靜脈全麻復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯對(duì)老年甲狀腺手術(shù)患者術(shù)后惡心嘔吐的影響

朱煒 楊許麗 崔士和 周路陽(yáng)

靜脈全麻復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯對(duì)老年甲狀腺手術(shù)患者術(shù)后惡心嘔吐的影響

朱煒 楊許麗 崔士和 周路陽(yáng)

目的 評(píng)估和比較雙側(cè)頸叢淺神經(jīng)阻滯聯(lián)合靜脈全麻和單純靜脈全麻對(duì)老年甲狀腺手術(shù)患者術(shù)后惡心嘔吐(postoperative nausea and vomiting,PONV)發(fā)生率的影響。 方法 選擇全麻下?lián)衿谛屑谞钕偈中g(shù)的老年患者60例,隨機(jī)分為A、B2組,每組30例。A組患者實(shí)施單純靜脈麻醉,常規(guī)快速誘導(dǎo)。B組在麻醉誘導(dǎo)平穩(wěn)10 min后實(shí)施雙側(cè)頸叢淺神經(jīng)阻滯。觀察并記錄2組術(shù)后12 h內(nèi)、12～24 h、24～48 h患者PONV的發(fā)生情況以及相同時(shí)點(diǎn)的疼痛評(píng)分(VAS評(píng)分)和意識(shí)評(píng)分(Ramsay評(píng)分)。 結(jié)果 A組術(shù)后12 h內(nèi)、12～24 h PONV發(fā)生率明顯高于B組(P<0.05),術(shù)后24～48 h 2組PONV發(fā)生率差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。A組術(shù)后各時(shí)點(diǎn)VAS評(píng)分均顯著高于B組(P<0.05),2組間Ramsay評(píng)分差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。 結(jié)論 靜脈全麻復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯對(duì)降低老年甲狀腺手術(shù)患者術(shù)后PONV的發(fā)生具有較好的作用。

甲狀腺; 頸淺叢阻滯; 靜脈全麻; 惡心嘔吐; 老年人

術(shù)后惡心嘔吐(postoperative nausea and vomiting,PONV)是影響老年患者術(shù)后舒適度及恢復(fù)的重要因素之一[1-2]。為此臨床上采取了許多預(yù)防措施,但PONV的發(fā)生率依然很高,據(jù)報(bào)道,其發(fā)生率仍高達(dá)20%～37%[3]。對(duì)于頸部手術(shù)患者,PONV也具有較高的發(fā)生率。目前一般采用單一或復(fù)合應(yīng)用止吐藥的方法防止PONV[4-5]。一般認(rèn)為,頸部手術(shù)PONV的發(fā)生與手術(shù)操作和鎮(zhèn)痛不全有關(guān),為此我們?cè)诶夏昙谞钕偈中g(shù)患者靜脈全麻的基礎(chǔ)上,采用復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯對(duì)患者PONV的發(fā)生率進(jìn)行了研究?，F(xiàn)報(bào)道如下。

1 資料與方法

1.1 一般資料 選擇2012年1月到2015年9月間就診于南京鼓樓醫(yī)院,擇期全麻下行甲狀腺手術(shù)患者60例,ASA分級(jí)Ⅰ或Ⅱ級(jí),體質(zhì)量45～70 kg。隨機(jī)分為全麻組(A組)、全麻復(fù)合頸叢神經(jīng)阻滯組(B組),A組年齡60～78歲,平均(68.5±6.5)歲,其中男5例,女25例;B組年齡63～82歲,平均(69.3±7.6)歲,其中男7例,女23例。2組患者性別、年齡比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),有可比性。排除標(biāo)準(zhǔn):局麻藥過(guò)敏、局部感染、嚴(yán)重高血壓、呼吸道梗阻、甲狀腺功能亢進(jìn)、嚴(yán)重胃腸道疾病等可能發(fā)生嘔吐的患者,最近服用止吐藥物、抗膽堿藥物、激素類藥物或抗組胺受體藥物等患者。本研究已獲本院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn),并與患者或家屬簽署知情同意書(shū)。

