胸椎旁神经阻滞与多点肋缘下腹横肌平面阻滞在开腹肝脏手术术后镇痛的应用比较

Comparison of thoracic paravertebral nerve block and transverse abdominal plane block for multiple costal margins in anal-gesia after open liver surgery

目的:探讨胸椎旁神经阻滞(thoracic paravertebral nerve block,TPVB)与多点肋缘下腹横肌平面阻滞(transverse abdominal plane block,TAPB)在开腹肝脏手术术后镇痛中的应用价值。方法:拟行开腹肝脏手术的患者60例(手术切口均为经典反"L"型切口),ASA分级Ⅰ~Ⅲ级,采用随机数字表法分为TPVB组(TP组)和多点肋缘下TAPB组(TA组),每组30例。两组均在术前行超声引导下神经阻滞,TP组行双侧T 7-T 8和T 8-T 9 TPVB,TA组行双侧肋缘下和经典肋缘与髂前上棘之间的TAPB,共4个阻滞点。记录并比较两组阻滞操作时间,记录切皮前(T 0)、切皮后(T 1)、上腔静脉阻断时(T 2)、肝切除时(T 3)、缝皮时(T 4)的MAP和心率,记录手术时间、术中液体入量、瑞芬太尼消耗量、术后PACU停留时间,记录术后即刻(患者拔管苏醒后,可进行正常语言交流)、术后2h、术后6h的静息及运动VAS评分,记录术后6h内给予阿片类药物的例数、术后第1次给予阿片类药物的时间。结果:TA组的阻滞操作时间短于TP组(P<0.05)。两组患者T 0时MAP和心率差异没有统计学意义(P>0.05),但在T 1、T 3、T 4时TP组的MAP和心率均低于TA组(P<0.05)。TP组术中瑞芬太尼消耗量、术后PACU停留时间、术后即刻和术后2h的静息及运动VAS评分也明显少于TA组(P<0.05),但术后第1次给予阿片类药物的时间,TP组长于TA组(P<0.05)。其余观察指标两组差异无统计学意义(P>0.05)。结论:在开腹肝脏手术中,TPVB较多点肋缘下TAPB能提供更加平稳的血流动力学变化,减少阿片类药物的用量,提供更完善的围手术期镇痛。

Objective To evaluate the analgesic application of thoracic paravertebral blockade(TPVB)and transverse abdom-inal plane block(TAPB)for multiple costal margins after open liver surgery.Methods A total of sixty patients[American Society Anesthesiologists(ASA)Ⅰ-Ⅲ]who were scheduled for open liver surgery(with a classical reverse L-shaped incision)were enrolled.The patients were divided into two groups according to the random number table method(n=30):a TPAB group(group TP)and a group of TAPB for multiple costal margins(group TA).Both groups received ultrasound guided nerve block before surgery.Group TP under-went bilateral TPVB at T7-T8 and T8-T9,while group TA underwent TAPB under bilateral costal margins and the classical site between the costal margin and the anterior inferior iliac spine,with a total of four block points.Then,both groups were compared and recorded for the duration of block procedures;the mean arterial pressure(MAP)and heart rate before incision(T0),after incision(T1),and at the times of block of the superior vena cava(T2),liver removal(T3)and stitching(T4);surgical duration,the inflow of liquid during surgery,the consumption of remifentanil,and the length of post-anesthesia care unit(PACU)stay after surgery;the Visual Analogue Scale(VAS)scores at resting and during movement immediately after surgery(when patients were awaken after extubation and able to communicate normally),and 2 h and 6 h after surgery;and the number of patients requiring opioids within 6 h after surgery and the time when opioids were first given after surgery.Results Group TA presented shorter duration of block procedures than group TP(P<0.05).There was no statistical difference between the two groups as to MAP and heart rate at T0.However,compared with group TA,decreases in MAP and heart rate were found in group TP at T1,T2,T3 and T4(P<0.05).Compared with group TA,group TP also presented remarkable de-creases in the consumption of remifentanil during surgery,the length of PACU stay after surgery,and the VAS scores at resting and dur-ing movement immediately after surgery and 2 h after surgery(P<0.05).However,group TP required longer time when opioids were first given after surgery than group TA(P<0.05).There was no statistical difference in other indictors between the two groups(P>0.05).Conclusions During open liver surgery,compared with TAPB for multiple costal margins,TPVB can maintain more stable hemody-namics,require less doses of opioids and improve perioperative analgesia.