右美托咪定不同给药方式复合腹横肌平面阻滞在结直肠肿瘤手术中的临床应用研究

Clinical application of dexmedetomidine given by different methods of administration combined with transversus abdominis plane block in patients with colorectal tumor

目的:观察右美托咪定不同给药方式联合腹横肌平面阻滞(TAPB)对结直肠癌根治性切除术患者术后镇痛及早期恢复的影响。方法:择期行结直肠癌根治性切除术的患者100例,随机分为右美托咪定静脉泵注联合罗哌卡因TAPB组(DV-T组)、右美托咪定混合罗哌卡因TAPB组(DR-T组)、罗哌卡因TAPB组(R-T组)、生理盐水TAPB对照组(C组),每组25例。DV-T组于麻醉诱导前10 min开始静脉泵注右美托咪定0.5μg·kg^-1(10 min内泵注完毕),随后按0.5μg·kg^-1·h^-1的速度持续泵注至手术结束前30 min。各组患者均于麻醉诱导后行超声引导下TAPB,DR-T组给予右美托咪定1μg·kg^-1混合0.375%罗哌卡因共40 ml,DV-T组和R-T组给予0.375%罗哌卡因40 ml,C组注入生理盐水40 ml,每侧各20 ml。记录麻醉诱导前10 min(T0)、TAPB后10 min(T1)、手术开始时(T2)、手术开始30 min(T3)、手术开始60 min时(T4)、手术结束时(T5)收缩压(SBP)、舒张压(DBP)及心率(HR);观察术后2、6、12、24及48 h静息状态和运动状态下VAS评分;记录术中严重心动过缓、低血压以及术后恶心、呕吐发生率,术后首次下床时间、肛门排气时间、住院天数,记录术后24 h内舒芬太尼用量及镇痛泵有效按压次数。结果:与C组比较,DR-T组、DV-T组于T2~T5时点SBP、DBP均显著降低(P<0.05)。与C组及R-T组比较,DR-T组和DV-T组于T1~T5时点HR显著减慢(P<0.05)。与C组比较,R-T组、DV-T组于术后6、12 h,DR-T组于术后6、12、24 h活动时视觉模拟评分法(VAS)评分均显著降低(P<0.05);与R-T组比较,DR-T组术后12 h活动时VAS评分均显著降低(P<0.05)。与C组比较,R-T组、DR-T组、DV-T组术后24 h舒芬太尼用量及术后24 h镇痛泵按压次数均显著减少(P<0.05),且DR-T组术后24 h舒芬太尼用量和术后24 h镇痛泵按压次数均少于R-T组、DV-T组(P<0.05)。R-T组、DR-T组、DV-T组术后下床时间均显著早于C组(P<0.05);DR-T组、DV-T组肛门首次排气时间亦显著早于C组(P<0.05)。而DV-T组术中严重心动过缓发生率明显高于C组(P<0.05)。结论:右美托咪定两种给药方式联合TAPB用于结直肠癌根治术均可显著减轻手术应激引起的血压升高、心率增快,促进患者早期恢复,其中右美托咪定混合罗哌卡因TAPB镇痛作用时间更长,可减少术后阿片类药物的用量,严重心动过缓等不良反应发生率更低。

Objective:To observe the effects of dexmedetomidine given by different methods of administration combined with transversus abdominis plane block(TAPB)on postoperative analgesia and early recovery in patients undergoing radical colorectal resection.Methods:A total of 100 patients scheduled for elective radical colorectal resection were randomly divided into four groups(n=25 in each group):dexmedetomidine intravenous plus TAPB group(group DV-T),dexmedetomidine mixed with ropivacaine TAPB group(group DR-T),ropivacaine TAPB group(group R-T)and control group(group C).In group DV-T,dexmedetomidine was given intravenously at 0.5μg/kg over 10 minutes before anesthesia induction,followed by intravenous infusion at the rate of 0.5μg/kg.h.Ultrasound guided bilateral TAPB was performed in all patients after anesthesia induction,group DR-T with dexmedetomidine 1μg/kg plus 0.375%ropivacaine of 40 ml and group DV-T,group R-T with 0.375%ropivacaine of 40 ml,and equal volume of saline was used in group C.Systolic blood pressure(SBP),diastolic blood pressure(DBP),and heart rate(HR)were recorded before induction(T0),10 minutes after TAPB(T1),at the beginning of operation(T2),30 min(T3),60 min(T4)after the beginning of operation,at the end of operation(T5).VAS score at rest and on movement at 2,6,12,24 and 48 h after operation were assessed.The requirements of sufentanil and the total times of pressing the analgesia pump on the first day after operation,the frequency of severe hypotension,bradycardia,nausea and vomiting,the first off-bed time,the first flatus time and the length of postoperative hospital stay were also recorded.Results:Compared with group C,SBP,DBP in group DR-T and group DV-T were significantly decreased at T2-T5(P<0.05).Compared with group C and group R-T,HR in group DR-T and group DV-T were obviously decreased at T1-T5(P<0.05).Compared with group C,VAS scores on movement at 6 h,12 h after operation in group R-T and group DV-T,at 6,12 and 24 h after operation in group DR-T were decreased(P<0.05).VAS scores on movement at 12 h after operation in group DR-T were significantly lower than those in group R-T(P<0.05).Compared with group C,the requirements of sufentanil and the total times of pressing the analgesia pump in the first day after operation in group R-T,group DR-T and group DV-T were significantly decreased(P<0.05),and the requirements of sufentanil and the total times of pressing the analgesia pump in the first day after operation in group DR-T were obviously less than those of in group R-T and group DV-T(P<0.05).In group R-T,group DR-T and group DV-T,the first time of getting down from bed was significantly shorter than that in group C(P<0.05).The first flatus time in group DR-T and group DV-T was also earlier than that in group C.Compared with group C,the frequency of severe bradycardia in group DV-T was obviously increased(P<0.05).Conclusion:Both of dexmedetomidine intravenous plus TAPB and dexmedetomidine mixed with ropivacaine for TAPB can significantly reduce the increase of blood pressure and heart rate caused by surgical stress,and promote earlier recovery.But dexmedetomidine mixed with ropivacaine can prolong the time of postoperative analgesia with a lower incidence of severe bradycardia.