高胸段硬膜外阻滞在手术中应用的研究进展

doi:10.13481/j.1671-587x.20200237

摘要/Abstract

摘要： 高胸段硬膜外阻滞（HTEA）通过在T3-4或T4-5棘突间隙内穿刺、置管，注入麻醉药物后选择性阻断起始于T1~T5的传入和传出神经。近年来研究显示：HTEA可有效缓解疼痛，解除冠脉痉挛和防止血栓形成，减少儿茶酚胺的释放，扩张冠脉血管，改善心室壁的运动能力，改善心肌血液供应和新陈代谢，减弱心肌自噬和细胞凋亡导致的缺血再灌注损伤，最终逆转心室重构，并且能减少炎症介质释放，保护易受损的心肌，并能减小患者术后应激的表现，更好地维持患者葡萄糖代谢，还可改善术后患者呼吸功能，减少患者阿片类药物使用量，缩短住院时间。目前HTEA已广泛用于心脏外科和胸外科等手术的围术期管理，并对加速康复外科有着积极作用。现综合分析最新相关文献，阐述HTEA在多种手术中的应用及可能存在的机制，分析现有技术存在的不足及争议，并展望HTEA的发展趋势。

关键词: 麻醉, 硬膜外阻滞, 冠状动脉旁路移植术, 胸科手术

中图分类号:

R614.3

王赫, 朴光宇, 黄学洙. 高胸段硬膜外阻滞在手术中应用的研究进展[J]. 吉林大学学报(医学版), 2020, 46(02): 425-430.

