫細胞調(diào)節(jié)作用的研究進展[J];國外醫(yī)學(兒科學分冊);2004年04期

3 王輝,鄧潔英,史軼蘩;生長激素對免疫細胞功能調(diào)節(jié)的研究進展[J];國外醫(yī)學(內(nèi)分泌學分冊);2000年02期

4 徐華;手術應激反應研究進展[J];國外醫(yī)學.麻醉學與復蘇分冊;2003年05期

5 陳平潔,陳莊,王祖昆,魏平華;生長激素分泌規(guī)律的研究概況[J];國外畜牧科技;1998年02期

6 黃偉波;;全身麻醉復合硬膜外阻滯對胸科手術病人HR及MAP的影響[J];廣西醫(yī)科大學學報;2006年05期

7 程向陽;顧爾偉;;相同麻醉深度下全麻聯(lián)合硬膜外阻滯和單純?nèi)砺樽淼谋容^[J];蚌埠醫(yī)學院學報;2013年02期

8 蔡英蔚,魏忠友,張輝;硬膜外阻滯復合全身麻醉用于胸科手術的臨床觀察[J];南京部隊醫(yī)藥;2002年05期

9 路圣成;全麻復合硬膜外阻滯用于胸科手術臨床研究[J];哈爾濱醫(yī)藥;2003年06期

10 韓雪萍;周志剛;馬君志;;依托咪酯全憑靜脈麻醉對胃癌根治術患者圍手術期血清皮質醇含量的影響[J];鄭州大學學報(醫(yī)學版);2006年02期

，

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