1、临床研究胸横肌平面阻滞对老年患者心肺转流下心脏瓣膜置换术后早期康复的影响张桦章扬文霜廖国豪杜航陈世彪DOI:1012089/jca202301005基金项目:江西省应用研究培育计划(20212BAG70034)作者单位:330038南昌市洪都中医院麻醉科(张桦);南昌大学第一附属医院麻醉科(章扬、陈世彪)，急诊科(杜航);江西省人民医院麻醉科(文霜);南昌大学第二附属医院急诊科(廖国豪)通信作者:陈世彪，Email:chenlaoshi1111 163com【摘要】目的探讨胸横肌平面(TTP)阻滞对老年患者心肺转流(CPB)下心脏瓣膜置换手术后早期康复的影响。方法选择择期行 CPB 下瓣膜置换
2、术的老年患者 58 例，男 39 例，女 19 例，年龄65 岁，BMI 1825 kg/m2，ASA 或级，NYHA 或级。采用随机数字表法将患者分为两组:胸横肌平面阻滞组(T 组)和对照组(C 组)，每组 29 例。T 组在麻醉诱导前使用超声定位于双侧45 肋间隙，在肋间内肌和胸横肌注入 0.25%罗哌卡因 20 ml。C 组直接行麻醉诱导。于术前1 d 和术后第 7 天采用神经心理组合量表评估患者的认知功能，记录术中舒芬太尼用量和术后早期认识功能障碍(POCD)的发生情况。记录麻醉诱导后切皮前 5 min、术后 24、72 h 的 S100 蛋白浓度。记录入手术室、麻醉诱导后切皮前 5
3、min、锯胸骨时、CPB 开始后 30 min、CPB 结束后 30 min、出手术室时的 H 和 MAP。分别于麻醉诱导后切皮前 5 min、CPB 开始后 30 min、CPB 结束后 30 min、术后 24、72h 检测血清 IL-6、TNF-浓度;检测麻醉诱导后切皮前 5 min、CPB 结束后 30 min、术后 72 h 的血糖和胰岛素浓度并计算各时点的胰岛素抵抗(I)指数。记录术后 24、72 h 的 VAS 疼痛评分、机械通气时间和 ICU 滞留时间。结果与 C 组比较，T 组术中舒芬太尼用量明显减少、术后第7 天 POCD 的发生率(45%vs 21%)明显降低(P0.05
4、)，术后24、72 h 血清 S100 蛋白浓度明显降低(P0.05)，锯胸骨时 H 明显减慢、MAP 明显降低(P0.05)，CPB 开始后 30 min、CPB 结束后 30 min 和术后 24 h 血清IL-6 浓度明显降低(P0.05)，CPB 开始后 30 min、CPB 结束后 30 min 血清 TNF-浓度明显降低(P0.05)，CPB 结束后 30 min 和术后 24 h 的 I 指数明显降低(P0.05)，术后 24 h 的 VAS 疼痛评分明显降低、机械通气时间和 ICU 滞留时间明显缩短(P0.05)。结论TTP 阻滞可有效降低老年患者CPB 下瓣膜置换术后早期 P
5、OCD 的发生率，有利于维持术中血流动力学稳定、减轻围术期炎症反应、改善 I 指数，从而促进患者术后早期康复。【关键词】术后认知功能;胸横肌平面阻滞;心肺转流;心脏瓣膜置换术Effect of transverse thoracic muscle plane block on early outcomes after valve replacement undercardiopulmonary bypass in elderly patientsZHANG Hua，ZHANG Yang，WEN Shuang，LIAO Guo-hao，DU Hang，CHEN Shibiao Departmen
6、t of Anesthesiology，Nanchang Hongdu Hospital of TCM，Nanchang 330038，ChinaCorresponding author:CHEN Shibiao，Email:chenlaoshi1111 163com【Abstract】ObjectiveTo investigate the effect of transverse thoracic muscle plane(TTP)blockon early outcomes after valve replacement under cardiopulmonary bypass(CPB)i
7、n elderly patientsMethodsFifty-eight elderly patients，39 males and 19 females，aged 65 years，ASA physical status or，and NYHA cardiac function class or，who underwent elective valve replacement under generalanesthesia with cardiopulmonary bypass were selected The patients were randomly divided into two
8、 groupsby random number table method:transversus pectoralis plane block group(group T)and control group(group C)，29 patients in each Before anesthesia induction，the patients in group T were located in the bi-lateral 45 costal space by ultrasound，and 0.25%ropivacaine 20 ml was injected into the inter
9、costal mus-cle and transverse thoracic muscle Patients in group C were induced by direct anesthesia The patientscognitive function was evaluated by neuropsychological combined scale on the first day before operation andseventh days after operation The intraoperative sufentanil consumption and incide
10、nce of postoperative cogni-tive dysfunction(POCD)were recorded The S100 protein was recorded at 5 minutes before skin incisionafter anesthesia induction，24 hours after surgery，and 72 hours after surgery When patients entered the op-32临床麻醉学杂志 2023 年 1 月第 39 卷第 1 期J Clin Anesthesiol，January 2023，Vol39
11、，No1erating room，5 minutes before skin incision after anesthesia induction，the sternum was sawed，30 minutesafter the start of CPB，30 minutes after the end of CPB，and out of the operating room，H and MAP wererecorded Serum IL-6 and TNF-concentrations were respectively recorded 5 minutes before skin in
12、cisionafter anesthesia induction，30 minutes after the start of CPB，30 minutes after the end of CPB，24 hours af-ter surgery，and 72 hours after surgery Concentrations of insulin and blood glucose concentrations were re-corded，and the insulin resistance(I)index was calculated 5 minutes before skin inci
13、sion after anesthesiainduction，30 minutes after the end of CPB，and 72 hours after surgery The VAS scores at 24 and 72 hoursafter surgery，mechanical ventilation time，ICU stay time were recorded esultsCompared with group C，the amount of sufentanil used during operation and the incidence of POCD in gro
14、up T(45%vs 21%)wassignificantly lower than that in group T(P 0.05)Compared with group C，the concentration of serumS100 protein 24 hours and 72 hours after operation in group T were significantly decreased(P 0.05)，the H and MAP of the T group decreased significantly during the sternum was sawed(P 0.0
15、5)Com-pared with group C，the concentrations of IL-6 in group T were significantly decreased 30 minutes after thestart of CPB，30 minutes after the end of CPB，and 24 hours after surgery(P 0.05);the concentrationsof TNF-in group T were significantly decreased 30 minutes after the start of CPB，and 30 mi
16、nutes after theend of CPB(P 0.05);the I index of group T were significantly lower 30 minutes after the end of CPBand 24 hours after surgery(P 0.05)Compared with group C，the VAS score at 24 hours after surgery，mechanical ventilation time and ICU stay time in group T were significantly reduced(P 0.05)ConclusionTransverse thoracic muscle plane block can effectively reduce the incidence of early POCD af-ter valve replacement under cardiopulmonary bypass in old patients，moreover，it can maintain hemod
