超声引导下连续胸椎旁神经阻滞对乳腺癌根治术患者术后慢性疼痛的影响

摘要

目的 探讨超声引导下连续胸椎旁神经阻滞对乳腺癌根治术患者术后慢性疼痛(CPSP)的影响.方法 选择2015年1月至2017年2月在河北医科大学附属哈励逊国际和平医院行单侧乳腺癌根治术的女性患者206例,应用随机数字表法分为2组,单纯全身麻醉组(GA组)行常规全身麻醉诱导,连续胸椎旁神经阻滞联合全身麻醉组(PG组)于全身麻醉诱导前在超声引导下行术侧肋间入路T3椎旁神经阻滞并置管.2组患者麻醉诱导成功后插入喉罩丙泊酚静脉靶控输注维持麻醉,术后PG组采用连续胸椎旁神经自控镇痛,GA组采用患者自控静脉镇痛.比较2组患者术中丙泊酚和芬太尼的用量、术后48 h镇痛泵有效按压次数以及补救镇痛率和镇痛满意率,比较术后不良反应发生情况以及术后3、6、12个月CPSP和神经病理性疼痛的发生率.结果 8例患者因未能完成随访而剔除,PG组入组102例,GA组入组96例.PG组术中丙泊酚用量和芬太尼用量均少于GA组(均P＜0.05).PG组术后48 h内镇痛泵有效按压次数、补救镇痛率均低于GA组[(2.5±1.2)次比(14.6±5.7)次,2.0％(2/102)比9.4％(9/96)],术后镇痛满意率高于GA组[95.1％ (97/102)比78.1％ (75/96)],差异均有统计学意义(均P＜0.05).PG组患者术后嗜睡、恶心呕吐及尿潴留发生率明显低于GA组[0％ (0/102)比13.5％ (13/96),2.9％(3/102)比27.1％(26/96),0％(0/102)比10.4％ (10/96)],差异均有统计学意义(均P＜0.05).PG组患者术后3、6、12个月CPSP和神经病理性疼痛发生率均明显低于GA组[16.7％(17/102)比37.5％(36/96)、7.8％(8/102)比28.1％(27/96)、5.9％(6/102)比19.8％(19/96),4.9％(5/102)比18.8％(18/96)、2.9％(3/102)比15.6％(15/96)、2.0％(2/102)比10.4％ (10/96)],差异均有统计学意义(均P＜0.05).结论 超声引导下连续胸椎旁神经阻滞镇痛用于乳腺癌根治术患者效果确切,不良反应少,可有效降低CPSP和神经病理性疼痛的发生率.%Objective To investigate the analgesic effect of ultrasound-guided continuous thoracic paravertebral nerve block on chronic post-surgical pain(CPSP) in patients undergoing radical mastectomy for breast cancer.Methods A total of 206 breast cancer patients scheduled for radical mastectomy from January 2015 to February 2017 in Harrison International Peace Hospital,Hebei Medical University were randomly divided into general anesthesia group (GA group) and continuous thoracic paravertebral nerve block combined with general anesthesia group(PG group).The GA group had conventional anesthesia induction;the PG group had ultrasound-guided T3 paravertebral block and intubation.All patients had propofol target-controlled infusion for anesthesia maintenance.The PG group had self-controlled thoracic paravertebral analgesia;the GA group had self-controlled intravenous analgesia.Consumptions of fentanyl and propofol during operation,times of effective self-controlled analgesia in 48 h after operation,remedial analgesia rate,analgesic satisfaction rate,postoperative adverse reaction rate,rates of CPSP and neuropathic pain in 3,6,12 months after operation were analyzed.Results Eight patients were withdrawn from observation;102 patients were included in PG group and 96 patients were included in GA group.Consumptions of fentanyl and propofol during operation in PG group were significantly less than those in GA group(P ＜0.05).Times of effective self-controlled analgesia in 48 h after operation and the remedial analgesia rate in PG group were significantly lower than those in GA group[(2.5 ± 1.2)times vs(14.6-±5.7)times,2.0％ (2/102) vs 9.4％ (9/96)];analgesic satisfaction rate in PG group was significantly higher than that in GA group[95.1％ (97/102)vs 78.1％ (75/96)] (P ＜ 0.05).Incidences of drowsiness,nausea and vomiting,urine retention in PG group were significantly lower than those in GA group[0％ (0/102)vs 13.5％ (13/96),2.9％ (3/102)vs 27.1％ (26/96),0％ (0/102)vs 10.4％ (10/96)] (P ＜ 0.05).Incidences of CPSP and neuropathic pain in postoperative 3,6,12 months in PG group were significantly lower than those in GA group[16.7％ (17/102) vs 37.5％ (36/96),7.8％ (8/102) vs 28.1％ (27/96),5.9％ (6/102)vs 19.8％ (19/96),4.9％ (5/102) vs 18.8％ (18/96),2.9％ (3/102) vs 15.6％ (15/96),2.0％ (2/102) vs 10.4％ (10/96)] (P ＜ 0.05).Conclusion Ultrasound-guided continuous thoracic paravertebral nerve block has a good analgesic effect on breast cancer patients undergoing radical mastectomy;it can effectively reduce the occurrences of CPSP and neuropathic pain with few adverse reactions.