胸段硬膜外麻醉的研究进展及应用

硬膜外应用局麻药为手术提供麻醉与镇痛,同时胸段硬膜外麻醉与镇痛也被广泛应用于心脏,大血管,胸部和腹部的手术中.它不仅可以加快病人麻醉后的苏醒,而且可以提供很好的术后镇痛.除了上述优点,许多基础及临床研究发现硬膜外麻醉还有许多其它方面的作用,如:减轻神经内分泌系统的应激反应、减少围术期并发症的发生,以及通过暂时性的阻滞胸交感神经提供心肺及胃肠道的保护作用,改善免疫和凝血功能.本文就近年来胸段硬膜外麻醉应用及研究进展作一综述.     

上胸段硬膜外阻滞治疗慢性心力衰竭合并房颤的临床研究

目的:比较上胸段硬膜外阻滞对有无合并房颤的扩张型心肌病心衰患者的疗效差异。方法:入选40例扩张型心肌病心衰患者,根据入院心电图有无房颤分为房颤组和非房颤组。所有患者均在抗心力衰竭常规治疗基础上,给予胸段硬膜外阻滞治疗4周,比较治疗前、后NYHA心功能分级、血浆N末端脑钠肽前体(NT-pro BNP)水平、左室射血分数(LVEF)、左室舒张期内径(LVEDD)及左房前后径(LAD)的变化情况。结果:与治疗前比较,两组患者经治疗后的NYHA心功能分级、NT-pro BNP、LVEF、LVEDD及LAD均明显改善(均P0.05),差异有统计学意义,但两组间各指标治疗前后的差值无统计学意义(P0.05)。结论:对于慢性心力衰竭合并房颤的患者而言,给予抗心力衰竭常规治疗基础上联合上胸段硬膜外阻滞治疗有效,且房颤的存在与否不影响上胸段硬膜外阻滞的疗效。     

胸段硬膜外阻滞对家猪肝缺血再灌注时微循环的影响

目的：探讨胸段硬膜外阻滞对家猪肝缺血再灌注时微循环的影响。方法：14只健康幼年家猪,随机分为两组：硬膜外组（E组）和对照组（C组）,每组7只。基础麻醉后,进行气管插管机械通气,侧卧位行胸段硬膜外穿刺（T8-9）置管。经腹正中切口暴露肝脏,分离肝十二肠韧带,游离肝左动脉及门静脉左支备用。E组给予0．5％布比卡因0．75mL／节段（阻滞T5-T12脊神经）,C组给予相同容积的生理盐水。硬膜外给药15min后,夹闭肝左动脉及门静脉左支45min,然后开放肝左动脉及门静脉左支进行再灌注4h。分别在缺血前（TO）,缺血末（T1）,再灌注1h（T2）,2h（T3）,4h（T4）采血样用于测定AST,ALT,NO,ET-1,TNF-α,IL-1β和ATP。实验结束后取肝脏组织样本测定MDA和观察肝脏病理变化。结果：E组各时点MAP水平低于C组,有统计学差异（P〈0．05）;pH值以及PaC02两组间无明显差异;E组各时点AST,ALT,ET-1,TNF-α,IL-1β浓度低于C组,有统计学差异（P〈0．05）,NO及ATP浓度高于C组,有统计学差异（P〈0．05）;MDA含量c组高于E组,有统计学差异（P〈O．05）。光镜下可见E组肝组织损伤程度轻于C组。结论：胸段硬膜外阻滞可以增加肝脏能量的生成,纠正NO／ET的失衡,减少促炎介质的生成,从而改善微循环障碍的程度减轻肝缺血再灌注损伤。     