1.2 麻醉方法 所有患者術(shù)前禁飲食8 h,術(shù)前均不置胃管,且不術(shù)前用藥?；颊呷胧中g(shù)室后去枕平臥于手術(shù)床上,監(jiān)測(cè)生命體征。麻醉誘導(dǎo)為:咪唑安定0.1 mg/kg、芬太尼3 μg/kg、丙泊芬1.5 mg/kg、維庫(kù)溴銨0.1 mg/kg, 面罩加壓給氧3 min后行氣管插管,縫皮前2組患者均給予芬太尼1 μg/kg靜推。男性患者選擇ID 7.5 mm氣管導(dǎo)管,女性患者選擇ID 7.0 mm氣管導(dǎo)管。確定氣管導(dǎo)管位置滿意后,接麻醉機(jī)人工呼吸。麻醉維持:丙泊酚4～6 mg/(kg·h)、瑞芬太尼0.2 μg/(kg·min)、順苯磺酸阿曲庫(kù)銨0.06～0.12 mg/(kg·h)、右旋美托咪定2～5 μg/(kg·min)。B組在麻醉誘導(dǎo)平穩(wěn)后10 min予以實(shí)施雙側(cè)頸叢淺神經(jīng)阻滯,其余麻醉方法同A組。去枕,頭偏向?qū)?cè),在胸鎖乳突肌后緣中點(diǎn)(即神經(jīng)點(diǎn))處穿刺進(jìn)針。局部麻醉藥為0.125%布比卡因溶液5 ml/側(cè)。

術(shù)中根據(jù)血流動(dòng)力學(xué)變化和手術(shù)刺激強(qiáng)度調(diào)整靜脈麻醉藥物,以確保術(shù)中動(dòng)脈壓和心率的變化維持在誘導(dǎo)前基礎(chǔ)值的80%～120%之間。手術(shù)結(jié)束前30 min,2組均常規(guī)予以恩丹西酮8 mg靜推。

1.3 觀察指標(biāo) 觀察并記錄術(shù)后0～12 h、12～24 h、24～48 h時(shí)間段患者PONV的發(fā)生情況以及疼痛評(píng)分(VAS評(píng)分)和意識(shí)評(píng)分(Ramsay評(píng)分)。記錄患者術(shù)中血流動(dòng)力學(xué)的變化、手術(shù)時(shí)間和麻醉時(shí)間。并隨訪有無(wú)頭暈、焦慮、錐體外系反應(yīng)等不良反應(yīng)的發(fā)生。

2 結(jié)果

2.1 2組一般情況比較 2組手術(shù)時(shí)間、麻醉時(shí)間、平均血壓(MBP)、心率(HR)比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表1。

表1 2組患者麻醉時(shí)間、手術(shù)時(shí)間、術(shù)中血壓、心率等一般情況比較±s,n=30)

2.2 2組PONV發(fā)生率比較 A組術(shù)后12 h、12～24 h PONV發(fā)生率均明顯高于B組(P均<0.05),術(shù)后24～48 h與B組相比,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表2。

2.3 2組VAS評(píng)分、Ramsay評(píng)分比較 術(shù)后A組各時(shí)間點(diǎn)VAS評(píng)分均顯著高于B組(P<0.05);2組術(shù)后Ramsay評(píng)分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義。見(jiàn)表3。

表2 2組患者術(shù)后0～12 h、12～24 h、24～48 h PONV發(fā)生率比較(n,%, n=30)

注:與A組比較,*P<0.05

2.4 不良反應(yīng) A組術(shù)后發(fā)生頭痛1例,低血壓2例,鎮(zhèn)靜過(guò)度1例,B組患者發(fā)生頭痛1例,低血壓5例,鎮(zhèn)靜過(guò)度1例。2組不良反應(yīng)發(fā)生率比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。2組均未發(fā)生錐體外系反應(yīng)及心臟意外事件。

表3 2組患者術(shù)后各時(shí)點(diǎn)VAS評(píng)分和Ramsay評(píng)分的變化,分，n=30)

注:與A組比較,*P<0.05

3 討論

老年甲狀腺手術(shù)患者術(shù)后大多數(shù)會(huì)經(jīng)歷PONV,給老年患者帶來(lái)不便的同時(shí)增加術(shù)后并發(fā)癥的風(fēng)險(xiǎn)。目前認(rèn)為其原因主要為:(1)術(shù)中頸部過(guò)度后仰致雙側(cè)頸動(dòng)脈血流速度減少、牽拉迷走神經(jīng),以及術(shù)前禁飲食,腸道準(zhǔn)備導(dǎo)致脫水低血容量,從而引起腦部和腸道的灌注不足;(2)患者術(shù)前并存惡心嘔吐或暈動(dòng)病史，麻醉方式的選擇、使用阿片類鎮(zhèn)痛藥、手術(shù)操作、手術(shù)時(shí)間的長(zhǎng)短、肥胖、高齡;(3)老年患者由于各器官系統(tǒng)生理機(jī)能衰退、痛覺(jué)的敏感性增高，但是對(duì)藥物的耐受性差,疼痛控制效果欠佳[6-7]。

既往對(duì)于PONV的預(yù)防一般采用靜脈給予鎮(zhèn)吐藥物,由于老年甲狀腺手術(shù)患者PONV的發(fā)生率較高且比較難治,因此其策略一般是聯(lián)合應(yīng)用多種止吐藥物,例如地塞米松聯(lián)合昂丹司瓊或阿瑞匹坦類鎮(zhèn)吐藥[8-9]。但是,文獻(xiàn)顯示,鎮(zhèn)吐效果依然欠佳[10]。

