胸横肌平面阻滞对老年患者心肺转流下心脏瓣膜置换术后早期康复的影响

Effect of transverse thoracic muscle plane block on early outcomes after valve replacement under cardiopulmonary bypass in elderly patients

中文关键词: 术后认知功能  胸横肌平面阻滞  心肺转流  心脏瓣膜置换术

英文关键词: Postoperative cognitive function  Transverse thoracic muscle plane block  Cardiopulmonary bypass  Heart valve prosthesis implantation

中文摘要:

      
目的 探讨胸横肌平面（TTP）阻滞对老年患者心肺转流（CPB）下心脏瓣膜置换手术后早期康复的影响。
方法 选择择期行CPB下瓣膜置换术的老年患者58例，男39例，女19例，年龄≥65岁，BMI 18～25 kg/m²，ASA Ⅱ或Ⅲ级，NYHA Ⅱ或Ⅲ级。采用随机数字表法将患者分为两组：胸横肌平面阻滞组（T组）和对照组（C组），每组29例。T组在麻醉诱导前使用超声定位于双侧4—5肋间隙，在肋间内肌和胸横肌注入0.25%罗哌卡因20 ml。C组直接行麻醉诱导。于术前1 d和术后第7天采用神经心理组合量表评估患者的认知功能，记录术中舒芬太尼用量和术后早期认识功能障碍(POCD)的发生情况。记录麻醉诱导后切皮前5 min、术后24、72 h的S100β蛋白浓度。记录入手术室、麻醉诱导后切皮前5 min、锯胸骨时、CPB开始后30 min、CPB结束后30 min、出手术室时的HR和MAP。分别于麻醉诱导后切皮前5 min、CPB开始后30 min、CPB结束后30 min、术后24、72 h检测血清IL-6、TNF-α浓度；检测麻醉诱导后切皮前5 min、CPB结束后30 min、术后72 h的血糖和胰岛素浓度并计算各时点的胰岛素抵抗（IR）指数。记录术后24、72 h的VAS疼痛评分、机械通气时间和ICU滞留时间。
结果 与C组比较，T组术中舒芬太尼用量明显减少、术后第7天POCD的发生率（45% vs 21%）明显降低（P＜0.05），术后24、72 h血清S100β蛋白浓度明显降低（P＜0.05），锯胸骨时HR明显减慢、MAP明显降低（P＜0.05），CPB开始后30 min、CPB结束后30 min和术后24 h血清IL-6浓度明显降低（P＜0.05），CPB开始后30 min、CPB结束后30 min血清TNF-α浓度明显降低（P＜0.05），CPB结束后30 min和术后24 h的IR指数明显降低（P＜0.05），术后24 h的VAS疼痛评分明显降低、机械通气时间和ICU滞留时间明显缩短（P＜0.05）。
结论 TTP阻滞可有效降低老年患者CPB下瓣膜置换术后早期POCD的发生率，有利于维持术中血流动力学稳定、减轻围术期炎症反应、改善IR指数，从而促进患者术后早期康复。

英文摘要:

      
Objective To investigate the effect of transverse thoracic muscle plane (TTP) block on early outcomes after valve replacement under cardiopulmonary bypass(CPB) in elderly patients.
Methods Fifty-eight elderly patients, 39 males and 19 females, aged ≥ 65 years, ASA physical status Ⅱ or Ⅲ, and NYHA cardiac function class Ⅱ or Ⅲ, who underwent elective valve replacement under general anesthesia with cardiopulmonary bypass were selected. The patients were randomly divided into two groups by random number table method: transversus pectoralis plane block group (group T) and control group (group C), 29 patients in each. Before anesthesia induction, the patients in group T were located in the bilateral 4-5 costal space by ultrasound, and 025% ropivacaine 20 ml was injected into the intercostal muscle and transverse thoracic muscle. Patients in group C were induced by direct anesthesia. The patients' cognitive function was evaluated by neuropsychological combined scale on the first day before operation and seventh days after operation. The intraoperative sufentanil consumption and incidence of postoperative cognitive dysfunction (POCD) were recorded. The S100β protein was recorded at 5 minutes before skin incision after anesthesia induction, 24 hours after surgery, and 72 hours after surgery. When patients entered the operating room, 5 minutes before skin incision after anesthesia induction, the sternum was sawed, 30 minutes after the start of CPB, 30 minutes after the end of CPB, and out of the operating room, HR and MAP were recorded. Serum IL-6 and TNF-α concentrations were respectively recorded 5 minutes before skin incision after anesthesia induction, 30 minutes after the start of CPB, 30 minutes after the end of CPB, 24 hours after surgery, and 72 hours after surgery. Concentrations of insulin and blood glucose concentrations were recorded, and the insulin resistance (IR) index was calculated 5 minutes before skin incision after anesthesia induction, 30 minutes after the end of CPB, and 72 hours after surgery. The VAS scores at 24 and 72 hours after surgery, mechanical ventilation time, ICU stay time were recorded.
Results Compared with group C, the amount of sufentanil used during operation and the incidence of POCD in group T (45% vs 21%) was significantly lower than that in group T (P < 0.05). Compared with group C, the concentration of serum S100β protein 24 hours and 72 hours after operation in group T were significantly decreased (P < 0.05), the HR and MAP of the T group decreased significantly during the sternum was sawed (P < 0.05). Compared with group C, the concentrations of IL-6 in group T were significantly decreased 30 minutes after the start of CPB, 30 minutes after the end of CPB, and 24 hours after surgery (P < 0.05); the concentrations of TNF-α in group T were significantly decreased 30 minutes after the start of CPB, and 30 minutes after the end of CPB (P < 0.05); the IR index of group T were significantly lower 30 minutes after the end of CPB and 24 hours after surgery (P < 0.05). Compared with group C, the VAS score at 24 hours after surgery, mechanical ventilation time and ICU stay time in group T were significantly reduced (P < 0.05).
Conclusion Transverse thoracic muscle plane block can effectively reduce the incidence of early POCD after valve replacement under cardiopulmonary bypass in old patients, moreover, it can maintain hemodynamic stability, reduce perioperative inflammatory response, improve IR and promote early outcomes after surgery.