腹横肌平面阻滞联合全身麻醉用于腹腔镜手术老年患者的改良效果

Modifying efficacy of transversus abdominis plane block combined with general anesthesia in elderly patients undergoing laparoscopic surgery

目的 评价腹横肌平面阻滞联合全身麻醉用于腹腔镜手术老年患者的改良效果.方法 选择行腹部腹腔镜手术患者60例,年龄65 - 80岁,BMI 18.5-24.0 kg/m^2,性别不限,采用随机数字表法分为2组（n=30）：全身麻醉组（GA组）和腹横肌平面阻滞联合全身麻醉组（TAP＋ GA组）.TAP＋GA组采用双侧臀后位入路法行腹横肌平面阻滞,两侧分别注入0.25％罗哌卡因20 ml.静脉注射咪达唑仑、依托咪酯、舒芬太尼和苯磺酸顺阿曲库铵诱导麻醉,麻醉维持采用全凭静脉麻醉.术后VAS评分≥4分时静脉注射地佐辛5 mg进行镇痛.分别于入室后5 min（T0）、切皮后2 min（T1）和气腹结束（T2）时采集静脉血样,采用ELISA法测定血浆NE浓度.记录术中丙泊酚和瑞芬太尼用量、术中舒芬太尼和术后地佐辛的使用情况;记录有关不良反应的发生情况.结果 与GA组比较,TAP＋GA组T12时血浆NE浓度降低,术中丙泊酚和瑞芬太尼用量减少,术中舒芬太尼使用率和术后地佐辛使用率降低（P＜0.05）,不良反应发生率差异无统计学意义（P＞0.05）.结论 相对于单纯全身麻醉而言,腹横肌平面阻滞联合全身麻醉用于腹腔镜手术老年患者,有助于实现低阿片类药物麻醉模式,更有利于术中应激反应及术后痛敏反应的抑制.

Objective To evaluate the modifying efficacy of transversus abdominis plane （TAP） block combined with general anesthesia in elderly patients undergoing laparoscopic surgery.Methods Sixty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes,aged 65-80 yr,with body mass index of 18.5-24.0 kg/m2,scheduled for elective abdominal laparoscopic surgery,were divided into 2 groups （n =30 each） using a random number table：general anesthesia group （group GA） and TAP block combined with general anesthesia group （group TAP＋GA）.In group TAP＋GA,bilateral TAP block was performed using the posterior approach,and 0.25% ropivacaine 20 ml was injected into the two sides.Anesthesia was induced with Ⅳ midazolam,etomidate,sufentanil and cisatracurium besylate.Anesthesia was maintained using total intravenous anesthesia.When postoperative visual analog scale score ≥4,dezocine 5 mg was intravenously injected for analgesia.At 5 rmin after admission to the operating room,at 2 min after skin incision and at the end of pneumoperitoneum,venous blood samples were collected for determination of plasma norepinephrine concentrations.The intraoperative consumption of propofol and remifentanil and intraoperative requirement for sufentanil and postoperative requirement for dezocine were recorded.The development of adverse reactions was also recorded.Results Compared with group GA,the plasma norepinephrine concentrations were significantly decreased at 2 min after skin incision and at the end of pneumoperitoneum,the intraoperative consumption of propofol and remifentanil was reduced,the intraoperative requirement for sufentanil and postoperative requirement for dezocine were decreased （P〈0.05）,and no significant change was found in the incidence of adverse reactions in group TAP＋GA （P〉0.05）.Conclusion When TAP block combined with general anesthesia is used in elderly patients undergoing laparoscopic surgery,it is helpful in carrying out anesthetic model of low-consumption opioids and more helpful in inhibiting intraoperative stress responses and postoperative pain responses than general anesthesia alone.