腹横筋膜阻滞联合全身麻醉对急诊开腹胃肠道手术患者组织灌注和术后疼痛的影响

Effects of transverse abdominal fascia block combined with general anesthesia on tissue perfusion and postoperative pain in patients undergoing open gastrointestinal surgery

目的观察超声引导下腹横筋膜阻滞(TAPB)联合全身麻醉对急诊开腹胃肠道手术患者组织灌注和术后疼痛的影响。方法采用回顾性队列研究分析2019年2月至12月在中山大学孙逸仙纪念医院行急诊开腹胃肠道手术ASA分级Ⅰ或Ⅱ级60例患者,其中男性39例,女性21例;年龄20~65岁,平均(48.1±4.1)岁。根据麻醉方案的不同分为TAPB组和对照组。针对两组患者基本临床特征的差异,采用倾向性得分匹配的方法,匹配按照1∶1比例进行,每组得到30例。TAPB组患者在气管插管全身麻醉的基础上联合应用超声引导下双侧TAPB,对照组患者接受气管插管全身麻醉。比较两组患者各项临床指标:(1)血流动力学指标:观察入室后、切割皮肤、分离肌肉层和分离壁层腹膜时平均动脉压(MAP)和心率(HR)的变化。(2)组织灌注情况:手术开始时(T0)、手术开始1 h(T1)、手术开始2 h(T2)、术毕(T3)时中心静脉血氧饱和度(ScvO2)和动脉血乳酸(ABL)水平。(3)手术相关结局:术中麻醉药物(七氟烷、瑞芬太尼)用量、血管活性药物(去甲肾上腺素、阿托品)用量,术后2 h、24 h、48 h视觉模拟评分法(VAS)评分,以及术后曲马多用量。记录并统计TAPB相关并发症的发生率。结果与对照组相比较,TAPB组切割皮肤、分离肌肉层和分离壁层腹膜时MAP、HR更平稳,术中T1[(75.9±4.5)%比(73.1±3.2)%]、T2[(75.4±4.6)%比(72.8±3.3)%]、T3[(74.7±4.4)%比(71.5±3.5)%]时ScvO2水平更高,术中T3时ABL水平更低[(0.8±0.4)mmoL/L比(1.2±0.4)mmoL/L];且术中七氟烷[(52.4±7.9)mL比(61.6±10.4)mL]、瑞芬太尼[(1.7±0.4)mg比(2.6±0.5)mg]、去甲肾上腺素[(0.8±0.3)mg比(1.4±0.5)mg]、阿托品[(0.2±0.1)mg比(0.4±0.2)mg]以及术后曲马多[(127.4±32.6)mg比(252.3±62.5)mg]用量更少,术后2 h[(2.4±0.6)分比(3.8±1.0)分]、24 h[(2.0±0.5)分比(2.5±0.7)分]的VAS评分更低。差异均有统计学意义(P均<0.05)。所有患者未发生TAPB相关并发症。结论TAPB联合全身麻醉可保证急诊开腹胃肠道手术患者术中良好组织氧合灌注,有利于维持术中血流动力学稳定,减少患者术中麻醉药物和血管活性药的用量,降低患者术后疼痛程度,值得推广应用。

Objective To observe the effect of ultrasound guided TAPB combined with general anesthesia on tissue perfusion and postoperative pain in patients undergoing open gastrointestinal operation.Methods This was a single institute retrospective cohort study.From February to December 2019,sixty patients with ASA I or II undergoing emergency open gastroenterotomy in Sun Yat-Sen Memorial Hospital of Sun Yat-sen University were eligible to be analyzed and divided into control group and TAPB group.There were 39 males and 21 females,aged 20~65 years,with an average age of 48.1±4.1 years.Propensity score matching method was used to balance the baseline characteristics.Two groups were matched in a 1∶1 ratio.There were 30 cases per group after matched.The TAPB group received bilateral TAPB on the basis of general anesthesia,and the control group received general anesthesia with tracheal intubation.The changes of MAP and HR were observed after entering the room,cutting skin,separating muscle layer and separating parietal peritoneum.ScvO2 and ABL at the beginning of operation(T0),1 h after the beginning of operation(T1),2 h after the beginning of operation(T2),and the end of operation(T3)were also observed;The dosage of sevoflurane,remifentanil,norepinephrine or atropine,and VAS scores after operation between the two groups were compared.The incidence of TAPB related complications was recorded and analyzed.Results The MAP and HR in the TAPB group were more stable than that in the control group(P<0.05);The ScvO2 in the TAPB group at T1[(75.9±4.5)%vs.(73.1±3.2)%],T2[(75.4±4.6)%vs.(72.8±3.3)%]and T3[(74.7±4.4)%vs.(71.5±3.5)%]was higher and the ABL at T3[(0.8±0.4)mmoL/L vs.(1.2±0.4)mmoL/L]was significantly lower than that in the control group(P<0.05);Compared with the control group,the amount of sevoflurane[(52.4±7.9)mL vs.(61.6±10.4)mL],remifentanil[(1.7±0.4)mg vs.(2.6±0.5)mg],norepinephrine[(0.8±0.3)mg vs.(1.4±0.5)mg]or atropine[(0.2±0.1)mg vs.(0.4±0.2)mg]and tramadol[(127.4±32.6)mg vs.(252.3±62.5)mg]in the TAPB group was less,and the VAS scores of postoperation 2 h[(2.4±0.6)vs.(3.8±1.0)],24 h[(2.0±0.5)vs.(2.5±0.7)]were lower(P<0.05).No TAPB related complications occurred in all the patients.Conclusion TAPB combined with general anesthesia can ensure a good tissue perfusion during the open gastrointestinal operation,maintain the hemodynamic stability,significantly reduce the amount of anesthetics and vasoactive drugs during the operation,and reduce the postoperative pain of the patients,which is worth popularizing.