斜肋下腹横肌平面阻滞用于腹腔镜胆囊切除术后的镇痛研究

摘要

目的 探讨腹腔镜引导斜肋下入路腹横肌平面阻滞用于腹腔镜胆囊切除术后的镇痛效果.方法 择期腹腔镜胆囊切除手术全麻患者40例,用随机数字表法均分为两组,斜肋下腹横肌平面阻滞组(A组)与静脉镇痛组(B组).A组于术后行腹腔镜引导斜肋下入路双侧腹横肌平面阻滞,分别注射0.25％罗哌卡因(含5 mg·L-1肾上腺素)30 mL同时静脉泵注生理盐水2mL·h-1.B组同样行腹腔镜引导斜肋下入路双侧腹横肌平面穿刺注射30 mL生理盐水而静脉泵注舒芬太尼1 mg·L-1,2mL h-1.当视觉模拟(VAS)评分≥4分或患者需要时单次静注吗啡1 mg作镇痛补救.比较两组术后1、4、8、12和24h的VAS评分;Ramsay镇静评分;首次吗啡使用时间,记录术后24h单次静注吗啡次数、吗啡的总用量、镇痛满意度、观察并记录术后注药完毕、1、4、8、12、24 h收缩压(SBP)、舒张压(DBP)、心率(HR)的变化及不良反应发生率.结果 A组术后1、4、8、12 h的VAS评分均低于B组(P＜0.01),而24 h及Ramsay镇静评分差异无统计学意义.术后24 h吗啡的使用情况:A组和B组首次注射时间分别为(7.0±0.5)h和(3.0±0.9)h(P＜0.01);补充次数分别为(1.6±0.6)次和(3.2±0.7)次(P＜0.01);总用量分别为(1.6±0.6) mg和(3.2±0.7) mg(P＜0.01).镇痛满意度B组97分高于A组93分;两组生命体征平稳,组间比较差异无统计学意义(P＞0.05);B组发生恶心、呕吐等不良反应2例,A组则无不良反应发生;两组均无穿刺部位血肿、感染及皮肤瘙痒、呼吸抑制、尿潴留等不良反应的发生.结论 腹腔镜引导斜肋下腹横肌平面阻滞在腹腔镜胆囊切除术后能提供有效的镇痛,减少术后静脉镇痛药的需要量及不良反应发生率.%Objective To explore the analgesic effect of laparascopic-guided oblique subcostal transversus abdominis plane block (LOS-TAPB) after laparascopic cholecystectomy.Methods Forty adult patients undergoing laparoscopic cholecystectomy under standard general anesthesia were randomly assigned into LOS-TAPB group and PCIA group,which were termed as groups A and B.Group A was treated with bilateral laparascopic-guided oblique subcostal transversus abdominis plane block by using 0.25％ ropivacaine plus 5 mg · L-1 epinephrine 30 ml in each side (60 mL in total) together with 100 ml continuous pump of saline infusion 2 mL · h-1 (n =20);group B was intravenous analgesia group,also treated with bilateral laparascopic-guided oblique subcostal transversus abdominis plane block by using 30 ml saline on each side and continuous pump of sufentanil 1 mg · L-1,2 mL · h-1 (n =20).An intravenous injection of 1 mg of morphine was conducted when visual analogue scale (VAS) was equal or greater than 4 points or when it was in the need of the patients.Comparison was made of the VAS scores between these two groups on 1hr,4hrs,8hrs,12hrs and 24hrs postoperatively,Ramsay sedation score,the recorded time for first morphine use.And observations were made of the total number of single intravenous injection of morphine,total consumption,analgesia satisfaction,changes in systolic blood pressure (SBP),diastolic blood pressure (DBP),heart rate (HR) immediately after the injection and on 1 hr,4hrs,8hrs,12hrs and 24hrs postoperatively and the incidence of adverse reactions.Results The scores of the VAS on 1 hr,4hrs,8hrs,and 12hrs postoperatively in group A was significantly lower than group B (P ＜ 0.01);while score on 24hrs postoperatively and Ramsay sedation score in both groups showed no statistically significant differences (P ＞ 0.05).As for morphine use on 24hrs postoperatively,the first injection time of morphine in group A and group B was (7.0 ± 0.5) h and (3.0 ± 0.9) h,(P ＜ 0.01).The times of supplementation were (1.6 ± 0.6) and (3.2 ± 0.7) (P ＜ 0.01).The total dosage was (1.6 ± 0.6) mg and (3.2 ± 0.7)mg (P ＜ 0.01).The score of analgesia satisfaction in group B was higher than group A (97 points vs 93 points).Vital signs in both groups were stable and were not statistically different (P ＞ 0.05).There were two nausea and vomiting cases in group B,which was significantly higher than group A (no case was recorded).No puncture site hematoma,infection,itch of skin,respiratory depression,urinary retention and other adverse reactions occurred in both groups.Conclusions Oblique subcostal transversus abdominis plane blocks could indeed provide pain relieving outcomes and decrease the usage of postoperative intravenous analgesics and adverse reactions.