本研究結(jié)果顯示A組患者術(shù)后12 h,24 h及48 h時(shí)間點(diǎn)VAS評(píng)分均顯著高于B組;2組患者術(shù)后均有PONV發(fā)生,但B組患者術(shù)后0～12 h,12～24 h期間PONV的發(fā)生率與A組相比顯著降低，提示甲狀腺手術(shù)在靜脈全麻的基礎(chǔ)上復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯在顯著減輕老年患者術(shù)后疼痛的同時(shí),對(duì)防止術(shù)后PONV的發(fā)生具有較好的作用。由于2組術(shù)后均未予以阿片類藥物,鎮(zhèn)吐藥也一致,故我們認(rèn)為B組患者術(shù)后0～12 h和12～24 h期間PONV的發(fā)生率較低可能與其術(shù)后疼痛顯著下降有關(guān)。2組患者術(shù)后24～48 h期間的PONV發(fā)生率差異無(wú)統(tǒng)計(jì)學(xué)意義,我們推測(cè)其原因是:(1)一般情況下PONV的發(fā)生率隨時(shí)間的推移逐漸下降；(2)頸淺叢神經(jīng)阻滯的效果逐漸消失。

綜上所述,靜脈全麻的基礎(chǔ)上復(fù)合雙側(cè)頸叢淺神經(jīng)阻滯對(duì)預(yù)防老年甲狀腺手術(shù)患者PONV的發(fā)生具有較好的作用,這可能與雙側(cè)頸淺叢神經(jīng)阻滯顯著減輕老年患者的術(shù)后疼痛程度有關(guān)。

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[4] Lee M, Lee K, Kim H, et al.Comparison of ramosetron plus dexamethasone with ramosetron alone on postoperative nausea, vomiting, shivering and pain after thyroid surgery[J].Pain, 2015, 28(1):39-44.

[5] Li B, Wang H.Dexamethasone reduces nausea and vomiting but not pain after thyroid surgery: a meta-analysis of randomized controlled trials[J].Med Sci Monit, 2014,31(20):2837-2845.

[6] Lee W, Kim M, Kang S， et al.Type of anaesthesia and patient quality of recovery: a randomized trial comparing propofol-remifentanil total i.v. anaesthesia with desflurane anaesthesia[J].Br J Anaesth, 2015,114(4):663-668.

[7] 吉愛(ài)軍. 100例門(mén)診中重度老年癌痛患者使用3種阿片類藥物療效回顧性分析[J].實(shí)用老年醫(yī)學(xué), 2012, 26(6):480-482.

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Effect of intravenous anesthesia combined with bilateral superficial cervical plexus block on the incidence of postoperative nausea and vomiting in elderly patients undergoing thyroid surgery

ZHU Wei, YANG Xu-li, CUI Shi-he, ZHOU Lu-yang.

Department of Anesthesiology, Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China

Objective To evaluate and compare the of incidence rate of postoperative nausea and vomiting (PONV) between patients receiving intravenous anesthesia completely or combined with bilateral superficial cervical plexus block in thyroid surgery. Methods Sixty elderly patients scheduled to thyroid surgery under general anesthesia were randomly divided into two groups, with 30 cases in each group. Patients in group A only underwent intravenous anesthesia, with conventional rapid induction. Patients in group B received bilateral superficial cervical plexus nerve block 10 min after the same induction with group A. At the time period of 0-12 h, 12-24 h and 24-48 h postoperation, the incidence rate of PONV was recorded, the pain score (VAS score) and consciousness score (Ramsay score) were accessed at the time points of 12 h, 24 h and 48 h. Results At the time period of 0-12 h, 12-24 h after operation, the incidence rate of PONV in group A was significantly higher than that in group B, but there was no significant difference at the time of 24-48 h postoperation between two groups. The VAS score at each time point in group A was significantly higher than that in group B. There was no significant difference in Ramsay score between two groups. Conclusions Intravenous general anesthesia combined with bilateral superficial cervical plexus block has a good effect on reducing the incidence of PONV in elderly patients with thyroid surgery, and can significantly reduce the use of other antiemetics.

thyroid; superficial cervical plexus block; intravenous anesthesia; nausea and vomiting; aged

南京市醫(yī)學(xué)科技發(fā)展重點(diǎn)項(xiàng)目(ZKX14025)；南京市醫(yī)學(xué)科技發(fā)展項(xiàng)目(YKK13069)

210008江蘇省南京市，南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院麻醉科

R 614.2

A

10.3969/j.issn.1003-9198.2016.12.009

2016-05-05)