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【摘要】 目的 观察联合应用氟比洛芬酯和舒芬太尼术后静脉镇痛对肺癌手术患者围术期免疫反应及儿茶酚胺的影响。方法 选择择期行肺癌根治术患者26例,ASAⅠ-Ⅱ级,随机分为氟比洛芬酯联合舒芬太尼镇痛组(F组,n=13)和舒芬太尼镇痛组(S组,n=13)。两组患者均采用相同的异丙酚、芬太尼、维库溴铵及异氟醚静吸复合麻醉。术毕分别用氟比洛芬酯联合舒芬太尼和单纯舒芬太尼行静脉术后镇痛,采用VAS镇痛评分评价镇痛效果,并分别于于麻醉前(T0)、切皮后1 h(T1)和术毕(T2)、术后24 h(T3)、48 h(T4)检测外周血CD3、CD�4、CD�8、CD�+��23�B细胞及单核细胞HLA-DR表达的变化。同时测定外周血肾上腺素(E)、去甲肾上腺素(NE)的浓度。结果 两组术后镇痛效果无显著性差异(P>0.05)。S组切皮后1 h及术毕CD3细胞下降,术后24 hCD�4细胞和CD�4/CD�8比值降低(P0.05)。结论 氟比洛芬酯联合舒芬太尼和单纯舒芬太尼术后镇痛都取得良好的镇痛效果,但前者更有利肺癌患者术后细胞免疫功能的恢复。
【关键词】 术后镇痛;氟比洛芬酯;舒芬太尼;肺肿瘤;淋巴细胞;免疫
Effect of flurbiprofen axetil combined with sufentanyl on perioperative immune response and catecholamine in patients undergoing lung cancer surgery
SHI Shi-jian,ZHANG Yi-wen,XING Zu-min. Department of Anesthesiology,The First People’s Hospital of Shunde,Foshan 528300,China
【Abstract】 Objective To evaluate the effect of postoperative analgesia with flurbiprofen axetil combined with sufentanyl on perioperative immune response and catecholamine in patients undergoing lung cancer surgery. Methods Twenty-six patients ASAⅠ-Ⅱ patients aged 46-73years undergoing radical operation of lung cancer were randomly assigned into two groups: F group and S group. All patients were given identical intravenous combined with inhalational anesthesia with propofol, fentanyl, vecuronium and isoflurane. Then patients received post-operative analgesia with flurbiprofen axetil combined with sufentanyl after operation in F group, but only sufentanyl in S group. Peripheral blood CD3, CD�4, CD�8, CD�+��23�B and HLA-DR on monocyte were measured before induction of anesthesia(T1), 1 h after incision(T2), 24 h(T3) and 48 h(T4) after the completion of the surgery. Peripheral blood epinephrine(E) and norepinephrine(NE) were observed in the same time. Results There was no significant difference in visual analogue scale (VAS) between F group and S group. In CD3% decreased at T2 and CD�4%, CD�4/CD�8 ratio decreased at T3 in the group S, but not in the group F. CD�4/CD�8 ratio increased at T2 in group S. CD�+��23�B% lymphocyte increased and fluorescene of HLA-DR expression on monocyte decreased significantly in both groups. Blood NE level in group C didn’t significantly differ from that in group G during and after operation.Conclusion Postoperative analgesia with flurbip rofen axetil and sufentanyl orwith sufentanyl alone shows a similar postoperative analgesic effect in patients undergoing radical operation of lung cancer, but the former protocol more contributes to recover cell-mediated immunity of the patients.