胸段硬膜外麻醉对心肌缺血再灌注损伤的影响

摘要 目的：心肌缺血再灌注损伤常常会导致心肌的凋亡和坏死,有研究表明胸段硬膜外麻醉（Thoracic epidural anesthesia,TEA）在心肌缺血再灌注损伤中的作用,因此,我们建立了心肌缺血损伤模型和胸段硬膜外麻醉模型来探讨胸段硬膜外麻醉对大鼠心肌缺血再灌注损伤(Myocardial ischemia-reperfusion injury,I/R)的影响。方法：SPF小鼠60只,随机分为正常组、I/R组及TEA组,分别采用TTC、HE染色、免疫组化、Western-blot等方法检测各组小鼠心肌组织及相关蛋白表达情况。结果：1.与正常组比较,I/R组和TEA组有较高的心肌梗死面积。与I/R组相比,TEA组心肌梗死面积明显减少,差异具有统计学意义（P<0.05）。2.TEA组上调了Akt、Hes1和Bcl-2的蛋白表达,下调了Notch 1、DTNA、BAX和HIF-1α的表达。结论：TEA对小鼠心肌缺血再灌注损伤具有保护作用。     

静脉全麻复合硬膜外麻醉行食管癌手术观察

目的 观察静脉全麻复合硬膜外麻醉行食管癌手术的麻醉及对循环、呼吸功能的影响。方法 36例食管癌病人随机分为静脉全麻组和静脉全麻复合硬膜外麻醉组各18例。分别监测麻醉前、麻醉插管后、游离食管时以及拔管后平均动脉压（MAP）、心率（HR）、呼吸频率（RR）、脉搏血氧饱和度（SpO2）、分钟通气量（MV）。结果 发现静脉全麻配合硬膜外麻醉行食管癌手术时MAP、HR、RR、SpO2、MV各时期与麻醉前相比无明显变化（P＞0．05）;单纯静脉全麻组各时期与麻醉前比较有明显或高或增快,MAP、HR（P＜0．05或P＜0．01）。结论 静脉全麻配合硬膜外麻醉行食管癌手术可提高麻醉质量,降低围术期应激反应,保持循环、呼吸功能稳定,静脉用药量少,且保证术后良好的镇痛作用。     

寰枢关节尾向置管建立上胸段硬膜外阻滞大鼠模型

目的为持续上胸段硬膜外阻滞的试验研究提供稳定可靠的动物模型。方法以大鼠为研究对象,经寰枢关节尾向于硬膜外腔置入PE-10导管,采用特殊的固定和管理措施。4周后,大鼠硬膜外腔注入美蓝100μL/kg,尸检鉴定模型成功和药液的分布范围。结果置管后4周的成功率为65%,硬膜外腔的感染率为2.5%。结论本研究证实了经寰枢关节尾向置管建立持续上胸段硬膜外模型和特殊管理的可行性,并具有成功率高,稳定性好的特点。     

胸4～5椎间隙直视下硬膜外头端置管建立上胸段硬膜外阻滞大鼠模型

目的为上胸段硬膜外阻滞的动物试验研究提供经济、稳定、可靠的模型。方法以大鼠为研究对象,经胸4～5椎间隙,直视下向头端于硬膜外腔置入经拉撕等处理后的临床用硬膜外导管,采用椎旁肌肉缝扎导管,皮下隧道预留缓冲长度等方法固定导管。48 h后大鼠硬膜外腔注入美蓝100μL/kg,尸检鉴定模型成功和药液的分布范围。结果置管48 h后的成功率为85.8%,硬膜外腔的感染率为0,导管脱出几率5%。结论本研究证实了经胸4～5椎间隙直视下头端置管建立上胸段硬膜外阻滞大鼠模型的可行性,并具有损伤小、稳定性好、成功率高、费用低及周期短等优点。     

