椎旁神经阻滞和竖脊肌平面阻滞对单孔胸腔镜胸外手术镇痛效果的影响

目的比较超声引导下椎旁神经阻滞和竖脊肌平面阻滞对单孔胸腔镜胸外手术的镇痛效果。方法选择2019年5月至2021年5月本院择期行单孔胸腔镜手术患者60例,ASA分级Ⅰ~Ⅱ级,BMI18~30 kg/m^(2),随机分为胸椎旁神经阻滞(T组,n=30)、竖脊肌平面阻滞(E组,n=30),术后常规采用PCIA,当VAS≥4分用帕瑞昔布钠补救镇痛。麻醉诱导前T组在超声引导下行胸椎旁神经阻滞,E组行竖脊肌神经阻滞,5 min后开始用冰块法测定阻滞平面,记录穿刺深度、神经阻滞的操作时间及起效时间,记录两组患者术后拔管即刻(T1)、6 h(T2)、12 h(T3)、24 h(T4)、48 h(T5)静息及咳嗽状态下VAS评分,记录术后镇痛泵首次按压时间,有效按压次数及帕瑞昔布钠用量,记录术中瑞芬太尼、丙泊酚、血管活性药用量以及诱导前(T1)、切皮(T2)、进胸(T3)、标本切除(T4)时平均动脉压和心率,记录术后恶心呕吐、肺不张等不良反应的发生率。结果与T组相比,E组神经阻滞穿刺时间明显缩短(P<0.05)、穿刺深度变浅(P<0.05)、术中瑞芬太尼用量明显增多(P<0.05)、术中平均动脉压和心率升高(P<0.05)。两组患者术中丙泊酚、血管活性药用量差异无统计学意义(P>0.05)。术后6 h及术后24 h咳嗽VAS评分E组高于T组(P<0.05)。两组患者术后首次镇痛泵按压时间、按压次数、帕瑞昔布钠的用量差异无统计学意义(P>0.05)。两组患者恶心呕吐、肺不张等不良反应的发生率差异无统计学意义(P>0.05)。结论胸椎旁神经阻滞和竖脊肌平面阻滞在单孔胸腔镜手术中、术后均能提供良好的镇痛,但胸椎旁神经阻滞镇痛效果优于竖脊肌平面阻滞镇痛效果。

Objective To compare the effects of ultrasound-guided paravertebral nerve block and erector spinus plane block on analgesic efficacy of single port thoracoscopic external thoracic surgery.Methods Sixty patients who underwent elective single port thoracoscopic surgery in our hospital from May 2019 to May 2021 were selected,ASA gradeⅠ~Ⅱ,BMI18~30 kg/m^(2),and randomly divided into thoracic paravertebrinal nerve block(T group,n=30)and eriospinal plane block(E group,n=30).PCIA was used routinely after surgery,and parecoxib sodium was used to relieve pain when VAS≥4.Before anesthesia induction,the T group received thoracic paravertebral nerve block under ultrasound guidance,and the E group received erector spinal nerve block.5 minutes later,the block plane was determined by ice cube method,and the puncture depth,operation time and onset time of nerve block were recorded.VAS scores were recorded immediately after extubation(T1),6 hours(T2),12 hours(T3),24 hours(T4),48 hours(T5)at resting and coughing state in the two groups.The first time of postoperative analgesic pump compression,the number of effective compression and the dosage of parecoxib sodium were recorded.The intraoperative dosage of remifentanil,propofol and vasoactive agents as well as the mean arterial pressure and heart rate before induction(T1),skin resection(T2),thoracotomy(T3)and specimen resection(T4)were recorded,and the incidence of postoperative adverse reactions such as nausea,vomiting and atractysis were recorded.Results Compared with group T,the puncture time of nerve block in group E was significantly shortened(P<0.05),the puncture depth was significantly shallower(P<0.05),the intraoperative dosage of remifentanil increased significantly(P<0.05),intraoperative mean arterial pressure and heart rate significantly increased(P<0.05).There was no statistical significance in the intraoperative dosage of propofol and vasoactive drugs between the two groups(P>0.05).The scores of cough VAS at 6 h and 24 h after surgery in group E were higher than those in group T(P<0.05).There was no significant difference in the first postoperative analgesic pump compression time,number of compressions and dosage of parecoxib sodium between the two groups(P>0.05).There was no significant difference in the incidence of nausea,vomiting,atelectasis and other adverse reactions between the two groups(P>0.05).Conclusion Thoracic paravertebral nerve block and erector spine plane block can provide good analgesia during and after single port thoracoscopic surgery,but the analgesia effect of thoracic paravertebral nerve block is better than that of erector spine plane block.