腹横肌平面阻滞联合羟考酮用于肾移植术患者的优化效果

Optimized efficacy of transversus abdominis plane block combined with oxycodone in patients undergoing kidney transplantation

目的 评价腹横肌平面（TAP）阻滞联合羟考酮用于肾移植术患者的优化效果.方法 择期行亲属活体肾移植手术的尿毒症患者90例,性别不限,年龄22～ 45岁,体重45 ～ 75 kg,ASA分级Ⅲ级,采用随机数字表法分为3组（n=30）：空白对照组（C组）、TAP阻滞组（TAP组）和TAP阻滞＋羟考酮组（TAP＋O组）.TAP组和TAP＋O组分别于全麻诱导前30 min在超声引导下行术侧侧入路TAP阻滞,注射0.375％罗哌卡因＋5 mg地塞米松混合液20 ml.依次静脉注射咪达唑仑,TCI瑞芬太尼和丙泊酚,静脉注射顺式阿曲库铵诱导麻醉,置入喉罩后行机械通气,维持PET CO2 35～ 45mmHg.静脉输注丙泊酚和瑞芬太尼,吸入七氟醚维持麻醉,间断静脉注射顺式阿曲库铵维持肌松,术中维持Narcotrend值37～ 46.TAP＋O组于手术结束前20 min时静脉注射盐酸羟考酮0.1 mg/kg.术毕采用舒芬太尼1.5 μg/kg（用生理盐水稀释至100 ml）行PCIA,背景输注速率1.5 ml/h,PCA剂量2 ml,锁定时间20 min,维持VAS评分≤4分.记录术中瑞芬太尼用量及术后24h内PCIA有效按压次数;于术前1d、术后2和5d时抽取肘正中静脉血样,采用放射免疫法检测血清Cr和BUN的浓度;记录术后24 h内恶心呕吐、头晕头痛、呼吸抑制以及TAP阻滞相关并发症（穿刺部位血肿、腹腔脏器损伤、局麻药中毒）的发生情况.结果 与C组相比,TAP组和TAP＋O组术中瑞芬太尼用量减少,术后24 h内PCIA有效按压次数降低,术后2d时血清Cr和BUN浓度降低（P＜0.05）;与TAP组相比,TAP＋O组术后24 h内PCIA有效按压次数降低,术后2d时血清Cr和BUN浓度降低（P＜0.05）,术中瑞芬太尼用量差异无统计学意义（P＞0.05）.TAP组和TAP＋O组均未见TAP相关并发症发生.3组术后恶心呕吐和头晕头痛的发生率差异无统计学意义（P＞0.05）.结论 TAP阻滞联合羟考酮用于肾移植术患者可减少术中阿片类药物用量,抑制术后痛敏反应,有利于促进移植肾功能的早期恢复.

Objective To evaluate the optimized efficacy of transversus abdominis plane （TAP） block combined with oxycodone in patients undergoing kidney transplantation.Methods Ninety patients of both sexes,aged 22-45 yr,weighing 45-75 kg,of American Society of Anesthesiologists physical status Ⅲ,scheduled for elective living donor kidney transplantation,were divided into 3 groups （n =30 each） using a random number table：blank control group （group C）,TAP block group （group TAP） and TAP block combined with oxycodone group （group TAP＋O）.Ultrasound-guided lateral approach to TAP block was performed on the operated side with the mixture （20 ml） of 0.375% ropivacaine and 5 rng dexamethasone at 30 min before induction of anesthesia in TAP and TAP＋O groups.Anesthesia was induced by injecting midazolam,target-controlled infusion of remifentanil and propofol and injecting cisatracurium.The patients were mechanically ventilated after placement of the laryngeal mask airway,and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg.Propofol and remifentanil were intravenously injected and sevoflurane was inhaled to maintain anesthesia,and cis-atracurium was intermittently injected to maintain muscle relaxation.Narcotrend value was maintained at 37-46 during operation.Oxycodone 0.1 mg/kg was intravenously injected at 20 min before the end of surgery in group TAP＋O.Patient-controlled intravenous analgesia （PCIA） was performed with sufentanil 1.5 μg/kg in 100 ml of normal saline at the end of surgery,the PCIA pump was set up to deliver a 2 ml bolus dose,a 20 min lockout interval and background infusion at a rate of 1.5 ml/h,and visual analog scale score was maintained ≤4.The consumption of intraoperative remifentanil and effective pressing times of PCIA within 24 h after surgery were recorded.Blood samples were collected at 1 day before surgery and 2 and 5 days after surgery from the median cubital vein for determination of blood urea nitrogen and creatinine （Cr） concentrations in serum.The occurrence of nausea and vomiting,dizziness and headache,respiratory depression and TAP block-related complications （hematoma at puncture site,injury to abdominal organs,local anesthetic intoxication） was recorded within 24 h after surgery.Results Compared with group C,the consumption of intraoperative remifentanil was significantly reduced,the effective pressing times of PCIA within 24 h after surgery were decreased,and the concentrations of creatinine and blood urea nitrogen in serum were decreased at 2 days after surgery in TAP and TAP＋O groups （P〈0.05）.Compared with group TAP,the effective pressing times of PCIA within 24 h after surgery were significartly decreased,the concentrations of creatinine and blood urea nitrogen in serum were decreased at 2 days after surgery,and no significant change was found in the consumption of intraoperative remifentanil in group TAP＋O （P〉0.05）.TAP block-related complications were not found in TAP and TAP＋O groups （P〉0.05）.There was no significant difference in the incidence of nausea and vomiting or dizziness and headache among three groups （P〉0.05）.Conclusion TAP block combined with oxycodone can reduce the intraoperative consumption of opioids,inhibit postoperative hyperalgesia and be helpful for early recovery of transplanted kidney function in patients undergoing kidney transplantation.