不同容量胸段经椎间孔硬膜外注射阻滞范围的CT影像研究及诊断性阻滞的可行性分析

摘要 目的：探讨不同容量对胸段经椎间孔硬膜外注射（TFEI）药液扩散范围和镇痛效果的影响以及胸段TFEI用于诊断性阻滞的可行性。方法：选择2021年1月至2022年12月南京大学医学院附属鼓楼医院收治的胸段带状疱疹相关疼痛患者140例,随机分为4组,实施单次TFEI并分别注入不同容量含造影剂局麻药（A组：0.2 mL;B组：0.5 mL;C组：1.0 mL;D组：2 mL）,CT扫描并观察造影剂在硬膜外向头侧、尾侧及总扩散节段,造影剂在椎间孔、同侧椎旁间隙、同侧及对侧硬膜外间隙扩散情况,判断是否为选择性神经根阻滞。评估注射前、注射后30分钟及24小时视觉模拟评分（VAS）。结果：头侧和尾侧扩散节段以及总扩散节段数,D组最多,A组最少（P<0.05）;C组、D组造影剂扩散≥3个节段发生率明显高于B组（P<0.05）;C组、D组病例造影剂扩散至同侧椎旁间隙和对侧硬膜外间隙的发生率明显高于A组、B组（P<0.05）,仅A组37.1%的病例实现选择性神经根阻滞,其余各组均无选择性阻滞病例。注射后30分钟,C、D组VAS评分显著低于A、B组（P<0.05）;注射后24小时,D组VAS评分显著低于A、B组（P<0.05）。结论：胸段带状疱疹相关疼痛患者TFEI药液扩散范围随注射容量的增加而扩大,且在硬膜外倾向于头侧扩散,2 mL容量单次TFEI可阻滞3个以上的神经节段,获得良好的镇痛效果。胸段TFEI行诊断性阻滞的可行性较差。     

高位硬膜外阻滞用于乳腺癌改良根治术的临床观察

目的探讨1．33％利多卡因用于高位硬膜外阻滞乳腺癌改良根治术麻醉中对呼吸、循环功能的影响。方法选择ASAⅠ～Ⅱ级拟行乳癌根治术患者60例,随机分为1．33％利多卡因组（A组）和0．25％布比卡因组（B组）,每组各30例。于T2～3间隙行硬膜外穿刺,向头端置管,分别注入1．33％利多卡因或0．25％布比卡因。结果两组硬膜外阻滞效果均满意．注入局麻药后两组RR增加（P〈0．05）,BP降低（P〈0．05或〈0．01）,A组RR增加和BP下降幅度小于B组（P〈0．05或〈0．01）。硬膜外阻滞后A组SpO2维持在96％～97％,无呼吸困雌发生,8组出现轻度呼吸困难4例。结论1.33％利多卡因用于高位硬膜外阻滞施行乳腺癌改良根治术的麻醉效果满意,对通气功能的抑制比0．25％布比卡因轻。     

不同麻醉和镇痛方法对食管癌手术患者生活质量的影响

目的:观察不同麻醉和镇痛方法下食管癌手术患者生活质量的影响情况.方法:将56例食管癌手术患者按入院顺序随机分为A组(n=28)和B组(n=28),A组患者采用全凭静脉麻醉,术后行患者自控静脉镇痛;B组患者采用胸段硬膜外阻滞复合静脉全麻,术后行患者自控硬膜外镇痛.术前和术后采用欧洲癌症研究与治疗组织(EOR℃)QLQ-C30生命质量问卷(中文版)进行调查,比较两组患者生命质量的变化情况.结果:A组患者手术前食欲丧失项目的评分明显低于手术后(P＜0.05),其他子量表的评分手术前后差异均没有统计学意义(P＞0.05);而B组食管癌患者手术前总体健康状况和食欲丧失项目的评分明显低于手术后,疲倦和疼痛项目评分明显高于手术后(P＜0.05),其他子量表的评分手术前后差异均没有统计学意义(P＞0.05).A和B组患者的各子量表评分差异均没有统计学意义(P＞0.05).结论:胸段硬膜外阻滞复合静脉全麻及术后患者自控硬膜外镇痛可以影响食管癌患者术后的部分症状,但是不同麻醉和镇痛方法对患者的生活质量的差异不明显.     

Appendectomy in rabbits with extended unilateral anesthesia.

Thoracic paravertebral anesthesia was not believed to accompany numbness in the lumbar nerve region. However, we recently discovered that thoracic paravertebral anesthesia could produce analgesia in the lumbar region. We called this block extended unilateral anesthesia. In this study, appendectomy was attempted in rabbits with extended unilateral anesthesia. After a catheter was inserted into the endothoracic fascia in the paravertebral region on the right side at the level of the 11th thoracic vertebra, a 3-ml dose of 2% mepivacaine was injected repeatedly through the catheter. After an injection of the local anesthetic we could observe motor and sensory paralysis unilaterally from the chest down to the lower limb in all the rabbits, the extended unilateral anesthesia. With this anesthesia, we could accomplish appendectomy. This is the initial report of extended unilateral anesthesia applied to appendectomy in rabbits. We think that this anesthesia could be beneficial in future medical and veterinary use.     

