腹横肌平面阻滞联合腹直肌鞘阻滞在老年腹股沟直疝修补术中的应用

Application of transversus abdominis plane block combined with rectus sheath block in elderly patients with hernioplasty for direct inguinal hernia

目的探讨老年患者腹股沟直疝修补术中,超声引导下腹横肌平面阻滞(TAPB)联合腹直肌鞘阻滞(RSB)的应用效果。方法择期行腹股沟直疝修补术老年患者46例,均为男性,年龄65~82岁,BMI 20~27 kg/m^2,ASAⅡ或Ⅲ级,随机数字表法分为TAPB联合RSB组(TR组)和TAPB组(T组),每组23例。TR组患者接受TAPB联合RSB,T组患者接受单纯TAPB,所有神经阻滞采取的局麻药均为0.25%罗哌卡因复合右美托咪定0.7μg/kg。记录麻醉诱导前(T0)、手术开始时(T1)、手术开始后20 min(T2)、手术结束时(T3)、术后12 h(T4)、术后24 h(T5)两组HR、SBP、DBP,并计算心率收缩压乘积(RPP)。记录T1-T3时静息时VAS评分,T4-T5时活动时VAS评分。记录围术期补救镇痛情况和神经阻滞失败、恶心呕吐、血压升高或降低幅度>基础值30%、心脑血管意外、局麻药中毒等不良反应发生情况。结果与T0时比较,T1-T3时两组HR均明显增快(P<0.05),SBP、DBP、RPP均明显升高(P<0.05)。T1-T3时TR组HR明显慢于T组,SBP、DBP、RPP明显低于T组(P<0.05)。T1-T3时TR组静息时VAS评分明显低于T组(P<0.05),T4-T5时TR组活动时VAS评分明显低于T组(P<0.05)。TR组术中补救镇痛和围术期恶心呕吐发生率均明显低于T组(P<0.05)。两组术后均不需要补救镇痛,围术期均未发生血压升高或降低幅度>基础值30%、心脑血管意外、局麻药中毒等不良反应。结论超声引导下腹横肌平面阻滞联合腹直肌鞘阻滞用于老年患者腹股沟直疝修补术,麻醉效果确切,术后镇痛完善,恶心呕吐发生率低。

Objective To investigate the effect of ultrasound-guided transversus abdominis plane block combined with rectus sheath block anesthesia in elderly patients with hernioplasty for direct inguinal hernia. Methods Forty-six elderly patients undergoing hernioplasty for direct inguinal hernia, aged 65-82 years, all males, with a BMI 20-27 kg/m^2, falling into ASA physical status Ⅱ or Ⅲ, were randomly divided into two groups, 23 cases each group. Patients in group TR received TAPB combined with RSB anesthesia, and patients in group T received TAPB anesthesia alone. All local anesthetics adopted for nerve block were 0.25% ropivacaine mixed with dexmedetomidine 0.7 μg/kg. HR, SBP and DBP were recorded at these time points: before induction of anaesthesia(T0), beginning of operation(T1), twenty minutes after the beginning of operation(T2), operation finished(T3), twelve hours postoperation(T4), twenty-four hours postoperation(T5), and calculate the rate-pressure-product(RPP). The resting VAS scores were recorded at T1, T2 and T3, and the active VAS scores were recorded at T4 and T5. Perioperative remedial analgesia, failure of nerve block, nausea and vomiting, increase or decrease of blood pressure by 30%, cardiovascular and cerebrovascular accidents, local anesthetic poisoning and other adverse reactions were recorded. Results HR in both groups was faster than that at T0, and SBP, DBP and RPP at T1-T3 were all higher than that at T0(P<0.05), however, HR of group TR was significantly slower than that of group T, and SBP, DBP and RPP were significantly lower than that of group T(P<0.05). The resting VAS scores were lower in group TR at T1-T3(P<0.05). The activite VAS scores were lower in group TR at T4 and T5(P<0.05). The incidence of remedial analgesia and nausea and vomiting in the group TR were lower than that of the group T(P<0.05). There was no need for remedial analgesia after operation in both groups, and no adverse reactions such as increased blood pressure or reduced by 30% during perioperative period, cardiovascular and cerebrovascular accidents, local anesthetics poisoning and so on. Conclusion Ultrasound-guided transversus abdominis plane block combined with rectus sheath block anesthesia is safe and effective in elderly patients with hernioplasty for direct inguinal hernia. The postoperative analgesic is complete andthe incidence of postoperative nausea and vomiting is lower.