本文選題：多模式鎮(zhèn)痛 + 開胸��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:本研究以開胸手術(shù)食管癌患者為研究對象,采用多模式鎮(zhèn)痛模式,觀察其鎮(zhèn)痛的效果及不良反應(yīng)的種類、術(shù)后認(rèn)知功能障礙發(fā)生率和多項(xiàng)炎癥因子(IL-6,S100β)的變化.方法:選擇自2015年1月至2016年8月間衡水市第二人民醫(yī)院擇期食管癌根治術(shù)患者50例,隨機(jī)數(shù)字法分為兩組多模式鎮(zhèn)痛組(M組)和對照組(C組),每組25例。所有患者采用全憑靜脈麻醉。依次給予舒芬太尼0.3μg/kg,丙泊酚1-1.5 mg/kg,依托咪酯0.2-0.3 mg/kg待患者意識消失后,靜脈給予順式阿曲庫銨0.2 mg/kg。麻醉維持:丙泊酚持續(xù)4~8mg/(kg·h)泵入,瑞芬太尼0.02~0.2μg/(kg·min),同時間斷推注順式阿曲庫銨0.05 mg/kg,使BIS值在45~60之間,術(shù)中輸液以醋酸林格氏液和羥乙基淀粉130\0.4為主,術(shù)中血壓在基礎(chǔ)血壓的±30%波動。關(guān)胸前靜注氟比洛芬酯50 mg。術(shù)畢停用麻醉藥。關(guān)胸前由外科醫(yī)生進(jìn)行肋間神經(jīng)阻滯,選擇切口及切口上下兩個肋間,分別在腋前線、腋中線及腋后線等各注射3~5 ml。M組:0.75%羅哌卡因20ml+1μg/kg右美托咪定用生理鹽水稀釋至40 ml;C組:給予生理鹽水40 ml在相應(yīng)肋間相同注射點(diǎn)注射。后接靜脈鎮(zhèn)痛泵,M組:舒芬太尼2μg/kg+右美托咪定1.5μg/kg+托烷司瓊5 mg,生理鹽水稀釋至150 ml,泵速2 ml/h,PCA3 ml,間隔時間15min,鎮(zhèn)痛時間48 h;C組:舒芬太尼2μg/kg+托烷司瓊5 mg,生理鹽水稀釋至150 ml,其它參數(shù)設(shè)置同M組。統(tǒng)計患者一般情況(性別、年齡、體重、ASA分級、受教育年限、病灶位置和病理分型),圍術(shù)期指標(biāo)(手術(shù)時間、術(shù)后蘇醒時間、術(shù)中出血量、尿量、輸液量)。蘇醒后4h、8h、12h、24h、48h進(jìn)行視覺模擬(VAS)疼痛評分和Ramsay鎮(zhèn)靜分級。記錄術(shù)后48h內(nèi)PCA有效自控按壓次數(shù)。手術(shù)前1天,術(shù)后6h,術(shù)后3d檢測IL-6、S100β水平。術(shù)前1d、術(shù)后1d、3d、7d運(yùn)用簡易精神狀態(tài)量表(MMSE)為患者的精神狀態(tài)評分。記錄不良反應(yīng)發(fā)生率。結(jié)果:M組和C組性別、年齡、體重、ASA分級、受教育年限、病灶位置和病理類型比較,差異均無統(tǒng)計學(xué)意義(P0.05)。M組和C組患者手術(shù)時間、術(shù)后蘇醒時間、術(shù)中出血量、尿量、輸液量比較,差異均無統(tǒng)計學(xué)意義(P0.05)。蘇醒后4h、8h、12h、24h、48h M組和C組患者VAS評分比較,差異均無統(tǒng)計學(xué)意義(P0.05)。蘇醒后4h、8h、12h、24h、48h M組和C組患者Ramsay鎮(zhèn)靜分級比較,差異均無統(tǒng)計學(xué)意義(P0.05)。手術(shù)前1天,M組和C組IL-6、S100β水平比較差異無統(tǒng)計學(xué)意義(P0.05);術(shù)后6h,術(shù)后3d,M組3d IL-6、S100β水平均顯著低于C組(P0.05)。術(shù)前1d,M組和C組患者M(jìn)MSE評分比較差異無統(tǒng)計學(xué)意義(P0.05);術(shù)后1 d、3 d、7 d M組MMSE評分顯著高于C組(P0.05)。術(shù)后1 d、3 d、7 d,M組POCD發(fā)生率均顯著低于C組(P0.05)。M組和C組患者術(shù)后不良反應(yīng)發(fā)生率比較差異無統(tǒng)計學(xué)意義(P0.05)。結(jié)論:多模式鎮(zhèn)痛有助于降低開胸食管癌根治術(shù)患者術(shù)后IL-6、S100β蛋白水平,改善術(shù)后認(rèn)知功能,降低術(shù)后認(rèn)知功能障礙的發(fā)生率。
[Abstract]:Objective: to observe the effect of analgesia and the types of adverse reactions, the incidence of cognitive dysfunction and the changes of multiple inflammatory cytokines (IL-6S100 尾) in patients with esophageal carcinoma undergoing thoracotomy. Methods: from January 2015 to August 2016, 50 patients with esophageal cancer were randomly divided into two groups: group M (n = 25) and group C (n = 25). All patients received total intravenous anesthesia. Sufentanil (0.3 渭 g / kg), propofol (1-1.5 mg / kg), etomidate (0.2-0.3 mg/kg) were given intravenously to atracurium (0.2 mg / kg) after consciousness disappeared. Anesthesia maintenance: propofol was continuously pumped into 4~8mg/(kg, remifentanil was injected with 0. 2 渭 g/(kg / min, and cis atracurium was injected at 0. 05 mg / kg. The BIS value was between 45 and 60. The intraoperative infusion consisted mainly of Ringer acetate and hydroxyethyl starch 130\ 0.4. The blood pressure fluctuated 鹵30% of the baseline blood pressure during the operation. 