超声引导腹横肌平面阻滞联合纳布啡对腹腔镜胃癌病人术后镇痛和炎症反应的影响

Effect of ultrasound-guided TAP block combined with nalbuphine on the postoperative analgesia and inflammatory response in laparoscopic gastric cancer patients

目的评价超声引导腹横肌平面(TAP)阻滞联合纳布啡静脉注射对腹腔镜胃癌根治术病人术后镇痛和炎症反应的影响。方法选择2017年4月至2018年10月安徽医科大学第二附属医院择期行腹腔镜胃癌根治术病人共60例,均采用静吸复合全身麻醉,按随机数字表法分为病人自控静脉镇痛组(PCIA组)、超声引导TAP阻滞组(TAP组)、TAP阻滞联合纳布啡组(复合组),各20例;比较各组病人气管导管拔除后2、6、12、24、48 h的疼痛视觉模拟评分法(VAS评分)、Ramsay镇静评分和舒适度评分(Bruggrmann Comfort Scale,BCS),镇痛泵按压次数,麻醉不良反应,肛门排气、下床活动和拔除导尿管时间,气管导管拔除即刻、12 h、24 h和48 h血清炎性因子超敏C反应蛋白(hs-CRP)、白细胞介素6(IL-6)和肿瘤坏死因子α(TNF-α)水平。结果复合组各时刻VAS评分明显降低[2 h(4.0±0.8)比(6.7±1.2)比(4.3±1.1),6 h(3.8±0.5)比(5.2±0.8)比(4.2±0.7),12 h(2.9±0.3)比(3.5±0.6)和(3.0±0.5)分],镇静满意率提高(2 h:95.0%比65.0%比70.0%,6 h:95.0%比70.0%比70.0%,12 h:90.0%比60.0%比60.0%,24 h:90.0%比55.0%比60.0%,48 h:85.0%比55.0%比55.0%),BCS舒适度评分增加[2 h(0.7±0.1)比(0.3±0.1)比(0.5±0.1),6 h(1.5±0.3)比(0.9±0.3)比(1.3±0.3),12 h(2.2±0.4)比(1.9±0.4)比(2.1±0.4)分],镇痛泵按压次数减少[(4.5±0.8)比(5.9±1.3)比(5.3±1.1)次](P<0.05)。复合组麻醉不良反应发生率降低(10.0%比40.0%和40.0%),肛门排气[(10.5±1.6)比(14.5±2.6)比(12.2±2.3)h]、下床活动[(3.3±0.5)比(4.2±0.6)和(3.9±0.6)d]和拔除导尿管时间[(66.5±4.3)比(72.3±4.9)比(69.8±4.6)h]显著缩短,差异有统计学意义(P<0.05)。复合组各时刻血清hs-CRP、IL-6和TNF-α水平明显降低[hs-CRP:即刻(13.6±2.2)比(16.2±2.5)比(15.7±2.4),12 h(10.5±1.9)比(13.5±2.4)比(13.2±2.2),24h(7.8±1.5)比(10.3±1.9)比(9.6±1.7),48 h(6.2±1.2)比(8.1±1.5)比(7.9±1.4)mg/L;IL-6:即刻(23.5±4.6)比(29.6±4.8)比(28.9±4.7),12 h(20.5±4.3)比(25.6±4.6)比(24.5±4.5),24 h(15.7±3.5)比(19.5±3.9)比(18.9±3.8),48 h(10.5±3.3)比(15.2±3.9)比(14.6±3.6)μg/L;TNF-α:即刻(15.7±3.6)比(21.2±3.9)比(19.5±3.8),12 h(13.4±3.4)比(17.5±3.8)比(16.6±3.7),24 h(10.5±3.2)比(13.9±3.6)比(13.4±3.5),48 h(7.5±2.2)比(11.2±2.9)比(9.6±2.6)μg/L],差异有统计学意义(P<0.05)。结论超声引导TAP阻滞联合纳布啡在腹腔镜胃癌术后有较好的镇痛效果,促进快速康复,减轻机体炎症反应,有较好的应用价值。

