超声引导下腹横肌平面阻滞用于腹腔镜下全腹膜外补片疝修补术的镇痛效果

Analgesic effect of ultrasound-guided transversus abdominis plane block in laparoscopic total extraperitoneal hernia repair

目的观察超声引导下腹横肌平面阻滞(TAPB)应用于腹腔镜下全腹膜外补片疝修补术(TEP)术中和术后的镇痛效果。方法采用前瞻性、随机、对照临床试验,选择单侧腹股沟斜疝患者40例,美国麻醉医师学会分级Ⅰ或Ⅱ级,既往无精神疾病和长期服用镇痛类药物史,无区域麻醉禁忌证和局部麻醉药过敏史。将患者随机分入试验组和对照组,每组20例。患者均采用全身麻醉,试验组患者在术前30min于超声定位下行双侧TAPB(每侧各注射0.375%的罗哌卡因20mL),对照组患者术前不行神经阻滞。两组术后均予静脉镇痛泵镇痛,药物为(曲马多600mg+氯诺昔康16mg)/100mL,剂量为2mL/h。术毕进入麻醉后恢复室(PACU),如疼痛视觉模拟评分(VAS评分)>3分给予芬太尼25μg/次。比较两组术中和PACU的芬太尼用量,术后20min(苏醒拔除气管插管即刻)和1、4、8、24h静息和咳嗽时的疼痛VAS评分,以及术后患者的镇痛满意度。结果试验组术中和PACU的芬太尼用量均显著少于对照组(P值均<0.01)。试验组术后20min和1h静息和咳嗽时的疼痛VAS评分均显著低于对照组同时间点、同状态(P值分别<0.01、0.05),术后4和8h咳嗽时的疼痛VAS评分均显著低于对照组同时间点(P值分别<0.01、0.05)。试验组患者的术后镇痛满意度显著高于对照组(P<0.05)。结论 TEP术前实施超声引导下TAPB能明显减少患者围术期芬太尼用量,并明显缓解术后静息和咳嗽时的疼痛,且患者满意度高。

Objective To investigate the analgesic effect of ultrasound-guided transversus abdominis plane block （TAPB） on laparoscopic total extraperitoneal hernia repair （TEP）. Methods Forty patients with American Society of Anesthesiologists （ASA） grade I or 11＂ undergoing general anesthesia for elective unilateral TEP were recruited in this prospective, randomized, control study. None of the patients had history of opioid or antipsychologic medication, anesthetic contraindication or hypersensitive history of local anesthetic. The patients were randomly divided into experiment group and control group （n = 20）. The patients in the experiment group received ultrasound guided bilateral TAPB with 0. 375% ropivacaine 20 mL before surgery, while TAPB was not performed in control group. All the patients received patient-controlled analgesia （PCA, tramadol 600 mg and Iornoxicam 16 mg diluted to 100 mL, 2 mL/h）. Once the visual analog scale （VAS） score was over 3 in postanesthesia care unit （PACU）, 25 IJg fentanyl was injected intravenously. Total amount of fentanyl within and after operation, VAS scores at rest and in cough at 20 rain, 1 h, 4 h, 8 h and 24 h after surgery and the patient＇s satisfaction were compared between groups. Results The total amount of fentanyl used within and after surgery in the experiment group were much less than that in the control group （P〈0.01, 0.05）. The VAS scores at rest and in cough at 20 min and 1 h after surgery, and i n cough at 4 h and 8 h after surgery were significantly lower than those in control group （P〈0.01, 0.05）. The patients in the experiment group were more satisfied than the patients in the control group （P〈0.05）. Conclusion Ultrasound-guided TAPB before TEP can effectively reduce the dosage of fentanyl during perioperative period and relive pain at rest and in cough. （Shanghai Med J, 2014, 37 = 644-647）