50 mg flurbiprofen ester was intravenously injected before closing the chest. The anesthetic was discontinued at the end of the operation. The intercostal nerve block was performed by a surgeon before closing the chest. The incision and the upper and lower intercostals were selected respectively at the axillary front. The midaxillary line and posterior axillary line were injected with 5 ml.M: 0.75% ropivacaine 20ml 1 渭 g/kg dexmetomidine diluted to 40 ml C group: 40 ml normal saline 40 ml injection at the corresponding intercostal injection point. Group M: sufentanil 2 渭 g/kg dexmetomidine 1.5 渭 g/kg tropisetron 5 mg, saline diluted to 150ml, pump speed 2 ml / h PCA3, interval 15 min, analgesia time 48 h: sufentanil 2 渭 g/kg tropisetron 5 mg, saline dilute Release to 150 ml, other parameters set the same as M group. The patients' general condition (sex, age, weight, ASA grade, years of education, location of lesion and pathological classification, perioperative time, postoperative recovery time, intraoperative bleeding volume, urine volume, transfusion volume) were statistically analyzed. The pain score and Ramsay sedation grade of visual analogue VAS were performed at 4 h, 8 h, 12 h, 24 h and 48 h after recovery. The number of effective automatic control pressing of PCA was recorded within 48 hours after operation. The level of IL 6 S 100 尾 was measured 1 day before operation, 6 hours after operation and 3 days after operation. MMSE was used to evaluate the mental state of the patients 1 day before operation and 3 days after operation. The incidence of adverse reactions was recorded. Results there were no significant differences in sex, age, body weight, ASA grade, education years, location of lesion and pathological type between the two groups. There was no significant difference in operation time, postoperative recovery time, intraoperative bleeding volume and urine volume between group M and group C. There was no significant difference in infusion volume (P 0.05). There was no significant difference in VAS score between group M and group C (P 0.05). There was no significant difference in Ramsay sedation grade between group M and group C at 12h, 12h, 12h and 48h after recovery. There was no significant difference in Ramsay sedation grade between group M and group C (P 0.05). There was no significant difference in the level of IL-6S100 尾 between group M and group C one day before operation, but the level of IL-6S100 尾 in group M was significantly lower than that in group C at 6 hours after operation and 3 days after operation. There was no significant difference in MMSE score between group M and group C 1 day before operation, but the MMSE score of group M was significantly higher than that of group C (P 0.05) 1 day after operation at 3 days and 7 days after operation. The incidence of POCD in group M was significantly lower than that in group C (P 0.05) and group C (P 0.05). There was no significant difference in the incidence of postoperative adverse reactions between group C and group C (P 0.05). Conclusion: Multi-mode analgesia is helpful to reduce the level of IL-6S100 尾, improve postoperative cognitive function and reduce the incidence of postoperative cognitive dysfunction in patients with open esophageal carcinoma after radical operation.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R614;R735.1

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