不同剂量右美托咪定联合TAP阻滞对全子宫切除患者血流动力学和麻醉苏醒质量的影响

Effects of Different Doses of Dexmedetomidine Combined with TAP Block on Hemodynamics and Quality of Anesthesia Awakening in Patients with Total Hysterectomy

目的探讨不同剂量的右美托咪定联合罗哌卡因行腹横肌平面(TAP)阻滞对腹式全子宫切除患者的血流动力学和麻醉苏醒质量的影响。方法选取2018年1月至2020年12月拟在天门市第一人民医院择期行腹式全子宫切除术的160例患者作为研究对象,入组患者术前均在超声引导下行双侧TAP阻滞,并按随机数字表法分为A组(0.375%罗哌卡因注射液+0.9%氯化钠注射液)、B组(0.375%罗哌卡因注射液+0.5μg/kg右美托咪定注射液)、C组(0.375%罗哌卡因注射液+1.0μg/kg右美托咪定注射液)、D组(0.375%罗哌卡因注射液+1.5μg/kg右美托咪定注射液),每组40例,每侧均为20 ml。比较各组患者在TAP阻滞前(T_(0))、开腹前(T_(1))、开腹后0.5 h(T_(2))、气管导管拔管后10 min(T_(3))的血流动力学指标[平均动脉压(MAP)、心率]、血糖水平、苏醒质量指标[唤醒睁眼时间、拔管时间、视觉模拟评分法(VAS)评分和Riker镇静躁动评分(RSAS评分)]变化,及不良反应发生情况。结果MAP、心率组间、时点间的主效应差异有统计学意义(P<0.01),组间与时点间存在交互作用(P<0.01)。与同组T_(0)时比较,A组T_(1)时MAP升高,而D组T_(1)~T_(3)时MAP、心率均降低(P<0.05)。T_(1)时,B组、C组、D组的MAP、心率均低于A组(P<0.05),D组的MAP、心率均低于B组与C组(P<0.05);T_(2)时,D组的MAP、心率均低于A组、B组、C组(P<0.05);T_(3)时,C组的MAP低于A组,心率高于A组,D组的MAP、心率均低于A组、B组、C组(P<0.05)。血糖水平组间、时点间的主效应差异有统计学意义(P<0.01),组间与时点间存在交互作用(P<0.01)。与同组T_(0)时比较,A组T_(1)~T_(3)时的血糖水平均升高,而D组的血糖水平下降(P<0.05)。T_(1)~T_(3)时,B组、C组、D组的血糖水平均低于A组(P<0.05),D组的血糖水平均低于B组与C组(P<0.05)。B组、C组及D组的唤醒睁眼时间、拔管时间均长于A组,RSAS评分、VAS评分均低于A组(P<0.05);D组的唤醒睁眼时间、拔管时间均长于B组(P<0.05)。B组、C组及D组术中高血压、心动过速发生率以及术后镇痛药使用率均显著低于A组(P<0.05),D组术中心动过缓发生率显著高于A组、B组及C组(P<0.05)。结论0.5μg/kg的右美托咪定联合罗哌卡因行TAP阻滞可有效减轻腹式全子宫切除术患者围手术期应激反应,稳定患者血流动力学,减轻苏醒后躁动情况,且安全性较好。

Objective To investigate the effects of different doses of dexmedetomidine combined with ropivacaine for transversus abdominis plane(TAP)block on the hemodynamics and quality of anesthesia awakening in patients undergoing abdominal total hysterectomy.Methods One hundred and sixty patients who were to undergo elective abdominal total hysterectomy at Tianmen First People′s Hospital from Jan.2018 to Dec.2020 were included.All the patients underwent preoperative ultrasound-guided bilateral TAP block,and were divided into group A(0.375%ropivacaine injection+0.9%sodium chloride injection),group B(0.375%ropivacaine injection+0.5μg/kg dexmedetomidine injection),group C(0.375%ropivacaine injection+1.0μg/kg dexmedetomidine injection),group D(0.375%ropivacaine injection+1.5μg/kg dexmedetomidine injection)according to random number table method,40 patients in each group with 20 ml on each side.The hemodynamic parameters[mean arterial pressure(MAP),heart rate],blood glucose level before TAP block(T_(0)),before laparotomy(T_(1)),0.5 h after laparotomy(T_(2)),and 10 min after tracheal extubation(T_(3)),wake-up quality indicators[time to open eyes,time to extubation,visual analog scale(VAS)score and Riker sedation-agitation scale(RSAS score)]as well as the occurrence of adverse effects of each group were compared.Results There were significant differences in the main effects of MAP and heart rate between groups and time points(P<0.01),and there were interactions between groups and time points(P<0.01).Compared with the same group at T_(0),MAP in group A increased at T_(1),while MAP and heart rate in group D decreased from T_(1) to T_(3)(P<0.05).At T_(1),the MAP and heart rate of groups B,C and D were lower than those of group A(P<0.05),and those of group D were lower than those of groups B and C(P<0.05).At T_(2),the MAP and heart rate of group D were lower than those of groups A,B and C(P<0.05).At T_(3),the MAP of group C was lower than that of group A and the heart rate of group C was higher than that of group A,and the MAP and heart rate of group D were lower than those of groups A,B and C(P<0.05).There were significant differences in the main effect of blood glucose level between groups and time points(P<0.01),and there were interactions between groups and time points(P<0.01).In the same group compared with T_(0),blood glucose levels at T_(1)-T_(3) were increased in group A,but decreased in group D(P<0.05).Compared with group A,the blood glucose levels in groups B,C and D were lower at T_(1)-T_(3)(P<0.05),and compared with groups B and C,the blood glucose levels in group D were lower at T_(1)-T_(3)(P<0.05).The time to wake up and open eyes and the time to extubation were longer in groups B,C and D than in group A,and the RSAS score and VAS score were lower than those in group A(P<0.05).The time to wake up and open eyes and the time to extubation in group D were longer than those in group B(P<0.05).The incidence of intraoperative hypertension,tachycardia and postoperative analgesics in groups B,C and D were significantly lower than in group A(P<0.05);the incidence of intraoperative bradycardia was significantly higher in group D than in groups A,B and C(P<0.05).Conclusion The 0.5μg/kg dose of dexmedetomidine combined with ropivacaine TAP block can effectively reduce the perioperative stress response in patients with abdominal hysterectomy,stabilize the patient hemodynamics,reduce agitation after awakening,and has good safety.