弓状韧带上腰方肌前侧阻滞用于胸腔镜肺叶切除术患者术后镇痛的效果

Postoperative analgesic effect of anterior quadratus lumborum block at the supra-arcuate ligament in patients undergoing thoracoscopic pulmonary lobectomy

目的观察弓状韧带上腰方肌前侧阻滞(SA-AQLB)用于胸腔镜肺叶切除术患者术后镇痛的效果。方法选择2021年9月至2022年1月择期行单侧胸腔镜肺叶切除术患者80例,男39例,女41例,年龄36~74岁,BMI 20.6~27.1 kg/m^(2),ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:弓状韧带上腰方肌前侧阻滞镇痛组(SA组)和静脉镇痛组(IV组),每组40例。SA组在气管插管后行术侧弓状韧带上腰方肌-膈肌对合区向头侧穿刺置管,于手术结束前30 min经腰方肌-膈肌对合区留置的导管注射0.33%罗哌卡因负荷量30 ml,术毕时行患者自控神经阻滞镇痛(PCNA);IV组于手术结束前30 min静脉注射舒芬太尼负荷量0.1μg/kg,术毕时行患者自控静脉镇痛(PCIA)。记录术后12、24、48、72 h时的Prince-Henry疼痛评分。检测入室后和术后12、24、48、72 h的血浆皮质醇、血糖、C-反应蛋白(CRP)和降钙素原(PCT)浓度。测定入室后和术后72 h的用力肺活量(FVC)、第1秒用力呼气量(FEV1)和最大呼气中期流量(MMEF)。记录术后舒芬太尼补救次数、患者镇痛满意情况和不良反应发生情况。结果与IV组比较,SA组术后12、24、48、72 h的Prince-Henry疼痛评分、血浆皮质醇和血糖浓度明显降低(P<0.05),术后24、48、72 h时血浆CRP和PCT浓度明显降低(P<0.05),术后72 h时FVC、FEV1和MMEF明显升高(P<0.05),术后舒芬太尼补救次数明显减少(P<0.05),患者镇痛满意度明显升高(P<0.05),恶心呕吐和尿潴留等不良反应发生率明显降低(P<0.05)。结论胸腔镜肺叶切除术患者行SA-AQLB的术后镇痛效果优于静脉镇痛,能有效减轻应激反应,降低感染风险,促进术后肺功能康复。

Objective To observe the postoperative analgesic effect of anterior quadratus lumborum block at the supra-arcuate ligament(SA-AQLB)in patients undergoing pulmonary lobectomy.MethodsEighty patients undergoing unilateral thoracoscopic lobectomy were selected from September 2021 to January 2022,39 males and 41 females,aged 36-74 years,BMI 20.6-27.1 kg/m^(2),ASA physical statusⅠorⅡ.According to random number table method,patients were divided into two groups:SA-AQLB group(group SA)and intravenous analgesia group(group IV),40 patients in each group.In group SA catheter was placed cephalically between the quadratus lumborum and diaphragm at the supra-arcuate ligament after tracheal intubation.A loading dose of 0.33%ropivacaine 30 ml was administered via SA-AQLB catheter 30 minutes before the end of operation.Patient-controlled nerve block analgesia(PCNA)was given after operation.In group IV,a loading dose of sufentanil 0.1μg/kg was administered intravenously 30 minutes before the end of operation.Patient-controlled intravenous analgesia(PCIA)was given after operation.Prince-Henry scale was used to assess the intensity of pain 12,24,48,and 72 hours after operation.Plasma concentrations of cortisone,glucose,C-reactive protein(CRP)and procalcitonin(PCT)were determined after entering the operating room and 12,24,48,and 72 hours after operation.Forced vital capacity(FVC),forced expiratory volume first second(FEV1)and maximal mid-expiratory flow(MMEF)were measured after entering the operating room and 72 hours after operation.The times of sufentanil rescue analgesia,patient satisfaction with analgesia and occurrence of adverse reactions were recorded.Results Compared with group IV,Prince-Henry scores,plasma concentrations of cortisone and glucose were significantly reduced 12,24,48,and 72 hours after operation(P<0.05),plasma concentrations of CRP and PCT were decreased 24,48,and 72 hours after operation(P<0.05),FVC,FEV1and MMEF were increased 72 hours after operation(P<0.05),the times of sufentanil rescue analgesia were reduced(P<0.05),patient satisfaction with analgesia was increased(P<0.05),and the incidence of nausea and vomiting,urinary retention were decreased in group SA(P<0.05).Conclusion The postoperative analgesic effect of SA-AQLB in patients after thoracoscopic pulmonary lobectomy is better than that of intravenous analgesia,which can effectively reduce stress reaction and infection risk and promote postoperative pulmonary function recovery.