后路与肋缘下腹横肌平面阻滞应用于下腹正中纵切口剖宫产术后镇痛的比较

Comparison of posterior and subcostal approaches to transverse abdominis plane block for postoperative analgesia of cesarean delivery

目的比较后路与肋缘下腹横肌平面（transversus abdominis plane, TAP）阻滞应用于下腹正中纵切口剖宫产术后镇痛效果。方法选取行剖宫产术，ASA分级Ⅰ、Ⅱ级产妇100例，用随机数字表法分为A组和B组，每组50例。两组产妇均在蛛网膜下腔顿膜外腔联合麻醉下行腹部正中纵切口剖宫产手术，待手术结束之后超声引导下进行双侧TAP阻滞，A组产妇采用后路TAP阻滞，B组产妇采用肋缘下TAP阻滞，两侧腹壁分别给予0．375％罗哌卡因20ml。观察两组产妇术后2、6、12、24h静息及运动时VAS评分及两组患者自控静脉镇痛（patient controlled intravenous analgesia, PCIA ）术后24h按压泵次数、布托啡诺术后24h用量、镇痛满意度，同时观察比较两组产妇术后镇痛相关副作用的发生情况。结果A组产妇术后2、6、12h运动VAS评分[（0．8±1．0）、（2．1±0．9）、（2．0±0．9）分]明显低于B组[（1．8±1．4）、（4．3±1．9）、（4．6±2．2）分]（P〈0．05）；A组产妇PCIA术后24h按压泵次数、布托啡诺术后24h用量也明显少于B组（P〈0．05）；满意度高于B组（P〈0．05）。在术后镇痛相关副作用方面，A组瘙痒、呕吐发生明显少于B组（P〈0．05），两组均无呼吸抑制、局部血肿及局部麻醉药中毒发生。结论与肋缘下TAP阻滞比较，经后路TAP阻滞结合PCIA对下腹部正中纵切口剖宫产术后镇痛更为有效，术后阿片药使用剂量更小、副作用更少。

Objective To evaluate the effectiveness of posterior and subcostal transversus abdominis plane （TAP） block in analgesia for patients undergoing cesarean delivery. Methods At the end of the operation, 100 cases of participants with cesarean delivery are randomized divided into two different group. Patients in group A （n=50） received an ultrasound-guided posterior TAP block using 20 ml of 0.375% ropivaeaine on each side. Group B （n=50） underwent a subcostal TAP block with same solution. Patient controlled intravenous analgesia （PCIA） had also been applied. The resting and exercise VAS scores were evaluated at 2, 6, 12 h and 24 h after operation. The consumption of butorphanol within 24 h after operation, the number of successfully delivered doses within 24 h after operation were recorded. The rate of participants＂ satisfaction and the rate of adverse reactions were also recorded. Results The exercise VAS scores at 2,6,12 h after operation in group A [（0.8±1.0）, （2.1±0.9）, （2.0±0.9）] were significantly lower than scores in group B [（1.8±1.4）, （4.3±1.9）, （4.6±2.2）] （P〈0.05）. The consumption of butorphanol and the number of successfully delivered doses within 24 h after operation were also lower than in group B （P〈0.05）, while the rate of satisfaction were higher in group A （7.9±1.6） than in group B （7.1±2.3）（P〈0.05）. The incidence of adverse reactions was also significantly lower in group A than in group B （P〈 0.05）. Conclusions Compared with the subcostal approach, ultrasound-guided posterior TAP could afford a better effectiveness in in analgesia for patients undergoing cesarean delivery.