本文選題：區(qū)域神經(jīng)阻滯 + 聯(lián)合麻醉　； 參考：《廣西醫(yī)科大學(xué)》2016年博士論文

【摘要】：第一部分全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯對(duì)腹腔鏡結(jié)直腸癌根治術(shù)患者術(shù)中的影響目的:探討全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯對(duì)腹腔鏡輔助結(jié)直腸癌根治術(shù)患者術(shù)中麻醉藥物的消耗量、應(yīng)激反應(yīng)及炎癥反應(yīng)等的影響。方法:擇期行腹腔鏡輔助結(jié)直腸癌根治術(shù)患者90例,ASA I~Ⅲ級(jí),年齡32~65歲,體重46~82Kg。隨機(jī)分為三組:對(duì)照組(單純靜脈麻醉組,G組)、全身麻醉聯(lián)合硬膜外阻滯組(GE組)和全身麻醉聯(lián)合腹橫肌平面阻滯組(GT組)。三組患者全程監(jiān)測(cè)BIS,記錄麻醉前(T0,入室后平靜10min時(shí))、氣管插管前即刻(T1)、插管后5min(T2)、切皮前即刻(T3)、切皮后5min(T4)、建立氣腹后5min(T5)、術(shù)畢(T6)各時(shí)間點(diǎn)收縮壓(SBP)、舒張壓(DBP)、心率(HR),記錄丙泊酚和瑞芬太尼術(shù)中的用量,ELISA法檢測(cè)血漿中T0、T4、T6時(shí)間點(diǎn)的去甲腎上腺素(NE)、皮質(zhì)醇(Cor)、白細(xì)胞介素6(IL-6)和腫瘤壞死因子-α(TNF-α)的濃度。結(jié)果:切皮后5min(T4)和術(shù)畢(T6)G組SBP、DBP、HR比GE組和GT組高(P0.05);三組患者麻醉誘導(dǎo)意識(shí)消失時(shí)的BIS值和丙泊酚的濃度差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05);與G組相比,GE組和GT組丙泊酚和瑞芬太尼總用量和單位時(shí)間消耗量減少(P0.05)。G組術(shù)中芬太尼的使用量最多(P0.05);GE組和GT組患者T4及T6時(shí)點(diǎn)血清NE、Cor濃度升高的幅度比G組小(P0.05);GE組、GT組病人術(shù)畢時(shí)血清IL-6、TNF-α的濃度的升高幅度明顯低于G組(P0.05)。結(jié)論:全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯可以維持較穩(wěn)定的血流動(dòng)力學(xué),減少腹腔鏡下結(jié)直腸癌根治術(shù)的全身麻醉藥用量,減輕術(shù)中應(yīng)激反應(yīng),炎癥細(xì)胞因子釋放減少。第二部分全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯對(duì)腹腔鏡結(jié)直腸癌根治術(shù)患者術(shù)后的影響目的:探討全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯對(duì)腹腔鏡結(jié)直腸癌根治術(shù)患者術(shù)后應(yīng)激反應(yīng)、炎癥反應(yīng)、鎮(zhèn)痛效果、疼痛評(píng)分以及對(duì)患者術(shù)后恢復(fù)的影響。方法:擇期行腹腔鏡下結(jié)直腸癌根治術(shù)患者90例,ASA I~Ⅲ級(jí),年齡32~65歲,體重46~82Kg。隨機(jī)分為三組:對(duì)照組(單純靜脈麻醉組,G組)、全身麻醉聯(lián)合硬膜外阻滯組(GE組)和全身麻醉聯(lián)合腹橫肌平面阻滯組(GT組)。G組和GT組采用芬太尼0.5mg,氟比洛芬酯150mg,加生理鹽水稀釋至150ml,背景劑量3ml/h,PCA 3ml/次,鎖定時(shí)間20min,進(jìn)行術(shù)后鎮(zhèn)痛;GE組采用芬太尼0.4mg,0.75%羅哌卡因30ml,加生理鹽水稀釋至150ml,背景劑量3ml/h,PCA 3ml/次,鎖定時(shí)間20min,進(jìn)行術(shù)后鎮(zhèn)痛。觀察三組患者術(shù)后自主呼吸恢復(fù)時(shí)間,蘇醒時(shí)間,拔除氣管導(dǎo)管時(shí)間,術(shù)后6h、術(shù)后24h和48h的BP、HR、VAS評(píng)分,首次按壓鎮(zhèn)痛泵時(shí)間,0~12h、12~24h、24~48h PCA的有效按壓次數(shù),術(shù)后出現(xiàn)惡心嘔吐情況,首次肛門排氣時(shí)間,下床活動(dòng)時(shí)間,拔除尿管時(shí)間,隨訪患者術(shù)后住院時(shí)間,ELISA方法檢測(cè)患者術(shù)后6h、24h、48h血漿中去甲腎上腺素(NE)、皮質(zhì)醇(Cor)、白細(xì)胞介素-6(IL-6)和腫瘤壞死因子-α(TNF-α)濃度。以及術(shù)后24h、48h血漿胃動(dòng)素(MTL)濃度。結(jié)果:GT組和GE組自主呼吸恢復(fù)時(shí)間、蘇醒時(shí)間和拔除氣管導(dǎo)管時(shí)間比G組短(P0.05);與GE組和GT組相應(yīng)時(shí)點(diǎn)比較,G組患者T6、T7、T8時(shí)點(diǎn)SBP、DBP、HR較GE組和GT組高(P0.05);G組術(shù)后拔管后30min、術(shù)后6h、術(shù)后12h、術(shù)后24h VAS評(píng)分較GE組和GT組高(P0.05);GE組和GT組術(shù)后鎮(zhèn)痛泵首次按壓時(shí)間較G組長(zhǎng),其中GE組最長(zhǎng)(P0.05);G組術(shù)后24小時(shí)以內(nèi)的PCA有效按壓次數(shù)較GE組和GT組多(P0.05);GE組拔除尿管時(shí)間較G組和GT組遲(P0.05);T8、T9時(shí)點(diǎn)GE組和GT組NE、Cor、IL-6、TNF-α升高的幅度較G組低(P0.05)。結(jié)論:術(shù)中采用全身麻醉聯(lián)合區(qū)域神經(jīng)阻滯,可以改善患者術(shù)后鎮(zhèn)痛效果,減少術(shù)后阿片類藥物的用量,減少炎性細(xì)胞因子釋放,抑制術(shù)后48小時(shí)以內(nèi)的應(yīng)激反應(yīng),對(duì)機(jī)體有積極保護(hù)作用,可以作為患者術(shù)后多模式鎮(zhèn)痛的選擇。
[Abstract]:Part one effect of general anesthesia combined with regional nerve block on laparoscopic radical resection of colorectal cancer: Objective To explore the effects of general anesthesia combined with regional nerve block on the consumption of narcotic drugs, stress response and inflammatory reaction in laparoscopic assisted radical resection of colorectal cancer. 90 patients with radical resection of colorectal cancer, ASA I~ III, age 32~65, and weight 46~82Kg. were randomly divided into three groups: control group (simple intravenous anesthesia group, G group), general anesthesia combined with epidural block group (group GE) and general anesthesia combined with abdominal transverse muscle block group (group GT). The three groups were monitored all the time, BIS before anesthesia (T0, the calm 10min after admission). Immediately after intubation (T1), 5min (T2) after intubation, immediate (T3) before cutting, 5min (T4) after skin cutting, 5min (T5) after pneumoperitoneum, systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR) at the end of operation (T6), and the dosage of propofol and remifentanil. Results: the concentrations of interleukin 6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha). Results: SBP, DBP, HR were higher in group 5min (T4) and G group than in group GE and GT group (P0.05) after skin incision. There was no statistically significant difference between the three groups and the concentration of propofol and propofol and propofol and remifentanil. The dosage and unit time consumption decreased (P0.05) in group.G with the maximum use of fentanyl (P0.05); the increase of serum NE in GE and GT patients was smaller than that in the G group (P0.05). Block can maintain stable hemodynamics, reduce the amount of general anesthetics in laparoscopic radical resection of colorectal cancer, reduce intraoperative stress response, and decrease the release of inflammatory cytokines. Second the effect of partial general anesthesia combined with regional nerve block on postoperative laparoscopic radical resection of colorectal cancer Stress response, inflammatory response, analgesic effect, pain score and effect on postoperative recovery of patients with laparoscopic radical resection of colorectal cancer. Methods: 90 patients with laparoscopic radical resection of colorectal cancer, ASA I~ III, age 32~65, and weight 46~82Kg. were randomly divided into three groups: a control group (simple vein) Anesthesia group, G group, general anesthesia combined with epidural block group (group GE) and general anesthesia combined with abdominal transverse muscle block group (group GT) group.G and GT group.G and fentanyl 0.5mg, flurbiprofen ester 150mg, saline diluted to 150ml, background dose 3ml/h, PCA 3ml/ time, locking time 20min, postoperative analgesia; group of fentanyl, 0.75% Luo Pipivacaine 30ml, diluted to 150ml with physiological saline, background dose 3ml/h, PCA 3ml/, lock time 20min, for postoperative analgesia. Observe the recovery time of spontaneous breathing after operation, recovery time, extraction of tracheal catheter time, 6h after operation, 24h and 48h after operation, HR, VAS score after operation in three groups of patients. The time of nausea and vomiting, the first time of anus and vomiting, the time of the first anus, the time of removal of the bed, the removal of the catheter time, the time of hospitalization after the patients were followed up, and the ELISA method was used to detect the concentration of norepinephrine (NE), cortisol (Cor), interleukin -6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha) in the plasma of 6h, 24h, 48h, and the concentration of the serum -6 (IL-6) and tumor necrosis factor - alpha (TNF- alpha) after the operation. 24h, 48h plasma motilin (MTL) concentration. Results: the time of spontaneous breathing recovery in group GT and GE group was shorter than that of group G (P0.05). Compared with group GE and GT group, T6, T7, time points were higher than those of group GE and GT group. Compared with group GE and group GT (P0.05), group GE and GT group had longer compression time than G group, and GE group was the longest (P0.05), and PCA effective press times within 24 hours after operation in group G was more than that of GE group and GT group. Low (P0.05). Conclusion: the use of general anesthesia combined with regional nerve block can improve the postoperative analgesic effect, reduce the dosage of opioid drugs, reduce the release of inflammatory cytokines, inhibit the stress response within 48 hours after operation, and have a positive protective effect on the body, which can be used as a choice for postoperative multimodal analgesia.

【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R614;R735.34

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