目的:研究超声引导下不同入路的腹横肌平面阻滞与切口局部浸润麻醉在腹腔镜肾切除术后镇痛的疗效.方法:收集静脉复合麻醉下后腹腔镜单侧肾切除术患者60例,按数字随机表法分三组(每组20例):超声引导下腹横肌平面阻滞侧路法组(TM1组),后路法组(TM2组)与切口局部浸润组(M组).麻醉诱导采用静脉注射舒芬太尼、阿曲库铵和丙泊酚,气管插管后机械通气,全麻维持用静脉持续泵注丙泊酚和瑞芬太尼,间断注射阿曲库铵维持肌松,术中BIS值在40~60之间波动.麻醉诱导后三组均注射0.375%罗哌卡因30 mL,阻滞成功30 min后开始手术.三组患者拔管清醒后连接患者自控镇痛泵(PCA)作为镇痛补救用药.记录切皮前后患者心率、血压变化;术后2、6、12、24、48 h VAS评分、Ramsay评分及腹部阻滞平面范围;术后0~1、1~6、6~12和12~24 h时段记录舒芬太尼用量;记录患者术后首次下床活动时间、镇痛满意度及恶心、呕吐发生情况.结果:与M组相比,TM1和TM2组患者切皮前后血压、心率改变无明显差异(P>0.05);与M组相比,TM1和TM2组患者术后6、12、24、48 h VAS评分均下降(P<0.05),但TM1和TM2组患者术后2、4、6、12、48 h的VAS评分无明显差异(P>0.05);TM1和TM2组患者术后6、12 h时间点Ramsay评分高于M组(P<0.05),术后2、24、48 h无明显差异(P>0.05),且TM1和TM2两组间无明显差异(P>0.05);术后TM1和TM2两组患者腹壁阻滞平面6 h内在T4~T10之间,6~12 h平面在T9,12 h以后消失,能够维持较好的镇痛;与M组相比,TM1和TM2组术后0~1、1~6、6~12和12~24 h舒芬太尼量均低于M组(P<0.05);与M组相比TM1和TM2组术后镇痛满意度的更高(P<0.05),患者恶心呕吐发生率更低(P<0.05).结论:两种不同入路超声引导下腹横肌平阻滞均可对后腹腔镜肾切除术提供良好的术后镇痛效果,且均优于局部切口浸润阻滞.%Objective To investigate the efficacy of ultrasound-guided different road transversus abdominis plane block and incision local infiltration on analgesia after laparoscopic nephrectomy. Methods Sixty patients with retroperitoneal laparoscopic unilateral nephrectomy under combined intravenous anesthesia were collected. According to digital random table method, 60 patients were divided into three groups (n= 20): ultrasound-guided dypass road transversus abdominis plane block group (Group TM1), posterior road group (Group TM2), and incision local infiltration group (Group M). Anesthesia was induced by intravenous injection of sufentanil, atracurium and propofol, using mechanical ventical with tracheal intubation, continuous intravenous infusion of propofol and remifentanil, and intermittent injection of atracurium to maintain muscle relaxation. The BIS value undulated between 40 and 60 during the operation. After anesthesia induction, 0.375%ropivacaine (30 mL) was given, and the operation began after 30 min. The patients in three groups were connected with patient controlled analgesia pump (PCA) as a remedy for analgesia. Changes of heart rate and blood pressure were recorded before and after cutting. The VAS scores, Ramsay scores and abdominal block levels were evaluated at 2, 6, 12, 24 and 48 h after operation. The dosages of sufentanil were recorded during the periods of 0–1, 1–6, 6–12 and 12–24 h after operation, and the first time of getting out of bed after operation, satisfaction of analgesia and occurrence of nausea and vomiting were recorded. Results Compared with M group, there was no significant difference on blood pressure and heart rate in TM1 and TM2 groups before and after skin incision (P>0.05). Compared with M group, the VAS scores in TM1 and TM2 groups were lower at 6, 12, 24 and 48 h after operation (P<0.05), but the VAS scores in TM1 and TM2 groups had no significant difference at 2, 4, 6, 12 and 48 h after operation (P>0.05). The Ramsay scores in TM1 and TM2 groups were significantly higher than those in M group at 6 and 12 h after operation (P<0.05), but there was no significant difference at 2, 24 and 48 h after operation (P>0.05), and there was no significant difference between TM1 and TM2 groups (P>0.05). The abdominal wall block levels of TM1 and TM2 patients were between T4 and T10 within 6 h after operation, the plane was in T9 at 6–12 h, and it disappeared after 12 h, which could maintain better analgesic effect. Compared with M group, the levels of sufentanil in TM1 and TM2 groups were lower than those in M group at 0–1, 1–6, 6–12 and 12–24 h after operation (P<0.05). Compared with M group, TM1 and TM2 groups had higher postoperative analgesia satisfaction (P<0.05) and lower incidence of nausea and vomiting (P<0.05). Conclusion Both different approaches of ultrasound-guided lower abdominal transverse muscle block can provide good postoperative analgesic effect for retroperitoneal laparoscopic nephrectomy, and are better than local incision infiltration block.
展开▼
