| ObjectiveTo compare the effects of ultrasound-guided thoracic paravertebral block(TPVB)or thoracic epidural block(TEB)on the analgesia and immune response of patients with spontaneous ventilation during non-intubated video-assisted thoracoscopic sugery(VATS)lobectomy.So as to provide a theoretical basis for the accelerated rehabilitation of patients undergoing lobectomy.MethodsA total of 150 patients ASA I-II,aged 35-75 years old and body mass index of 20.5-25.8kg/m~2,received non-intubated VATS lobectomy with spontaneous ventilation.The patients randomly divided into thoracic paravertebral nerve block(TPVB),thoracic epidural block(TEB)and general anesthesia group(n=50).TPVB group and TEB group received anesthesia induction after TPVB and TEB respectively,while GA group received anesthesia induction directly.Given dexmedetomidine 0.5μg/kg,continuous pump injection for 10 minutes,intravenous injection of fentanyl 0.10-0.15 mg,graded target-controlled infusion of propofol,and the effect-site concentration was set at 1.5-2.0 mg/L.After inserting the laryngeal mask,continue to give oxygen at a flow rate of 2～3 L/min.Target-controlled infusion of propofol(concentration 1.0-3.0 mg/L)and dexmedetomidine 0.5-1.0μg/kg/h was used to maintain the BIS value at 40-60.Fentanyl 0.1mg/time was added intermittently according to the need of anesthesia in operation.The anesthesia induction and maintenance regimens of the three groups were the same.The epidural catheters placed in the TPVB and TEB groups were connected to a self-controlled analgesic pump(0.2%ropivacaine+10 ug/ml fentanyl),and they were continuously infused at a rate of 5 ml/h until 48 h after surgery.In the GA group,patient-controlled intravenous analgesia was performed 48 h after the operation.The formula was flurbiprofen axetil 150 mg plus fentanyl 0.5 mg,diluted to 100 ml with normal saline,the background infusion flow rate was set to 2 ml/h,the additional volume was 1 ml/time,and the lock time was 15 min.Record the visual analogue pain scale(VAS),operation time,anesthesia time,propofol dosage,dexmedetomidine dosage,and fentanyl supplementation at postoperatively 1,2,6,12,24,and 48 hours.The cellular and humoral immune indexes and the levels of related inflammatory factors were compared on the 1st and 3rd day after operation,and the incidence of adverse reactions such as hypertension,hypotension,arrhythmia and atelectasis were observed in the three groups.Results(1)Perioperative analgesia comparison:Compared with the TEB group,the VAS scores of TPVB patients decreased significantly at the 48 h postoperatively(p<0.05),and there was no significant difference in VAS scores between the two groups at other time points(p>0.05).The VAS scores of patients in the TPVB and TEB group were markedly decreased at the 1st,2nd,6th and 12th compared with that of GA group(p<0.05),but there was no statistical difference of the three groups at 24 h after surgery(p>0.05).Similarly,the results that in the TPVB group were significantly lower than GA group at 48th postoperatively,which was no statistical difference in TEB group(p>0.05).(2)Perioperative condition:There was no statistical difference on duration of surgery,duration of anesthesia,dosage of propofol and dexmedetomidine between these three groups(p>0.05).The additional dosage of fentanyl in both TPVB and TEB group was lower than that in GA group(p<0.05),but there was no significant difference between TPVB and TEB group(p>0.05).(3)Postoperative cellular immune function:A flow cytometry assay demonstrated that the positive rates of CD3~+CD4~+and CD3~+CD8~+T cells in TPVB group were both increased significantly on the 1st and 3rd day after operation compared with TEB group(p<0.05).Nevertheless,these expressions in TPVB group were markedly decreased compared with that of GA group(p<0.05).The levels of CD3~+CD4~+and CD3~+CD8~+T cells on the 3rd postoperative day in the TPVB group were higher than those on the 1st postoperative day(p<0.05),while there was no significant difference between the 3rd postoperative day and the 1st day in the TEB group(p>0.05).In particular,the percentages of CD19~+cells and CD3~-CD16~+CD56~+cells on the 1st and 3rd day after surgury were not statistically different among the three grougs(p>0.05).(4)Postoperative humoral immune function:There was no significant difference in the levels of IgG,IgA,IgM,CRP and hs-CRP on the first day after the operation of the patients in each group(p>0.05),while these indicators in the TPVB and TEB groups on the 3rd postoperative day were lower than those on the 1st day(p>0.05).Compared with the GA group,these levels in the TPVB and TEB groups were significantly lower on the 3rd day after surgery(p<0.05).Compared with TEB group,the expressions of IgA,IgM and hs-CRP in the TPVB group on the third day after surgery were decreased(p<0.05)but there were lack of statistical difference on the level of IgG and CRP(p>0.05).(5)Postoperative inflammatory factor levels:Compared with GA group,the concentration of IL-1β,IL-6 and TNF-αin the TPVB and TEB group were both decreased on the first day and third day after surgery(p<0.05).However,there was no significant difference in the concentrations of these indicators between the TPVB group and the TEB group on the 1st and 3rd day after surgery(p>0.05).These expressions on the 3rd postoperative day in each group were lower than those on the1st postoperative day(p<0.05).(6)Incidence of adverse reactions:The incidence of hypotension in the TEB group was significantly higher than that in the TPVB and GA group(p<0.05).There was no statistically significant difference in the incidence of hypertension,arrhythmia,atelectasis,pneumonia,and hypoxemia in each group of patients(p>0.05).Conclusion:Those patients with spontaneous ventilation undergoing TPVB for non-intubated VATS lobectomy showed more stable hemodynamics,preferable analgesia and improved cellular immune function after surgery. |
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