Influence of intravenous general anesthesia combined with epidural anesthesia and with ultrasound-guided bilateral transversus abdominis plane on laparoscopic colorectal cancer patients
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摘要:目的 探讨静脉全身麻醉分别联合硬膜外麻醉与超声引导双侧腹横肌平面(TAP)阻滞对腹腔镜结直肠癌手术患者血流动力学、应激水平及苏醒期躁动的影响。方法 选取102例腹腔镜结直肠癌手术患者为研究对象，按照随机数字表法进行1∶1配对分组，分为联合麻醉组、全麻组、全麻联合TAP组, 每组34例。比较麻醉诱导前10 min(T0)、麻醉诱导后30 min(T1)、停止麻醉时(T2)、拔出气管导管后10 min(T3)时点的收缩压(SBP)、舒张压(DBP)、心率(HR); 评估麻醉前、切皮后、术毕等时点血管紧张素Ⅱ(AngⅡ)、血糖以及麻醉前、气腹建立后、术后24 h的血清免疫球蛋白(Ig)M、IgG变化; 观察术后睁眼时间和躁动评分。结果 T0时点, 3组SBP、DBP、HR比较，差异无统计学意义(P>0.05); T1、T2时点，联合麻醉组SBP、DBP低于全麻组和全麻联合TAP组，差异有统计学意义(P < 0.05); 3组HR比较，差异无统计学意义(P>0.05); T3时点，联合麻醉组SBP、DBP、HR与全麻组和全麻联合TAP组比较，差异无统计学意义(P>0.05)。切皮后、术毕时点，联合麻醉组AngⅡ、血糖低于全麻组和全麻联合TAP组，差异有统计学意义(P < 0.05); 气腹建立后及术后24 h等时点，联合麻醉组IgM、IgG高于全麻组和全麻联合TAP组，差异有统计学意义(P < 0.05)。联合麻醉组睁眼时间、躁动评分均低于全麻组与全麻联合TAP组，差异有统计学意义(P < 0.05)。结论 腹腔镜结直肠癌手术中采用静脉全身麻醉复合硬膜外麻醉，有利于稳定血流动力学和降低应激水平，避免术后躁动事件的发生。Abstract:Objective To investigate the effects of intravenous general anesthesia combined with epidural anesthesia and with ultrasound-guided bilateral transversus abdominis plane (TAP) block on hemodynamics, stress level and agitation during recovery in patients with laparoscopic colorectal cancer surgery.Methods A total of 102 patients undergoing laparoscopic colorectal cancer surgery were selected as research subjects, and were divided into combined anesthesia group (intravenous general anesthesia combined with epidural anesthesia), general anesthesia group (intravenous general anesthesia), and general anesthesia combined with TAP group(intravenous general anesthesia combined with TAP) by 1∶1 pairing according to the random number table method, with 34 cases in each group. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) at 10 min before induction of anesthesia (T0), 30 min after induction of anesthesia (T1), cessation of anesthesia (T2) and 10 min after tracheal tube removal (T3) were compared. The changes of angiotensin Ⅱ(AngⅡ), blood glucose, serum immunoglobulin (Ig) M and IgG before anesthesia, after the establishment of pneumoperitoneum and 24 h after surgery were evaluated. Eye opening time and agitation score were observed.Results There were no significant differences in SBP, DBP and HR among the three groups at time point of T0 (P>0.05); at T1 and T2, the SBP and DBP of the combined anesthesia group showed no statistically significant differences when compared with the general anesthesia group and the general anesthesia combined with TAP group (P < 0.05); there was no significant difference in HR among the three groups (P>0.05); at T3, there were no significant differences in SBP, DBP and HR in the combined anesthesia group compared with the general anesthesia combined with TAP group and general anesthesia group (P>0.05). After skin incision and at the end of the operation, AngII and blood glucose in the combined anesthesia group were lower than those in the general anesthesia combined with TAP group and the general anesthesia group (P < 0.05); after the establishment of pneumoperitoneum and 24 hours after the operation, the IgM and IgG in the combined anesthesia group were higher than those in the general anesthesia group and the general anesthesia combined with TAP group (P < 0.05). The eye opening time was shorter, and agitation score was lower in the combined anesthesia group than those in the general anesthesia group and the general anesthesia combined with TAP group (P < 0.05).Conclusion Intravenous general anesthesia combined with epidural anesthesia in laparoscopic colorectal cancer surgery is beneficial to stabilize hemodynamics, reduce stress levels, and avoid occurrence of postoperative agitation events.
