肋间神经阻滞联合静脉自控镇痛对胸腔镜手术患者术后镇痛效果的观察

Intercostal Nerve Blockade Combined with Patient-Controlled Intravenous Analgesia for Pain Relief after Video-Assisted Thoracoscopy

目的：观察肋间神经阻滞联合静脉自控镇痛对电视辅助胸腔镜手术患者术后的镇痛效果。方法：28例美国麻醉医师学会（ASA）分级Ⅰ-Ⅱ级、年龄19-65岁、无慢性疼痛史、择期行电视辅助胸腔镜手术的胸外科患者。患者随机分为2组：肋间神经阻滞联合静脉自控镇痛组（INB＋PCIA组）和静脉自控镇痛组（PCIA组）。2组患者在手术结束前由胸外科医师在胸腔镜直视下在放置胸腔引流管的肋间和上下各一肋间行肋间神经阻滞,INB＋PCIA组用0.375%罗哌卡因,PCIA组给予0.9%氯化钠液。所有患者均采用芬太尼静脉自控镇痛。随访患者术后4h、24h和48h在平静状态和躯体活动（如咳嗽）时的切口疼痛情况。疼痛评分采用视觉模拟评分法（VAS评分）。记录患者术后4h、24h和48h静脉自控镇痛芬太尼累积用量和术后恶心、呕吐的发生率。观察患者术后有无肋间神经阻滞引起的并发症。结果：2组患者年龄、性别和术后胸腔引流管放置数量均无显著差异。INB＋PCIA组患者在术后4h静息状态、躯体活动状态和24h躯体活动状态时的VAS评分显著低于PCIA组（P〈0.01）。2组患者在术后24h静息状态和48h静息状态、躯体活动时的VAS评分均无显著差异。INB＋PCIA组术后静脉镇痛所需芬太尼累积剂量显著低于PCIA组（P〈0.05）。PCIA组有2例患者需术后追加芬太尼,INB＋PCIA组无患者术后追加麻醉性镇痛药,2组间无显著差异（P〉0.05）。2组患者术后恶心、呕吐发生率无显著差异（P〉0.05）。2组患者均无肋间神经阻滞引起的并发症。结论：用0.375%罗哌卡因行肋间神经阻滞联合静脉自控镇痛的镇痛方式能减轻胸腔镜手术患者术后24h内的急性疼痛,并且能减少静脉自控镇痛阿片类药物的累积用量。

Objective：To asses the effect of intercostal nerve blockade associated with patient-controlled intravenous analgesia for pain relief after video-assisted thoracoscopy.Methods：Twenty-eight American Society of Anesthesiologists（ASA）Ⅰ-Ⅱ patients,aged between 19 to 65 years old,undergoing elective video-assisted thoracoscopy were randomized into two groups.An intercostal nerve block with ropivacaine 0.375% was applied at the end of the operation by surgeons in the INB＋PCIA group,while the PCIA group received 0.9% saline.Postoperative pain management was the same in both groups with patient-controlled intravenous analgesia with fentanyl.Main outcome was pain evaluated with visual analog scale（VAS） scores within 48 hours after video-assisted thoracoscopy at rest and moving like coughing.The cumulative amount of intravenous fentanyl used,and postoperation nausea and vomiting were the secondary outcomes.Results： There were no significant differences between patients of Group INB＋PCIA and Group PCIA regarding age,sex and number of chest tube insertion after video-assisted thoracoscopy.Differences were significant at 4 h at rest and coughing,and at 24 h at coughing（P〈0.01）,while there were no differences between groups at 24 h at rest,and at 48 h at rest and coughing.Patients receiving INB were more satisfied than those in the PCIA group,and needed less fentanyl within 48 hours（P〈0.05）.Supplementary analgesia was required during the first two postoperative days in two patients in Group PCIA while no patients in Group INB＋PCIA（P〈0.05）.There were also no differences between groups about postoperation nausea and vomiting.In both groups,no complications were observed.Conclusions： Intercostal nerve block with ropivacaine 0.375% during video-assisted thoracoscopy combined with patient-controlled intravenous analgesia with fentanyl is effectively reducing the immediate postoperative pain within 24 hours and analgesic requirements.