腹横肌平面阻滞联合氟比洛芬酯对腹腔镜胆囊手术患者术后苏醒和疼痛的影响

Effect of transversus abdominis plane block combined with flurbiprofen axetil on postoperative recovery and pain in patients undergoing laparoscopic cholecystectomy

目的探讨腹横肌平面(TAP)阻滞联合氟比洛芬酯对腹腔镜胆囊切除手术患者术后苏醒和疼痛的影响。方法择期行腹腔镜胆囊切除术的患者80例,年龄35～65岁,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,按照随机数字表法将患者分为TAP阻滞组、氟比洛芬酯组、联合组和对照组,每组20例。TAP阻滞组于术前20min在超声引导下行双侧TAP阻滞,每侧予0.375%罗哌卡因20mL;氟比洛芬酯组于术前20min静脉缓慢注射氟比洛芬酯1mg/kg;联合组于术前20min同TAP阻滞组行双侧TAP阻滞,同时同氟比洛芬酯组给予氟比洛芬酯;对照组给予等容量的0.9%氯化钠溶液。观察并记录患者的手术时间(切皮至缝合完成的时间)、自主呼吸恢复时间(停药至自主呼吸恢复时间)和拔管时间(停药至拔除气管导管时间),分别于拔除气管导管后1h(T_1)、6h(T_2)、12h(T_3)和24h(T_4)评估患者咳嗽时的疼痛VAS评分,并观察苏醒期间的躁动情况。结果 4组患者的手术时间、自主呼吸恢复时间和拔管时间的差异均无统计学意义(P值均>0.05)。TAP阻滞组和联合组T_1至T_4时间点、氟比洛芬酯组T_1至T_3时间点的疼痛VAS评分均显著低于对照组同时间点(P值均<0.05),TAP阻滞组和联合组T1至T4时间点的疼痛VAS评分均显著低于氟比洛芬酯组同时间点(P值均<0.05)。联合组轻、中、重度苏醒期躁动的发生率均显著低于对照组(P值均<0.05);TAP阻滞组和氟比洛芬酯组重度苏醒期躁动的发生率均显著低于对照组(P值均<0.05),轻、中度苏醒期躁动的发生率均显著高于联合组(P值均<0.05)。结论 TAP阻滞可减轻腹腔镜胆囊切除术患者的术后疼痛,TAP阻滞联合氟比洛芬酯不仅提供了良好的术后镇痛,而且改善了患者的苏醒质量。

Objective To investigate the effect of transversus abdominis plane （TAP） block combined with flurbiprofen axetil on postoperative recovery and pain in the patients undergoing laparoscopic cholecystectomy. Methods Eighty patients aged 35- 65 years old, American Society of Anesthesiologists （ASA） grade Ⅰ or Ⅱ, scheduled for laparoscopic cholecystectomy were included and randomized into 4 groups （n =20）： TAP group, flurbiprofen group, combined group and control group. At 20 min before the operation, the patients in TAP group received TAP block with 0. 375% ropivacaine 20 mL in both sides under the guidance of ultrasound, patients in flurbiprofen group were intravenously given 1 mg/mg flurbiprofen axetil, patients in combined group received both TAP block and flurbiprofen infusion, and the equal volume of normal saline was given in control group. Operation time, spontaneous breathing recovery time and extubation time were recorded, visual analog scale （VAS） scores were measured at 1 h after extubation （T1）, 6 h after extubation （T2）, 12 h after extubation （T3）, and 24 h after surgery （T4）. The emergence agitation during recovery was evaluated. Results There were no significant differences in the operation time, spontaneous breathing recovery time or extubation time between the 4 groups （all P〉0.05）. VAS scores at T1 - T4 in TAP group and combined group, at T1 - T3 in flurbiprofen group were significantly lower than those in control group （all P〈0.05）. VAS scores at T1 - T4 in TAP group and combined group were also significantly lower than those in flurbiprofen group （all P 〈 0. 05）. As compared with control group, the incidences of emergence agitation in all degrees in the combined group were significantly decreased （all P〈0.05） ; the incidences of emergence agitation were also decreased in TAP group and flurbiprofen group, especially the severe agitation （both P〈0.05）. The incidences of mild and moderate emergence agitation in TAP group and flurbiprofen group were significantly higher than those in combined group （both P 〈 0. 05）. Conclusion TAP block can decrease the postoperative pain in patients undergoing taparoscopic cholecystectomy. Moreover, TAP block in combination with flurbiprofen axetil can not only achieve satisfactory analgesia, but also improve the recovery. （Shanghai Med J, 2018, 41 ： 424-427）