超声引导下前锯肌平面阻滞与胸椎旁神经阻滞用于VATS术后的镇痛效果比较

Analgesic effect of ultrasound-guided serratus anterior plane block and thoracic paravertebral nerve block for postoperative analgesia after video-assisted thoracoscopic surgery

目的比较超声引导下前锯肌平面阻滞(SPB)与胸椎旁神经阻滞(TPVB)用于电视辅助胸腔镜手术(VATS)术后镇痛的效果。方法选取2018年7月至2020年9月在厦门大学附属中山医院择期行VATS的93例患者,按随机数表法分为A组47例和B组46例,其中A组有2例中转开胸手术和1例出现心肌缺血,B组有1例中转开胸手术和1例术中出现心肌缺血而被剔除,故A组实际纳入44例,于麻醉诱导前行超声引导下SPB,B组实际纳入44例,于麻醉诱导前行超声引导下TPVB,均使用0.33%罗哌卡因20 mL。两组患者均采取气管插管静脉全麻,术后均应用静脉自控镇痛(PCIA)。于术后2 h、4 h、6 h、12 h、24 h、48 h应用视觉模拟评分法(VAS)评估两组患者安静、咳嗽状态下疼痛情况,于术前和术后4 h、12 h、24 h、48 h检测两组患者血清炎性因子水平[白介素-6(IL-6)、白介素-10(IL-10)],记录两组患者术后48 h内的PCIA按压次数、PCIA总用量及使用时间,并统计术后不良反应发生情况。结果两组患者术后2~48 h安静、咳嗽状态下VAS评分均先升后降,B组患者术后12 h、24 h时安静、咳嗽状态下的VAS评分明显低于A组,差异均有统计学意义(P<0.05),而其他时间点两组间比较差异均无统计学意义(P>0.05);两组患者术后4~48 h的血清IL-6、IL-10水平均先升后降,B组术后12 h、24 h时血清IL-6水平明显低于A组,血清IL-10水平明显高于A组,差异均有统计学意义(P<0.05),而其余时间点两组间比较差异均无统计学意义(P>0.05);B组患者的PCIA按压次数为(3.46±0.94)次,明显少于A组的(4.31±1.38)次,差异有统计学意义(P<0.05);A组患者气胸或穿刺部位血肿发生率为0,明显较B组的13.64%低,差异有统计学意义(P<0.05);两组患者的PCIA总用量、PCIA使用时间比较差异均无统计学意义(P>0.05)。结论超声引导下SPB联合术后应用PCIA对VATS术后疼痛、炎症的缓解作用不如TPVB联合术后应用PCIA,但其穿刺并发症发生率更低。

Objective To compare the analgesic effects of ultrasound-guided serratus anterior plane block(SPB)and thoracic paravertebral nerve block(TPVB)in patients undergoing video-assisted thoracoscopic surgery(VATS).Methods A total of 93 patients who underwent VATS in Zhongshan Hospital,Xiamen University from July2018 to September 2020 were selected and divided into group A(47 patients)and group B(46 patients)according to random number table method.Among them,2 cases in group A were converted to thoracotomy and 1 case developed myocardial ischemia,and 1 case in group B was converted to thoracotomy and 1 case developed myocardial ischemia during operation and was excluded.Therefore,44 cases in group A were actually included and SPB was guided by ultrasound before anesthesia induction,while 44 cases in group B were actually included and TPVB was guided before anesthesia induction and ultrasound.All patients were treated with 20 mL of 0.33%ropivacaine.Patients in both groups received endotracheal intubation intravenous general anesthesia,and postoperative intravenous controlled analgesia(PCIA)was applied.Visual Analogue Scale(VAS)was used to evaluate the pain in quiet and coughing state of the two groups at 2 h,4 h,6 h,12 h,24 h and 48 h after operation.The levels of serum inflammatory factors(IL-6 and IL-10)were detected before operation,4 h,12 h,24 h and 48 h after operation.The pressing times,total dosage and use time of PCIA in the two groups within 48 h after operation were recorded,and the incidence of postoperative adverse reactions in the two groups was statistically analyzed.Results After operation,the VAS scores of the two groups in quiet and coughing state at 2 h to 48 h increased first and then decreased;the VAS scores of group B in quiet and coughing state at 12 h and 24 h after operation were significantly lower than those of group A(all P<0.05),but there was no significant difference between the two groups at other time points(all P>0.05);the serum levels of IL-6 and IL-10 in both groups increased at first and then decreased at 4 h to 48 h after operation,the level of serum IL-6 at 12 h and 24 h after operation in group B was significantly lower than that in group A(P<0.05),and the serum level of IL-10 was significantly higher than that in group A(P<0.05),but there was no significant difference between the two groups at other time points(P>0.05);the pressing times of PCIA in group B was 3.46±0.94,significantly less than 4.31±1.38 in group A(P<0.05);the incidence of pneumothorax or hematoma at puncture site in group A was 0,significantly lower than 13.64%in group B(P<0.05);there was no statistically significant difference in the total amount of PCIA and the time of PCIA use between the two groups(P>0.05).Conclusion Ultrasound-guided SPB combined with postoperative PCIA is not as effective as TPVB combined with postoperative PCIA in relieving pain and inflammation after VATS,but the incidence of puncture complications is lower.