超声引导下肋下前路腰方肌阻滞对后腹腔镜肾脏手术后镇痛效果的影响

Effects of ultrasound-guided subcostal approach to anterior quadratus lumborum block on postope￣rative analgesia after retrolaparoscopic renal surgery

目的观察和比较超声引导下肋下前路腰方肌阻滞(QLB)与低位胸椎旁神经阻滞(TPVB)用于后腹腔镜肾脏手术后镇痛的效果。方法择期行后腹腔镜肾脏手术患者70例,男38例,女32例,年龄18~65岁,BMI 18~24 kg/m2,ASAⅠ或Ⅱ级。随机分为肋下前路QLB组(QLB组)和低位TPVB组(TPVB组),每组35例。QLB组行超声引导下患侧肋下前路QLB,TPVB组行超声引导下患侧T10横突水平TPVB,两组分别注入0.33%罗哌卡因30 ml,注药后20 min测定感觉阻滞平面。两组术后行羟考酮PCIA。记录术后0~24 h和24~48 h镇痛泵用量、有效按压次数、总按压次数;记录术后2、6、12、24、36、48 h静息时和运动时的NRS评分;记录术后48 h内补救镇痛和低血压、肌力减退、恶心呕吐、嗜睡等不良反应发生情况。结果 QLB组阻滞平面为T5—L2,TPVB组为T5—T12。QLB组术后0~24 h和24~48 h镇痛泵用量明显低于TPVB组(P<0.05),有效按压次数和总按压次数明显少于TPVB组(P<0.05),术后12、24、36、48 h运动时NRS评分明显低于TPVB组(P<0.05),术后48 h内补救镇痛、恶心呕吐和嗜睡发生率明显低于TPVB组(P<0.05)。两组低血压和肌力减退发生率差异无统计学意义。结论与低位TPVB比较,超声引导下肋下前路QLB联合羟考酮PCIA在后腹腔镜肾脏手术后镇痛的效果更显著,持续作用时间更长,不良反应更少。

Objective To compare the efficacy of ultrasound-guided subcostal approach to anterior quadratus lumborum block(QLB) with low thoracic paravertebral block(TPVB) on postoperative analgesia after retrolaparoscopic renal surgery. Methods Seventy patients, 38 males and 32 females, aged 18-65 years, with a BMI 18-24 kg/m2,ASA physical status Ⅰor Ⅱ, scheduled for retrolaparoscopic renal surge￣ry, were randomly divided into subcostal approach to anterior QLB group(group QLB, n = 35) and low TPVB group(group TPVB, n = 35).Subcostal approach to anterior quadratus lumborum block in group QLB, and thoracic paravertebral block of T10transverse process in group TPVB were guided by ultrasound, and injected with 0.33% ropivacaine 30 ml respectively, then sensory block planes were measured 20 min after injection. The two groups received patient-controlled intravenous analgesia(PCIA) with oxycodone for 48 h after surgery. The consumption, effective pressing numbers and total pressing numbers of analgesic pump during 0-24 h and 24-48 h after surgery were recorded. The numerical rating scale(NRS) scores of rest and movement 2, 6, 12, 24, 36, 48 h after surgery were recorded. Adverse reactions such as remedial treatment, hypotension, hypomyodynamia, nausea and vomiting, and drowsiness were recorded within 48 h after suegery. Results The main block planes of group QLB and group TPVB was T5-L2 dermatomes and T5-T12 dermatomes, respectively. Compared with group TPVB, the consumption, effective pressing numbers and total pressing numbers of analgesic pump during 0-24 h and 24-48 h after surgery in group QLB were significantly less than those in group TPVB(P < 0.05). The NRS scores of movement at 12, 24, 36, and 48 h after surgery in group QLB were significantly lower than those in group TPVB(P < 0.05). The incidence of postoperative nausea and vomiting, and drowsiness in group QLB was significantly lower than that in group TPVB(P < 0.05). There was no significant difference in the incidence of hypomyodynamia and hypotension between the two groups. Conclusion In retrolaparoscopic renal surgery, ultrasound-guided subcostal approach to anterior quadratus lumborum block compared with low thoracic paravertebral block could bring about better postoperative analgesia, longer duration, and fewer adverse reactions.