超声引导双侧外侧弓状韧带上腰方肌阻滞复合全身麻醉用于腹腔镜胃癌根治术可行性研究

Effectiveness of ultrasound-guided bilateral quadratus lumborum block at the lateral supra-arcuate ligament combined with general anesthesia for laparoscopic radical gastrectomy

目的评价超声引导双侧外侧弓状韧带上腰方肌阻滞复合全身麻醉用于腹腔镜胃癌根治术的可行性。方法选取莆田市第一医院拟行择期腹腔镜胃癌根治术患者60例,按照随机数表法随机分成2组:超声引导双侧外侧弓状韧带上腰方肌阻滞复合全身麻醉组(试验组)和单纯全身麻醉组(对照组)。两组患者都采用丙泊酚及瑞芬太尼血浆靶控输注全身麻醉,术后采用静脉自控镇痛,观察试验组阻滞后5、10、20、30min感觉阻滞平面、有创平均血压(mean arterial pressure,MAP)及心率(heart rate,HR)变化,术后阻滞并发症,观察两组手术时间,术中丙泊酚、舒芬太尼及瑞芬太尼用量,术中出血量及输液量,术后拔管时间,术后0.5、2、6、12、24、48h静息及运动时视觉模拟评分法(visual analogue score,VAS)评分,术后24h内及24~48h舒芬太尼用量,镇痛泵有效按压次数,补救镇痛例数。记录两组患者术后首次下床时间、行走时间、排气时间、拔除胃管时间、进食时间,术后出院时间及住院总花费。结果试验组阻滞后5min即可监测到感觉阻滞平面,30min时平面可达T_(7)~L_(1)(100%),未发现有创MAP及HR明显波动,未发现阻滞相关并发症。与对照组比较,试验组术中丙泊酚用量[(1140.0±223.9)mg比(1366.3±148.1)mg,P<0.001]、舒芬太尼用量[(40.3±5.7)μg比(55.0±6.2)μg,P<0.001]及瑞芬太尼用量[(1.8±0.4)mg比(2.4±0.4)mg,P<0.001]更少,术后拔管时间早[(10.5±1.9)min比(13.1±1.7)min,P<0.001)],术后2、6、12、24h静息及运动VAS评分更低(P<0.001),术后24h舒芬太尼用量更少[48(48,50)μg比51(48,54)μg,P<0.001],镇痛泵有效按压次数减少[0(0,1)次比1.5(0,3)次,P<0.001],补救镇痛例数更少[0例比10例(33.3%),P<0.001],差异均有统计学意义。试验组患者术后首次下床时间[1(1,1)d]、行走时间[1(1,2)d]比对照组早,差异有统计学意义(P≤0.001)。结论超声引导双侧外侧弓状韧带上腰方肌阻滞复合全身麻醉用于腹腔镜胃癌根治术,阻滞起效快、效果确切、并发症少,相对于单纯全身麻醉,术中麻醉药物用量少,术后第一天静息及运动VAS评分低,术后早下床早行走,符合快速康复理念,值得临床推广应用。

Objective To evaluate the effectiveness of ultrasound-guided bilateral quadratus lumborum block at the lateral supra-arcuate ligament combined with general anesthesia during laparoscopic radical gastrectomy.Method A total of 60 patients from The First Hospital of Putian City scheduled to undergo elective laparoscopic radical gastrectomy were elected and randomly allocated into the ultrasound-guided quadratus lumborum block at the lateral supra-arcuate ligament combined with general anaesthesia group(experimental group)and the sheer general anaesthesia group(control group)according to the random number table method.Both groups were treated under general anesthesia with target-controlled infusion of propofol and remifentanil.Patient-controlled intravenous analgesia(PCIA)was administered postoperatively.The level of sensory block was assessed,invasive mean arterial pressure(MAP),heart rate(HR)and postoperative block complications were observed at 5min,10min,20min and 30min after block in the experimental group.The operative time,the consumption of propofol,sufentanil and remifentanil during surgery,intraoperative blood loss,infusion volume,postoperative extubation time,the visual analogue scale(VAS)score at rest and during activity 0.5,2,6,12,24,and 48 hours after surgery,the sufentanil consumption within 24 hours and 24 to 48 hours after surgery,the valid number of pressing the analgesic pump,and the number of rescue analgesia were recorded in both groups.The time of first getting out of bed,the time to first ambulation,exhausting time,the time of gastric tube removal,the time of first eating,time to hospital discharge and total hospitalization expenses were recorded in both groups.Result In the experimental group,the segmental level of sensory block could be detected at 5min after block and reached T_(7)-L_(1)(100%)at 30min after block.Neither significant fluctuations of invasive MAP and HR nor block-related complications were found.Compared with the control group,consumptions of intraoperative propofol[(1140.0±223.9)mg vs(1366.3±148.1)mg,P<0.001],sufentanil[(40.3±5.7)μg vs(55.0±6.2)μg,P<0.001]and remifentanil[(1.8±0.4)mg vs(2.4±0.4)mg,P<0.001]were significantly lower in the experimental group.Postoperative extubation time[(10.5±1.9)min vs(13.1±1.7)min,P<0.001)]in the experimental group was earlier than that in the control group.The VAS score at rest and during activity 2,6,12,24,48 hours after surgery,the sufentanil consumption[48(48,50)μg vs 51(48,54)μg,P<0.001]within 24h after surgery,the valid number of pressing the analgesic pump[0(0,1)vs 1.5(0,3),P<0.001],the number of rescue analgesia[0 vs 10(33.3%),P<0.001]in the experimental group were significantly lower than those in the control group.The time of first getting out of bed[1(1,1)d vs 2(1,2)d,P=0.001]and time to first ambulation[1(1,2)d vs 2(2,3)d,P<0.001]were shorter in the experimental group than those in the control group.Conclusion Ultrasound-guided bilateral quadratus lumborum block at the lateral supra-arcuate ligament combined with general anesthesia for laparoscopic radical gastrectomy has rapid onset of block,high efficiency and few complications.Compared with sheer general anesthesia,the amount of intraoperative anesthetic drugs is less;the VAS scores at rest and during activity within first postoperative day are lower;the time of getting out of the bed and the postoperative ambulation are earlier in this anesthetic technique,which is in line with the concept of rapid recovery.