参考文献

[1] GRIFFITHS D P, DIAMOND A W, CAMERON J D. Postoperative extradural analgesia following thoracic surgery:a feasibility study[J]. Br J Anaesth, 1975,47(1):48-55.
[2] HASENBOS M, LIEM T H, KERKKAMP H, et al. The influence of high thoracic epidural analgesia on the cardiovascular system[J]. Acta Anaesthesiol Belg, 1988,39(1):49-54.
[3] JAKOBSEN C J. High thoracic epidural in cardiac anesthesia:a review[J]. Semin Cardiothorac Vasc Anesth,2015,19(1):38-48.
[4] WANG X, CHEN G, YANG S, et al. Effects of high thoracic epidural anesthesia on ischemic cardiomyopathy cardiac function and autonomic neural function[J]. Genet Mol Res, 2014,13(3):6813-6819.
[5] MA D, LIU L, ZHAO HW, et al.Thoracic epidural anesthesia reversed myocardial fibrosis in patients with heart failure caused by dilated cardiomyopathy[J]. J Cardiothorac Vasc Anesth,2017,31(5):1672-1675.
[6] 陈国忠,李中言,窦元元,等.高位胸段硬膜外阻滞治疗顽固性心绞痛的临床研究[J].中国疼痛医学杂志,2001,7(3):149-151.
[7] WINK J, VEERING B T, AARTS L, et al. Effects of thoracic epidural anesthesia on neuronal cardiac regulation and cardiac function[J]. Anesthesiology,2019,130(3):472-491.
[8] BAINBRIDGE D, CHENG DC. Early extubation and fast-track management of off-pump cardiac patients in the intensive care unit[J]. Semin Cardiothorac Vasc Anesth, 2015,19(2):163-168.
[9] STENGER M, FABRIN A, SCHMIDT H, et al. High thoracic epidural analgesia as an adjunct to general anesthesia is associated with better outcome in low-to-moderate risk cardiac surgery patients[J]. J Cardiothorac Vasc Anesth,2013,27(6):1301-1309.
[10] 方波,陈杰,李晓倩,等.胸段硬膜外阻滞对冠脉搭桥术预后影响的系统评价[J].中国循证医学杂志,2010,10(8):932-938.
[11] SEN A C, RAJAN S, BALACHANDRAN R, et al. Comparison of perioperative thoracic epidural fentanyl with bupivacaine and intravenous fentanyl for analgesia in patients undergoing coronary artery bypass grafting surgery[J]. Anesth Essays Res,2017,11(1):105-109.
[12] GURSES E, BERK D, SUNGURTEKIN H, et al. Effects of high thoracic epidural anesthesia on mixed venous oxygen saturation in coronary artery bypass grafting surgery[J]. Med Sci Monit, 2013,19:222-229.
[13] MAHAJAN A, TAKAMIYA T, BENHARASH P, et al. Effect of thoracic epidural anesthesia on heart rate variability in a porcine model[J]. Physiol Rep,2017,5(7):e13116.
[14] BEKTAS S G, TURAN S, KARADENIZ U, et al. Does high thoracic epidural analgesia with levobupivacaine preserve myocardium? A prospective randomized study[J]. Biomed Res Int,2015,2015:658678.
[15] WU S,FU S Y,LIU F Q, et al. Use of a high thoracic epidural analgesia for treatment of end-stage congestive heart failure secondary to coronary artery disease:effect of HTEA on CHF[J]. Int J Cardiol,2008,125(2):283-285.
[16] NESKOVIC V, MILOJEVIC P, UNIC-STOJANOVIC D, et al. High thoracic epidural anesthesia in patients with synchronous carotid endarterectomy and off-pump coronary artery revascularization[J]. Vojnosanit Pregl,2013,70(12):1132-1137.
[17] ZHAO Y J, LIU F Q, XIU C H, et al. The effects of high thoracic epidural anesthesia on sympathetic activity and apoptosis in experimentally induced congestive heart failure[J]. J Cardiothorac Vasc Anesth, 2014,28(2):317-322.
[18] BIGELEISEN P E, GOEHNER N. Novel approaches in pain management in cardiac surgery[J]. Curr Opin Anaesthesiol, 2015,28(1):89-94.
[19] GREISEN J, NIELSEN D V, SLOTH E, et al. High thoracic epidural analgesia decreases stress hyperglycemia and insulin need in cardiac surgery patients[J]. Acta Anaesthesiol Scand,2013,57(2):171-177.
[20] ZAWAR B P, MEHTA Y, JUNEJA R, et al. Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients[J]. Ann Card Anaesth, 2015,18(3):385-391.
[21] 简文亭,简道林,王康乐,等.胸段硬膜外阻滞对家兔颈迷走神经传出放电的影响[J].临床麻醉学杂志,2014,30(9):897-900.
[22] LI Z M, LONG H Q, HUANG F Y, et al. Impact of epidural versus general anesthesia on major lumbar surgery in elderly patients[J]. Clin Spine Surg.,2019,32(1):E7-E12.
[23] JAKOBSEN C J, BHAVSAR R, NIELSEN D V, et al. High thoracic epidural analgesia in cardiac surgery. Part 1:high thoracic epidural analgesia improves cardiac performance in cardiac surgery patients[J]. J Cardiothorac Vasc Anesth,2012,26(6):1039-1047.
[24] MCLEAN S R, VON HOMEYER P, CHENG A, et al. Assessing the benefits of preoperative thoracic epidural placement for lung transplantation[J]. J Cardiothorac Vasc Anesth,2018, 32(6):2654-2661.
