腹直肌后鞘阻滞较腹横肌平面阻滞在行二次腹部手术中的优势

The advantage of rectus sheath block compared to transversus abdominis plane block in second abdominal operation

目的比较全麻复合腹直肌后鞘阻滞(RBS)在二次腹部手术中与全麻复合腹横肌平面阻滞(TAP)的优劣。方法选取全麻下再次行腹部切口的手术的患者40例,随机分为A组(全麻复合腹直肌后鞘阻滞)和B组(全麻复合腹横肌平面阻滞)。记录两组患者的超声引导下穿刺点腹部肌肉分层情况、穿刺成功率、切皮应激反应、术中血流动力学波动、术后镇痛评分及术后下床时间差异。观察两组并发症(腹膜穿破、肠管及腹腔脏器损伤、局麻药中毒)发生情况。结果 A组患者穿刺点超声下显示腹膜结构清晰例数、肌肉筋膜分层清晰例数明显多于B组,穿刺操作时间明显短于B组,差异有统计学意义(χ^2分别=11.61、13.78,t=-4.75,P均<0.05),但两组穿刺成功率比较,差异无统计学意义(χ^2=1.02,P>0.05)。A组、B组组内各时点的MAP和HR比较,差异均有统计学意义(F分别=5.39、11.36、40.83、12.97,P均<0.05),A组切皮时(T2)及拔管后(T4)时MAP及HR低于B组,差异有统计学意义(t分别=-2.26、-2.94、-2.63、-3.40,P均<0.05)。A组术后1 hVAS评分明显低于B组,12 h内镇痛泵单击次数明显少于B组,差异有统计学意义(t分别=-3.63、-4.93,P均<0.05),两组患者术后下床活动时间比较,差异无明显统计学意义(t=0.40,P>0.05)。结论有开腹手术史患者再次行腹部手术时,全麻复合腹直肌后鞘阻滞比全麻复合腹横肌平面阻滞更有优势,术中血流动力学更平稳,镇痛效果更理想,穿刺点腹部肌肉分层紊乱发生率更低。

Objective To compare the effects of general anesthesia combined with rectus sheath block(RBS) and general anesthesia combined with transverse abdominis plane block(TAP) in second abdominal operation. Medthods Forty patients who had a history of open abdominal operation received second abdominal open operation under general anesthesia were selected.The patients were randomly divided into group A(general anesthesia combined with RBS)and group B(general anesthesia combined with TAP).The differences in abdominal muscle stratification at the puncture point in ultrasound observation,block success rate,cerebrovascular stress response,hemodynamic changes,postoperative visual analogue score,active time post-operation between two groups were analyzed.The complications such as penetration of peritoneum,intestinal and abdominal organ damage,local anesthetic intoxication were observed. Results The number of cases with clear peritoneal structure and clear muscle and fascia layers in group A were significantly more than those in group B,and the puncture operation time was significantly shorter than that in group B(χ^2=11.61,13.78,t=-4.75,P<0.05),but there was no significant difference in the success rate of puncture between the two groups(χ^2=1.02,P>0.05).The differences of MAP and HR among each point in group A and group B were statistically significant(F=5.39,11.36,40.83,12.97,P<0.05).The MAP and HR of group A at T2 and T4 were lower than those of group B(t=-2.26,-2.94,-2.63,-3.40,P<0.05).The VAS at 1 h after operation in group A was lower than group B,and the number of analgesic pump bolus of group A within 12 hours was less than group B(t=-3.63,-4.93,P<0.05).There was no significant difference in active time post-operation between two groups(t=0.40,P>0.05). Conclusions When the patients who had a history of open abdominal operation need a second abdominal operation, the general anesthesia combined with RBS is superior to general anesthesia combined with TAP with the more stable hemodynamics,better analgesic effect,and lower incidence of abdominal muscle stratification disorders at puncture points.