术前舌下含服褪黑素对胸腔镜肺叶切除术患者术后炎症反应及肺部并发症的影响

Effect of preoporative sublingual melatonin on postoperative inflammation and pulmonary complications in patients undergoing thoracoscopic lobectomy

关键词:  胸腔镜下肺叶切除术  褪黑素  炎症  术后肺部并发症  超氧化物歧化酶

Key words:  thoracoscopic lobectomy  melatonin  inflammation  postoperative pulmonary compli-cations  superoxide dismutase

摘要:

目的观察术前应用褪黑素对胸腔镜下肺叶切除术患者术后炎症反应及肺部并发症(postoperative pulmonary complications, PPCs)的影响。方法对2020年6月—2021年2月在同济大学附属东方医院胸外科择期行胸腔镜下肺叶切除术的患者83例，采用随机数字表将患者随机分为两组: 褪黑素组(M组)和对照组(C组)。M组于入室前30min舌下含服褪黑素0.4mg/kg；C组不做处理。两组患者均采用咪达唑仑0.04mg/kg，丙泊酚1.5~2.5mg/kg，舒芬太尼0.6μg/kg，罗库溴铵0.6mg/kg诱导麻醉，两组均给予右美托咪定0.5μg/kg静脉滴注，注射用帕瑞昔布钠40mg静脉推注。并行可视喉镜下双腔支气管插管，用纤维支气管镜检查正确的放置位置。术中静脉持续泵注丙泊酚4~8mg/(kg·h)，瑞芬太尼0.05~0.2μg/(kg·min)，顺式阿曲库铵0.1~0.15mg/(kg·h)，使BIS值维持在40~60；术后使用静脉自控镇痛装置(patient-controlled intravenous analgesia, PCIA)镇痛。观察并记录术后肺部并发症发生率(肺部感染、气胸、胸腔积液、肺不张、呼吸衰竭等)。分析术前及术后2、24、48h的中性粒细胞/淋巴细胞(neutrophil to lymphocyte ratio, NLR)、血小板/淋巴细胞(platelet to lymphocyte ratio, PLR)；术前及术后2、48h的白细胞介素6(interleukin 6, IL-6)、C反应蛋白(C-reactive protein, CRP)，超氧化物歧化酶(superoxide dismutase, SOD)；麻醉恢复室(postanesthesia care unit, PACU)及术后2、12、24h的VAS评分，住院时间以及术中麻醉药物使用情况等。结果与C组比较，M组术后全身炎症标志物水平(NLR、PLR、CRP、IL-6)降低(P<0.05)，并且能提高SOD水平(P<0.05)。与C组比较，M组术后肺部并发症的总体发生率显著降低(P<0.05)。此外M组能显著降低患者术后PACU的视觉模拟评分(visual analogue scale, VAS)，但对于术后2、12、24h的VAS评分及术中阿片类药物使用情况并无明显影响(P>0.05)。结论在胸腔镜下行肺叶切除手术患者术前舌下含服褪黑素可使术后全身炎症标志物(包括NLR、PLR、CRP、IL-6)降低，并且能提高SOD水平，降低术后肺部并发症的发生率。同时舌下含服褪黑素能降低胸腔镜下肺叶切除术患者在PACU的VAS评分，但对相关镇痛药物使用并无明显影响。

Abstract:

ObjectiveTo observe the effect of the preoperative application of melatonin on postoperative inflammation and pulmonary complications in patients undergoing thoracoscopic lobectomy. MethodsFrom June 2020 to February 2021, 83 patients who underwent thoracoscopic lobectomy at the Department of Thoracic Surgery, Tongji University Affiliated East Hospital, were randomly divided into melatonin group(Group M) and control group(group C). Group M received sublingual melatonin 0.4mg/kg 30min before entering the operation room; group C did not do any treatment. Both groups were given midazolam 0.04mg/kg, propofol 1.5-2.5mg/kg, sufentanil 0.6μg/kg, and rocuronium 0.6mg/kg to induce anesthesia. Both groups were given dexmedetomidine 0.5μg/kg intravenously, Teraline(parecoxib sodium for injection) 40 mg preemptive analgesia. And perform double-lumen bronchial intubation under visual laryngoscopy, and check the correct placement position with fiberoptic bronchoscopy. Intravenous continuous pump injection of propofol 4-8mg/(kg·h), remifentanil 0.05-0.2μg/(kg·min), and cis-atracurium 0.1-0.15mg/(kg·h) to maintain the BIS value between 40-60; Postoperatively, PCIA is used for analgesia. Observe and record the incidence of postoperative pulmonary complications(pulmonary infection, pneumothorax, pleural effusion, atelectasis, respiratory failure, etc.). The incidence of postoperative pulmonary complications were documented, Neutrophils/lymphocytes(NLR) and platelets/lymphocytes(PLR) before operation and 2h, 24h, 48h after operation were calculated; serum interleukin 6(IL-6), C-reactive protein(CRP), and superoxide dismutase(SOD) were measured before and 2h, 48h after operation. The VAS scores at PACU and 2h, 24h, 48h after operation, the length of hospital stay, and the use of intraoperative analgesics were documented. ResultsCompared with group C, the NLR, PLR, CRP, IL-6 levels in group M were decreased and SOD increased significantly(all P<0.05). Compared with group C, the overall incidence of postoperative pulmonary complications in group M was significantly lower(P<0.05). In addition, the M group significantly reduced the PACU VAS scores of patients after surgery, but it had no significant effect on the VAS scores of 2h, 12h, 24h and the use of opioids in the operation(P>0.05). ConclusionSublingual administration of melatonin in patients undergoing thoracoscopic lobectomy can reduce postoperative inflammation, and the incidence of postoperative pulmonary complications. At the same time, it can reduce the VAS pain score in PACU, but it has no significant effect on the use of related analgesics.