Research On Postoperative Analgesia And Immune Response To VATS By Programmed Intermittent Paravertebral Bolus

Objective:Operation is essential approach for treatment of lung cancer.Thoracic surgery is very traumatic,involving skin,muscle,rib,pleura,lung and other organs,as well as body and visceral receptors.Postoperative pain is considered to be one of the most serious surgical pain after thoracotomy.At present,the incidence of acute pain is among 80-96%after thoracotomy,of which about 40-50%can develop into chronic postoperative thoracic pain.Anesthesia and pain have the potential effect on the immune function which is not conducive to the removal of residual tumor cells.How to control postoperative acute pain more effectively,improve anesthesia,reduce side effects,and pay attention to the protection of immune function is an essential issue in thoracic surgery anesthesia.This clinical study based on modified analgesic method,programmed intermittent bolus infusion(PIB),which compared with continuous infusion(CI)for thoracic paravertebral analgesia and patient controlled intravenous analgesia(PCIA).Three different analgesic methods were used to investigate the postoperative analgesia effects,adverse reactions and immune responses of patients undergoing video-assisted thoracoscopic surgery(VATS).To evaluate the feasibility of programmed intermittent paravertebral bolus for analgesia after VATSMethods:By using prospective randomized controlled study,90 patients with non-small cell lung cancer who received video-assisted thoracoscopic surgery from Beijing Chest HospitalAffiliated to Capital Medical University from January 2019 to December 2019 were selected for systematic comparative study of different anesthesia methods.1.The research group:90 patients were randomly assigned to programmed intermittent paravertebral bolus infusion(group P,n=30),continuous paravertebral infusion(group S,n=30)and continuous patient-controlled intravenous analgesia group(group V,n=30).After the surgery,programmed intermittent paravertebral bolus analgesia,continuous paravertebral infusion analgesia and patient-controlled intravenous analgesia were administered respectively.2.Clinical outcome and time point:Numeric rating scales(NRS),Ramsay sedation score,perioperative hemodynamic parameters(MBP,HR,SpO2),demanded delivery,effective delivery,local anesthetic dosage,the consumption of narcotic drugs,adverse reactions,QoR-15 score were observed at before operation(T0),40 minutes after skin incision(T1),2 hours after skin incision(T2),end of procedure(T3),1 hour after surgery(T4),4 hours after surgery(T5),24 hours after surgery(T6)and 48 hours after surgery(T7).3.Selection and monitoring of immune response indicators:(1)Peripheral lymphocyte subsets(total lymphocytes,total T lymphocytes,B lymphocytes,helper T cells,Regulatory T cells,Cytotoxic T lymphocytes,NK cells)were continuously analyzed by using flow cytometry at T0,T2,T6.(2)Plasma cytokine concentration(IL-2,IL-4,IL-6,IL-10,TNF-?,IFN-?)was also analyzed by flow cytometry at T0,T2,T6 respectively,which based on assay of Cytometric Bead Array.Results:1.Changes in NRS pain score and Ramsay sedation score and perioperative hemodynamic parameters:Compared with the group S[0.0(0.8)?3.0(1.8)]and the group V[1.0(2.0)?4.0(1.0)],the NRS of resting and coughing pain at T5-7 was significantly reduced in group P[0.0(0.0)?3.0(1.0)](P<0.05).Compared with the group V[3.0(1.0),3.0(0.0)],the Ramsay sedation score at T4-5 were significantly reduced in group P[2.0(1.0),2.0(0.0)]and group S[3.0(1.0),2.0(0.8)](P<0.05).The perioperative hemodynamics of the three groups were not statistically different from To to T7(P>0.05).2.Comparison of consumption on analgesics and narcotic drugs:In terms of times of demanded delivery and effective delivery,compared with group P[0.0(0.0)to 2.0(3.0)],there was significant rising in group S[0.0(0.8)to 3.0(4.0)]and group V[0.0(1.0)to 5.0(5.0)]at T4-7 respectively.The dosage of local anesthetics(Ropivacaine)in group P[30.0(0.0)?525.0(37.5)]was significantly lower than that in group S[40.0(7.5)?540.0(40.0)]at T4-7(P<0.05).In terms of consumption of opioids(Sufentanil,Remifentanil)during operation,the group P and the group S were significantly lower than the group V(P<0.05).3.Comparison of postoperative adverse reactions:Compared with group V,the incidence of tachycardia and dizziness were significantly reduced in group P and group S(P<0.05).4.Changes in QoR-15 recovery quality score:The QoR-15 scores of group S(104.4±5.3,110.5±3.8)and group V(103.1±3.5,108.3±4.2)at T6 and T7 were significantly lower than group P(107.0±5.1,114.4±4.2)respectively(P<0.05).5.Effects of immune cells and cytokine concentrations:(1)Changes in lymphocyte subsets:There was no statistical difference between the three groups of lymphocyte subsets(total lymphocytes,total T lymphocytes,B lymphocytes,helper T cells,Regulatory T cells,Cytotoxic T lymphocytes,NK cells).However?There were significant differences among total lymphocytes,total T cells and helper T cells at T0,T2,T6 respectively(P<0.05):total lymphocytes(P:22.1±6.0?6.3±2.0;S:25.4±7.5?6.4 1.4;V:25.0±5.5?6.2±1.4)were gradually decreased at T0,T2,T6 respectively(P<0.05);and total T lymphocytes(P:72.9±7.4?64.5±9.9;S 73.3±8.0?68.4±9.0;V:74.0±7.5?68.2±12.9)were gradually decreased at T0,T2,T6 respectively(P<0.05);and helper T cells(P:41.9±4.6?35.6±4.2;S:42.3±7.4?35.8±5.4;V:41.6±7.6?35.1±10.6)were gradually decreased at T0,T2,T6 respectively(P<0.05)?There were significant differences in B lymphocytes and NK cells at T0,T2,T6 respectively(P<0.05):B lymphocytes(P:10.8±3.5?12.8±3.9;S:9.9±2.8?11.1±4.0;V:9.6±4.4?11.7±6.5)were increased gradually at T0,T2,T6(P<0.05)and NK cells(P 16.9±5.8?21.1±8.2;S:16.8±8.4?20.3±7.7;V:13.9±5.6?17.5±7.8)were increased gradually at T0,T2,T6(P<0.05)(2)changes in cytokines:There was no statistical difference between the three groups of cytokines(IL-2,IL-4,IL-6,IL-10,TNF-?,IFN-?).However,there were significant differences in IL-6 and IL-10 at T0,T2,T6 respectively.IL-6(P:4.6±2.2?82.4±61.3;S:4.9±1.9?72.9±39.5;V:4.6±1.7?125.4±77.4)were increased gradually at T0,T2,T6 respectively(P<0.05);and IL-10(P:3.8±1.4?5.4±2.0;S:3.3±0.8?5.2±2.4;V 3.4±0.8?6.0±4.3)were increased gradually at T0,T2,T6 respectively(P<0.05)Conclusion:(1)Programmed intermittent paravertebral bolus has good analgesic and sedative effects after VATS,with a low incidence of adverse reactions,less amount of local analgesia and good postoperative recovery quality.It is suitable for postoperative analgesia of VATS(2)Application of paravertebral preemptive analgesia can reduce the doses of intraoperative opioid administration and postoperative adverse reactions(3)Thoracic surgery and analgesia can lead to immunosuppression,and programmed intermittent paravertebral bolus has no advantage over intravenous analgesia in lymphocyte subsets and cytokines.The immunosuppression caused by thoracic surgery and analgesia deserves attention and necessary intervention.