双侧腹横肌平面阻滞复合双侧腹直肌鞘阻滞在腹腔镜胆囊切除术中的应用

摘要

Objective To evaluate the efficacy and safety of bilateral transversus abdominis plane block (TAPB)combined with bilateral rectus sheath block (RSB)in abdominal surgery. Methods Ninety ASA Ⅰ or Ⅱ patients,35 males,55 females,aged 19-79 years,with body mass index 18-30 kg/m2 ,scheduled for elective laparoscopic cholecystectomy were randomly divided into three groups(n=30):ultrasound-guided bilateral TAPB combined with bilateral RSB group (group TR),ultrasound-guided bilateral TAPB group (group T),patient-controlled intravenous analgesia (PCIA)group (group P).In group TR,ultrasound-guided bilateral TAPB were performed with 20 ml of 0.22% ropivacaine mesylate injection in each side and ultrasound-guided bilateral RSB were per-formed with 10 ml of 0.22% ropivacaine mesylate injection in each side before surgery.In group T, ultrasound-guided bilateral TAPB were performed with 20 ml of 0.22% ropivacaine mesylate injection in each side and ultrasound-guided bilateral RSB were performed with 10 ml of NS in each side before surgery.In group P,ultrasound-guided bilateral TAPB were performed with 20 ml of NS in each side and ultrasound-guided bilateral RSB were performed with 10 ml of NS in each side before surgery, and PCIA was applied in group P.BP,HR,SpO2 were observed when patients were sent into the op-erating room, 2 minutes before trocar puncture, and 2 minutes after trocar puncture, the consumption of propofol and remifentanil used during the surgery were recorded.The score of visual analogue scale (VAS)during rest and movement were recorded at 2,6,12,24 h after surgery.The patient analgesia satisfaction and the adverse reactions were recorded.Results Compared with group T and group P,group TR had less change of BP before and after trocar puncture(P <0.05).The VAS score was significantly lower in group TR after operation(P <0.05).There were no statistical significant differences of VAS score at 24 h after operation among the three groups.The patient anal-gesia satisfaction was significantly better in group TR than other two groups (P < 0.05 ). Conclusion Ultrasound-guided bilateral transversus abdominis plane block combined with bilateral rectus sheath block is of safety and much efficacy of postoperative analgesia in patients undergoing laparoscopic cholecystectomy.%目的：观察双侧腹横肌平面复合双侧腹直肌鞘阻滞在腹腔镜胆囊切除术患者中的镇痛效果及安全性。方法选择2015年5～9月拟在全麻下行腹腔镜胆囊切除术的患者90例，男35例，女55例，年龄19～79岁，BMI 18～30 kg／m2，ASA Ⅰ或Ⅱ级。将患者随机分为双侧腹横肌平面阻滞复合双侧腹直肌鞘阻滞组（TR 组）、腹横肌平面阻滞组（T 组）和静脉镇痛泵镇痛组（P 组），每组30例。麻醉诱导前，TR 组在超声引导下双侧腹横肌平面分别注射0.22％甲磺酸罗哌卡因20 ml，双侧腹直肌后鞘分别注射0.22％甲磺酸罗哌卡因10 ml；T 组在超声引导下双侧腹横肌平面分别注射0.22％甲磺酸罗哌卡因20 ml，双侧腹直肌后鞘分别注射生理盐水10 ml；P 组在超声引导下双侧腹横肌平面分别注射生理盐水20 ml，双侧腹直肌后鞘分别注射生理盐水10 ml，P 组术后使用 PCIA （配方：舒芬太尼50μg＋生理盐水50 ml）。记录三组患者入室后5 min（T1）、腹腔穿刺导入器置入前2 min （T2）和和置入后2 min （T3）的 SBP、DBP、HR、SpO2，术中瑞芬太尼及丙泊酚的用量，术后2、6、12、24 h 患者腹腔穿刺孔静态和动态视觉模拟疼痛（VAS）评分，同时评价术后镇痛满意度，记录不良反应的发生情况。结果与 T 组和 P 组比较，TR 组患者在腹腔穿刺导入器穿刺前后血压波动较小（P ＜0.05）；术后2、6、12 h TR 组剑突下穿刺孔的静态和动态 VAS 评分明显低于 T 组和 P 组（P＜0.05）；术后2、6 h TR 组脐穿刺孔的静态 VAS 评分和术后2、6、12 h TR 组脐穿刺孔的动态 VAS评分明显低于 T 组和 P 组，术后12 h TR 组脐穿刺孔的静态 VAS 评分明显低于 P 组（P ＜0.05）；术后2、6、12 h TR 组右侧肋缘下穿刺孔的静态和动态 VAS 评分明显低于 P 组（P ＜0.05），术后24 h三组患者的 VAS 评分差异无统计学意义，TR 组术后镇痛满意度明显高于 T 组和 P 组（P ＜0.05）。结论双侧腹横肌平面复合双侧腹直肌鞘阻滞应用于腹腔镜胆囊切除术患者有助于术中循环稳定，术后镇痛效果好，具有安全性。