Reversal of medetomidine-ketamine combination anesthesia in rabbits by atipamezole.

This study was performed to determine the optimal reversal dosage of atipamezole on medetomidine-ketamine combination anesthesia. The subject rabbits were divided into five groups (n=5/group), and all were anesthetized with intravenous medetomidine (0.35 mg/kg) and ketamine (5 mg/kg). Atipamezole was administered intravenously 35 min after administration of the medetomidine-ketamine mixture, at doses of a quarter, a half, equal, or two times higher than the preceding medetomidine -ketamine dose according to experimental group. Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR) and rectal temperature (RT) were measured every five minutes and the mean arousal time (MAT) was also recorded. This study revealed that the optimal atipamezole dosage to achieve reversal effects is equal to or double the dose of medetomidine. At these dosages, HR and MAP significantly recovered and MAT was significantly shortened with no side effects being observed (p<0.05).     

A comparison of medetomidine-propofol and medetomidine-midazolam-propofol anesthesia in rabbits.

We evaluated and compared the effects of medetomidine-propofol and medetomidine-midazolam-propofol anesthesia in rabbits. Fourteen New Zealand White rabbits were randomly assigned to receive either medetomidine (0.25 mg/kg, i.m.)-atropine (0.5 mg/kg, i.m.)-propofol (4 mg/kg, i.v.) (n = 7) or medetomidine (0.25 mg/kg, i.m.)-atropine (0.5 mg/kg, i.m.)-midazolam (0.5 mg/kg, i.m.)-propofol (2 mg/kg, i.v.) (n = 7). Five minutes after medetomidine-atropine or medetomidine-atropine-midazolam i.m. injection, propofol was administered i.v. Both medetomidine and medetomidine-midazolam rapidly (within 5 minutes) immobilized all rabbits and greatly eased the i.v. administration of propofol. Endotracheal intubation was accomplished easily after propofol injection in both groups. There was no significant difference between medetomidine-propofol and medetomidine-midazolam-propofol-treated rabbits in heart rate, respiratory rate, mean arterial pressure, or end-tidal CO2. The addition of midazolam to the medetomidine-propofol regimen significantly (P < 0.05) prolonged the duration of ear-pinch analgesia (25.0 +/- 7.1 vs. 36.7 +/- 8.9 minutes), the time from extubation to sternal recumbency (0.0 vs. 26.7 +/- 8.1 minutes), and the time from extubation to standing (0.0 vs. 39.5 +/- 11.3 minutes) without inducing significant changes in arterial blood pressure and end-tidal alveolar CO2. We consider both medetomidine-propofol and medetomidine-midazolam-propofol combinations to be safe and effective regimens for induction and short-term anesthesia in rabbits.     

Rheological properties of the thoracic aorta in normal and WHHL rabbits

The tension-strain, stress-strain and stress relaxation curves of longitudinal and circumferential strips of proximal thoracic aortas in normal and WHHL rabbits of different ages were determined using a tensile testing instrument. Wall distensibility of longitudinal and circumferential strips was the greatest in the normal aorta and decreased with advancing age in the atherosclerotic aorta. The wall thickness of the atherosclerotic aorta was positively related to age with a correlation coefficient of 0.66(p less than 0.01). The incremental elastic moduli calculated from the stress-strain curves increased with advancing age in the atherosclerotic aorta. Accordingly, the decreased distensibility of the atherosclerotic wall may be due to the increased wall thickness caused by the intimal thickening as well as to the increase in wall stiffness caused by the increased elastic modulus. The viscoelasticity of the atherosclerotic aorta was larger than that of the normal aorta. This reflects the mechanical effect of atherosclerotic changes that occurred in the thickened intima.