非体外循环冠脉搭桥术麻醉的优化策略:胸横肌平面阻滞联合全身麻醉

Optimized strategy of anesthesia in off-pump coronary artery bypass grafting:transversus thoracic muscle plane block combined with general anesthesia

目的评价胸横肌平面阻滞联合全身麻醉用于非体外循环冠脉搭桥术的改良效果。方法择期行非体外循环冠脉搭桥术患者60例,性别不限,年龄55~63岁,体重65~81 kg,ASA分级Ⅲ或Ⅳ级,采用随机数字表法分为2组(n=30):胸横肌平面阻滞联合全身麻醉组(TG组)和全身麻醉组(G组)。采用咪达唑仑-丙泊酚-舒芬太尼-罗库溴铵进行麻醉诱导,七氟烷-瑞芬太尼-丙泊酚维持麻醉。TG组于麻醉诱导前20 min行超声引导胸橫肌平面阻滞,于双侧肋间内肌与胸橫肌之间分别注入0.375%罗哌卡因+0.5%利多卡因共20 ml。术后2组均采用舒芬太尼PCIA,静脉注射羟考酮0.05 mg/kg补救镇痛,维持术后VAS评分≤4分。记录术中瑞芬太尼及丙泊酚用量、术后24 h内舒芬太尼用量、补救镇痛情况;术后ICU停留时间、排气时间、住院时间;术后恶心/呕吐、肺部炎症、皮肤瘙痒及神经阻滞相关并发症发生情况。结果与G组比较,TG组术中瑞芬太尼及术后舒芬太尼用量减少,术后补救镇痛率降低,PACU停留时间、住院时间和排气时间缩短,术后恶心/呕吐、肺部炎症发生率降低(P<0.05)。未见皮肤瘙痒和神经阻滞相关并发症发生。结论超声引导胸横肌平面阻滞联合全身麻醉可为非体外循环冠脉搭桥术患者提供良好的围术期镇痛,减少阿片类药物用量,有利于改善患者预后。

Objective To evaluate the improved efficacy of transversus thoracic muscle plane(TTP)block combined with general anesthesia for off-pump coronary artery bypass grafting(OP-CABG).Methods Sixty American Society of Anesthesiologists physical statusⅢorⅣpatients of both sexes,aged 55-63 yr,weighing 65-81 kg,scheduled for elective OP-CABG,were divided into 2 groups(n=30 each)using a random number table method:TTP block combined with general anesthesia group(group TG)and general anesthesia group(group G).Midazolam-propofol-sufentanil-rocuronium was used to induce anesthesia,and sevoflurane-remifentanil-propofol was used to maintain anesthesia.In group TG,ultrasound-guided TTP block was performed at 20 min before anesthesia induction,and 0.375% ropivacaine plus 0.5% lidocaine 20 ml was injected between bilateral intercostal and transverse pectoral muscles.Both groups received patient-controlled intravenous analgesia with sufentanil,oxycodone 0.05 mg/kg was intravenously injected as rescue analgesic,and the postoperative visual analogue scale scores were maintained≤4 points.The intraoperative consumption of remifentanil and propofol,consumption of sufentanil within 24 h after operation,and requirement for rescue analgesia were recorded.The postoperative length of stay in intensive care unit,time to first flatus,length of hospitalization,postoperative nausea/vomiting,lung inflammation,pruritus and nerve block-related complications were recorded.Results Compared with group G,the consumption of intraoperative remifentanil and postoperative sufentanil after operation were significantly reduced,the requirement for postoperative rescue analgesia was decreased,the postanesthesia care unit stay time,length of hospitalization and time to first flatus were shortened,and the incidence of postoperative nausea/vomiting and lung inflammation was decreased in group TG(P<0.05).No pruritus and nerve block-related complications were found in the two groups.Conclusion Ultrasound-guided TTP block combined with general anesthesia can provide good perioperative analgesia for the patients undergoing OP-CABG and reduce the amount of opioids used,which is helpful in improving the prognosis.