【Key words】 Postoperative analgesia;Flurbiprofen axetil;Sufentanyl;Lung neoplasma;Lymphocyte;Immunity
作者单位:528300 广东省佛山市顺德区第一人民医院麻醉科
机体免疫功能的低下可影响肿瘤发生、发展,围术期的手术应激、疼痛、麻醉性药物等都可能引起免疫功能抑制[1-3]。选用合适的镇痛药进行合理的镇痛治疗可减轻手术应激、疼痛所致的免疫抑制,从而保护机体的免疫功能,对于肿瘤患者有重要意义。本研究通过对择期行手术治疗肺癌患者采用舒芬太尼和氟比洛芬酯进行术后镇痛治疗,观察围术期T细胞、T辅助细胞及儿茶酚胺等的变化,探讨二者的镇痛效果及对细胞免疫功能的影响。
1 资料与方法
1.1 病例及分组 26例肺癌患者ASA Ⅰ-Ⅱ级,其中男15例,女11例;年龄46~73岁;体质量48~74 kg。所有患者均择期行肺癌根治切除手术,术前均未接受放疗、化疗及免疫抑制药物治疗。有严重消化道溃疡、血液系统疾病、肝肾功能严重异常、严重高血压以及有非甾体抗炎药过敏史、阿司匹林哮喘史及正在使用依洛沙星、洛美沙星、诺氟沙星的患者剔除本观察之外。患者随机分为舒芬太尼镇痛组(S组) 、氟比洛芬酯联合舒芬太尼镇痛组( F组),每组13例。
1.2 麻醉及术后镇痛 患者入室后开放上肢静脉,乳酸林格氏液扩容,面罩吸纯氧后开始诱导。静脉注射芬太尼3μg/kg、维库溴铵0.1 mg/kg、丙泊酚1.5 mg/kg诱导,行气管内插管,接机械通气。以静脉持续输注丙泊酚2~4 mg/(kg•h)、吸入异氟醚(呼气末浓度0.5-0.8MAC)及维库溴铵0.5 mg/(kg•h) 维持麻醉。用DATEX监护仪(芬兰Datex-Ohmeda公司)监测血压、心率、血氧饱和度。手术至关胸后、开始缝合皮肤时停止瑞芬太尼输注,S组给予舒芬太尼0. 20 μg/kg静脉注射, F组给予氟比洛芬酯1 mg/kg +舒芬太尼0. 10 μg/kg静脉注射。术毕接镇痛泵(珠海福尼亚科技集团)行术后自控镇痛,药物配方: S组,舒芬太尼200 μg +生理盐水总量100 ml; F组,氟比洛芬酯200 mg +舒芬太尼50μg +生理盐水总量100 ml。背景剂量2 ml/h,单次给药量(Bolus) 0.5 ml/次,锁定时间15 min。术后4 h、24 h、48 h用视觉模拟评分法 ( visual analogue scale,VAS)判定镇痛效果,评分0.05);单核细胞表达HLA-DR的荧光强度明显降低,术后24 h达43%、33%。两组间比较无显著性差异(P>0.05)(表3)。
2.3 两组血浆肾上腺素(E)、去甲肾上腺素(NE)浓度的变化 两组E及NE值分别于术中、术后均呈升高趋势,但差异无统计学意义,组间比较也无显著性差异(P>0.05)(表4)。
表3
淋巴细胞表面标志的变化(n=13, x±s)
T1T2T3T4
CD3%F组57.19±8.0260.29±7.9457.19±7.8261.19±8.84
S组59.45±7.9454.94±6.22��+※�62.14±7.0162.21±6.72
CD19%F组11.89±3.4711.24±3.2815.27±4.3114.41±3.23
S组9.42±4.317.78±3.2313.21±4.2113.02±4.91
CD�4F组28.13±6.2731.09±7.4230.31±7.2131.08±6.16
S组27.22±6.1526.73±8.3222.34±8.21��+※�30.43±5.16
CD�8F组31.43±7.3932.22±9.1731.23±7.4831.04±8.20
S组33.21±8.1535.02±8.0330.90±9.2332.71±5.61
CD�4/CD�8F组0.94±0.131.22±0.31+1.11±0.251.09±0.32
S组0.95±0.150.71±0.10�※0.69±0.08+1.11±0.16
CD�+��23��BF组21.11±7.2027.21±7.2137.13±6.24�+21.08±6.90
S组18.76±6.1629.24±7.7843.98±7.07+23.26±6.26
单核细胞HLA-DR
(荧光强度)F组55.60±30.1151.23±26.0733.56±17.02�+28.01±9.06�+
S组56.24±24.2148.41±26.3431.16±14.28�+31.62±13.64�+
注:组间比较,�*P
注:与T1比较,�+P
