腹腔镜妇科手术麻醉的优化策略:弓状韧带上腰方肌前侧阻滞联合全身麻醉

Optimization strategy of anaesthesia for laparoscopic gynecological surgery:anterior quadratus lumborum block at supra-arcuate ligament combined with general anesthesia

目的评价弓状韧带上腰方肌前侧阻滞(SA-AQLB)联合全身麻醉用于腹腔镜妇科手术的优化效果。方法择期行腹腔镜妇科手术患者80例,年龄28~64岁,体重52~78 kg,身高154~166 cm,ASA分级Ⅰ或Ⅱ级,采用随机数字表法分为2组(n=40):全身麻醉组(G组)和SA-AQLB联合全身麻醉组(SG组)。SG组麻醉诱导前在超声引导下行双侧SA-AQLB,分别注入0.4%罗哌卡因25 ml+地塞米松5 mg。2组均采用静吸复合麻醉。术毕采用舒芬太尼2μg/kg(用生理盐水稀释至150 ml)行PCIA,背景输注速率2 ml/h,PCA剂量2 ml,锁定时间15 min。于术后1、6、12、24和48 h时记录腹部、盆腔和肩部的疼痛VAS评分,VAS评分>4分时,采用氟比洛芬酯进行补救镇痛。记录术中心血管事件发生情况和舒芬太尼用量;记录术后镇痛泵首次按压时间、有效按压次数、补救镇痛次数和舒芬太尼用量;记录气管拔管时间、术后首次排气时间、首次下床时间、住院时间和术后48 h内恶心呕吐、尿潴留、呼吸抑制等的发生情况。结果与G组比较,SG组术中高血压和心动过速的发生率降低,低血压和心动过缓的发生率升高,术中舒芬太尼用量减少,气管拔管时间缩短,术后镇痛泵首次按压时间延长,镇痛泵有效按压次数、补救镇痛次数和舒芬太尼用量减少,首次排气时间、首次下床时间和住院时间缩短,术后各时点腹部、盆腔和肩部的疼痛VAS评分降低,恶心呕吐、尿潴留和呼吸抑制的发生率降低(P<0.01)。结论相对于单纯全身麻醉而言,SA-AQLB联合全身麻醉用于腹腔镜妇科手术时,可减少围术期阿片类药物用量,抑制术中应激反应及术后痛敏反应,促进患者术后早期康复。

Objective To evaluate the optimization efficacy of anterior quadratus lumborum block at supra-arcuate ligament(SA-AQLB)combined with general anesthesia for laparoscopic gynecological surgery.Methods Eighty American Society of Anesthesiologists physical statusⅠorⅡpatients,aged 28-64 yr,weighing 52-78 kg,with height of 154-166 cm,scheduled for elective laparoscopic gynecological surgery,were divided into general anesthesia group(group G,n=40)and SA-AQLB combined with general anesthesia group(group SG,n=40)using a random number table method.In group SG,bilateral SA-AQLB was performed under ultrasound guidance before anesthesia induction,and 0.4%ropivacaine 25 ml plus dexamethasone 5 mg was injected into both sides.Combined intravenous-inhalational anesthesia was applied in both groups.Patient-controlled intravenous analgesia(PCIA)with sufentanil 2μg/kg(in 150 ml of normal saline)was performed after surgery.The PCIA pump was set up to deliver a 2 ml bolus dose with a 15-min lockout interval and background infusion at 2 ml/h.Visual analogue scale(VAS)scores for abdomen,pelvis and shoulder pain were recorded at 1,6,12,24 and 48 h after operation.Flurbiprofen was used for rescue analgesia when VAS score>4.The occurrence of intraoperative cardiovascular events and amount of sufentanil used during operation were recorded.The time to first pressing the analgesia pump,effective pressing times of PCA,requirement for rescue analgesia and consumption of sufentanil after operation were recorded.The extubation time,time to first flatus after operation,first ambulation time,length of hospital stay and development of postoperative adverse reactions such as nausea and vomiting,urinary retention and respiratory depression within 48 h after operation were recorded.Results Compared with group G,the incidence of intraoperative hypertension and tachycardia was significantly decreased,the incidence of intraoperative hypotension and bradycardia was increased,the intraoperative consumption of sufentanil was reduced,the extubation time was shortened,the time to first pressing the analgesia pump was prolonged,the effective pressing times of PCA,requirement for rescue analgesia and postoperative consumption of sufentanil were reduced,the time to first flatus,first ambulation time and length of hospital stay were shortened,VAS scores for abdomen,pelvis and shoulder pain were decreased at each time point after operation,and the incidence of nausea and vomiting,urinary retention and respiratory depression after operation was decreased in group SG(P<0.01).Conclusions Compared with general anesthesia,the combination of SA-AQLB and general anesthesia can reduce the opioid consumption,inhibit intraoperative stress responses and postoperative hyperalgesia and promote early postoperative recovery when used for the patients undergoing laparoscopic gynecological surgery.