[25] HEMMERLING T M, ROMANO G, TERRASINI N, et al. Anesthesia for off-pump coronary artery bypass surgery[J]. Ann Card Anaesth. 2013,16(1):28-39.
[26] HUANG W Q, WEN J L, LIN R Q, et al. Effects of mTOR/NF-κB signaling pathway and high thoracic epidural anesthesia on myocardial ischemia-reperfusion injury via autophagy in rats[J]. J Cell Physiol. 2018,233(9):6669-6678.
[27] CHENG G S, ILFELD B M. An evidence-based review of the efficacy of perioperative analgesic techniques for breast cancer-related surgery[J]. Pain Med, 2017,18(7):1344-1365.
[28] GALVAGNO S M Jr, SMITH C E, VARON A J, et al. Pain management for blunt thoracic trauma:a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society[J]. J Trauma Acute Care Surg,2016,81(5):936-951.
[29] 陆惠元,范晓琳,赵辉,等.左旋布比卡因与布比卡因高位胸段硬膜外阻滞的麻醉和术后镇痛效果及对肺功能的影响[J].中国临床保健杂志,2015,18(6):618-621.
[30] MEHTA Y, VATS M, SHARMA M, et al. Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease[J]. Ann Card Anaesth, 2010,13(3):224-230.
[31] LI W, LI Y C, HUANG Q Y, et al. Short and long-term outcomes of epidural or intravenous analgesia after esophagectomy:a propensity-matched cohort study[J]. PLoS One,2016,11(4):e0154380.
[32] FARES K M, MOHAMED S, HAMZA H M, et al. Effect of thoracic epidural analgesia on pro-inflammatory cytokines in patients subjected to protective lung ventilation during Ivor Lewis esophagectomy[J]. Pain Physician,2014,17(4):305.
[33] 林浩,张绍刚,潘熊熊,等.硬膜外阻滞和术后镇痛对胸壁结核患者术后T细胞亚群及血浆皮质醇的影响[J].临床麻醉学杂志,2012,28(9):868-871.
[34] EGAN R J, HOPKINS J C, BEAMISH A J, et al.Randomized clinical trial of intraoperative superficial cervical plexus block versus incisional local anaesthesia in thyroid and parathyroid surgery[J]. Br J Surg,2013,100(13):1732-1738.
[35] BACUZZI A, DIONIGI G, DEL BOSCO A, et al. Anaesthesia for thyroid surgery:perioperative management[J]. Int J Surg,2008,6(Suppl 1):S82-S85.
[36] BELZARENA S D. Comparative study between thoracic epidural block and general anesthesia for oncologic mastectomy[J]. Rev Bras Anestesiol,2008,58(6):561-568.
[37] GROEBEN H, SCHÄFER B, PAVLAKOVIC G,et al. Lung function under high thoracic segmental epidural anesthesia with ropivacaine or bupivacaine in patients with severe obstructive pulmonary disease undergoing breast surgery[J].Anesthesiology, 2002,96(3):536-541.
[38] ETTA O E, UDEME N.Thoracic epidural for modified radical mastectomy in a high-risk patient[J]. Malawi Med J, 2017,29(1):61-62.
[39] LI X, HUO X, ZHANG C Y, et al. Role of continuous high thoracic epidural anesthesia in hippocampal apoptosis after global cerebral ischemia in rats[J]. Cell Physiol Biochem,2014,34(4):1227-1240.
[40] NIELSEN D V, BHAVSAR R, GREISEN J, et al. High thoracic epidural analgesia in cardiac surgery. Part 2:high thoracic epidural analgesia does not reduce time in or improve quality of recovery in the intensive care unit[J]. J Cardiothorac Vasc Anesth,2012,26(6):1048-1054.
[41] ROSEN D R, WOLFE R C, DAMLE A, et al. Thoracic epidural analgesia:Does it enhance recovery?[J]. Dis Colon Rectum,2018,61(12):1403-1409.
[42] KARLEKAR A, DUTTA D, DEV ARORA K, et al. Spinal-epidural hematoma presenting as paraplegia following mitral valve surgery:a case report[J].J Cardiothorac Vasc Anesth,2015,29(1):139-141.
[43] EMMERT A, GRIES G, WAND S, et al. Association between perioperative hypothermia and patient outcomes after thoracic surgery:A single center retrospective analysis[J]. Medicine (Baltimore), 2018,97(17):e0528.
[44] HONG J M, LEE H J, OH Y J, et al. Observations on significant hemodynamic changes caused by a high concentration of epidurally administered ropivacaine:correlation and prediction study of stroke volume variation and central venous pressure in thoracic epidural anesthesia[J]. BMC Anesthesiol,2017,17(1):153.
[45] SVIRCEVIC V, VAN DIJK D, NIERICH A P,et al.Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery[J].Anesthesiology, 2011,114(2):271-282.
[46] SALVI L, PAROLARI A, VEGLIA F, et al. High thoracic epidural anesthesia in coronary artery bypass surgery:a propensity-matched study[J]. J Cardiothorac Vasc Anesth,2007,21(6):810-815.
[47] BULTE C S, BOER C, HARTEMINK K J, et al. Myocardial microvascular responsiveness during acute cardiac sympathectomy induced by thoracic epidural anesthesia[J]. J Cardiothorac Vasc Anesth, 2017,31(1):134-141.