Objective To evaluate the effect of ultrasound-guided transverse abdominal muscle plane(TAP)block combined withintravenous injection of nalbuphine on postoperative analgesia and inflammatory response in patients undergoing laparoscopic radical gastrectomy for gastric cancerMethodsA total of 60 consecutives undergoing elective laparoscopic gastrointestinal surgery in The Second Hospital of Anhui Medical University from April 2017 to October 2018 were enrolled and received intravenous combined with inhalational general anesthesia;they were randomly divided into patient-controlled intravenous analgesia(PCIA)group,ultrasound-guided TAP block group(TAP group)and TAP block with Nalbuphine group(combined group),and 20 cases of each.Then to compare differences of pain VAS scores,Ramsay scores and BCS comfort scores after tracheal catheter extraction at 2 h,6 h,12 h,24 h and 48 h;adverse reactions of anesthesia,times of anal exhaust,out-of-bed activity and urinary catheter removal;serum inflammatory factors levels of high sensitive C reactive protein(hs-CRP),IL-6 and TNF-αat moment of tracheal catheter extraction,after 12 h,24 h and 48 h.ResultsThe VAS scores in combined group on different times all significantly lower[2 h(4.0±0.8)vs.(6.7±1.2)vs.(4.3±1.1),6 h(3.8±0.5)vs.(5.2±0.8)vs.(4.2±0.7),12 h(2.9±0.3)vs.(3.5±0.6)vs.(3.0±0.5)min],satisfactory rate of sedation more(2 h:95.0%vs.65.0%vs.70.0%,6 h:95.0%vs.70.0%vs.70.0%,12 h:90.0%vs.60.0%vs.60.0%,24 h:90.0%vs.55.0%vs.60.0%,48 h:85.0%vs.55.0%vs.55.0%),BCS scores higher[2 h(0.7±0.1)vs.(0.3±0.1)vs.(0.5±0.1),6 h(1.5±0.3)vs.(0.9±0.3)vs.(1.3±0.3),12 h(2.2±0.4)vs.(1.9±0.4)vs.(2.1±0.4)分],number of analgesic pressing less,too[(4.5±0.8)vs.(5.9±1.3)vs.(5.3±1.1)time](P<0.05).The adverse reactions rate of anesthesia in combined group was less(10.0%vs.40.0%vs.40.0%),and times of anal exhaust[(10.5±1.6)vs.(14.5±2.6)vs.(12.2±2.3)h],out-of-bed activity[(3.3±0.5)vs.(4.2±0.6)vs.(3.9±0.6)d]and urinary catheter removal shorter[(66.5±4.3)vs.(72.3±4.9)vs.(69.8±4.6)h],too(P<0.05).What’s more,The levels of hs-CRP,IL-6 and TNF-αin combined group on different times all significantly lower[hs-CRP:Immediate(13.6±2.2)vs.(16.2±2.5)vs.(15.7±2.4),12 h(10.5±1.9)vs.(13.5±2.4)vs.(13.2±2.2),24 h(7.8±1.5)vs.(10.3±1.9)vs.(9.6±1.7),48 h(6.2±1.2)vs.(8.1±1.5)vs.(7.9±1.4)mg/L;IL-6:Immediate(23.5±4.6)vs.(29.6±4.8)vs.(28.9±4.7),12 h(20.5±4.3)vs.(25.6±4.6)vs.(24.5±4.5),24 h(15.7±3.5)vs.(19.5±3.9)vs.(18.9±3.8),48 h(10.5±3.3)v(15.2±3.9)vs.(14.6±3.6)μg/L;TNF-α:Immediate(15.7±3.6)vs.(21.2±3.9)vs.(19.5±3.8),12 h(13.4±3.4)vs.(17.5±3.8)vs.(16.6±3.7),24 h(10.5±3.2)vs.(13.9±3.6)vs.(13.4±3.5),48 h(7.5±2.2)vs.(11.2±2.9)vs.(9.6±2.6)μg/L](P<0.05).ConclusionUltrasound-guided TAP block with Nalbuphine has a good analgesic effect after laparoscopic gastric cancer surgery,which can promote rapid rehabilitation and reduce inflammatory reaction and has good application value.