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表 1 3组一般资料比较[n(%)]
组别 性别 年龄/岁 BMI/(kg/m2) ASA 男 女 Ⅰ级 Ⅱ级 联合麻醉组(n=34) 17(50.00) 17(50.00) 57.92±3.38 22.98±2.30 18(52.94) 16(47.06) 全麻组(n=34) 18(52.94) 16(47.06) 58.11±2.96 23.09±2.21 20(58.82) 14(41.18) 全麻联合TAP组(n=34) 15(44.12) 19(55.88) 58.36±2.88 23.15±2.19 19(55.88) 15(44.12) BMI: 体质量指数; ASA: 美国麻醉师协会。 
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表 2 3组血流动力学指标比较(x±s)
指标 组别 n T0 T1 T2 T3 SBP/mmHg 联合麻醉组 34 114.52±12.02 117.25±13.12 116.01±12.68 114.25±11.85 全麻组 34 114.56±11.92 124.92±15.85*# 125.01±15.71*# 115.02±12.05 全麻联合TAP组 34 114.49±12.05 124.65±15.23*# 129.95±15.52*# 115.07±11.95 DBP/mmHg 联合麻醉组 34 76.25±8.52 79.30±10.32 69.78±7.25 77.05±8.45 全麻组 34 76.30±8.48 85.46±12.52*# 82.65±11.52*# 77.11±8.32 全麻联合TAP组 34 76.28±8.55 84.96±12.62*# 81.97±11.56*# 77.09±8.36 HR/(次/min) 联合麻醉组 34 68.52±7.32 70.05±8.12 68.36±6.52 68.82±7.25 全麻组 34 68.47±7.30 70.12±8.05 69.05±6.41 68.52±7.15 全麻联合TAP组 34 68.55±7.29 70.18±8.08 69.11±6.44 68.63±7.19 T0: 麻醉诱导前10 min; T1: 麻醉诱导后30 min; T2: 停止麻醉时; T3: 拔出气管导管后10 min; SBP: 收缩压;
DBP: 舒张压; HR: 心率。与T0时点比较, *P < 0.05; 与联合麻醉组比较, #P < 0.05。
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表 3 3组应激指标比较(x±s)
指标 组别 n 麻醉前 切皮后 术毕 血管紧张素Ⅱ/(ng/L) 联合麻醉组 34 26.32±6.02 27.02±6.25 32.52±7.02* 全麻组 34 26.36±5.95 33.45±8.12*△ 39.85±9.12*#△ 全麻联合TAP组 34 26.30±12.05 34.05±8.25*△ 40.05±9.18*#△ 血糖/(mmol/L) 联合麻醉组 34 5.21±1.25 5.32±1.74 5.48±1.80 全麻组 34 5.18±1.28 6.25±2.05*△ 7.69±2.52*#△ 全麻联合TAP组 34 5.24±1.22 6.30±2.14*△ 7.72±2.58*#△ 与麻醉前比较, *P < 0.05; 与切皮后比较, #P < 0.05; 与联合麻醉组比较, △P < 0.05。
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表 4 3组血清IgM、IgG比较(x±s)
g/L 指标 组别 n 麻醉前 气腹建立后 术后24 h 免疫球蛋白M 联合麻醉组 34 1.19±0.25 1.15±0.17 1.10±0.15 全麻组 34 1.22±0.18 1.02±0.11*△ 0.94±0.10*#△ 全麻联合TAP组 34 1.17±0.26 1.04±0.13*△ 0.90±0.08*#△ 免疫球蛋白G 联合麻醉组 34 7.42±1.62 7.20±1.32 7.08±1.18 全麻组 34 7.40±1.65 6.25±1.11*△ 5.92±1.03*△ 全麻联合TAP组 34 7.45±1.68 6.17±1.05*△ 5.85±0.95*△ 与麻醉前比较, *P < 0.05; 与气腹建立后比较, #P < 0.05; 与联合麻醉组比较, △P < 0.05。
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表 5 3组术后苏醒时间和躁动评分比较(x±s)
组别 n 睁眼时间/min 躁动评分/分 联合麻醉组 34 4.52±1.07 0.51±0.12 全麻组 34 8.79±1.25* 1.89±0.36* 全麻联合TAP组 34 9.02±1.32* 1.92±0.42* 与联合麻醉组比较, *P < 0.05。
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