腹横肌平面阻滞联合胸椎旁神经阻滞在老年肝切除术中的效果及安全性

Effect and Safety Analysis of Transverse Abdominis Plane Block Combined with Thoracic Paravertebral Block in Elderly Patients Undergoing Hepatectomy

目的分析腹横肌平面阻滞(TAPB)联合胸椎旁神经阻滞(TPVB)在老年肝切除术中的效果及安全性。方法选取2022年2月至2023年4月山东省立第三医院收治的110例行肝切除术治疗的老年患者为研究对象,根据麻醉方式不同分为对照组(58例)和联合组(52例),对照组采用全身麻醉,联合组在对照组的基础上给予TAPB(双侧腹横肌平面各注入15~20 ml浓度为0.3%的罗哌卡因)联合TPVB(椎间旁间隙注射10~15 ml浓度为0.5%的罗哌卡因)。比较两组患者麻醉诱导前、诱导时、手术开始后20 min、拔管时、拔管后30 min的血流动力学指标[心率、收缩压、舒张压、脉搏血氧饱和度(SpO_(2))、平均动脉压(MAP)]变化情况,术后6、12、24、48 h视觉模拟评分法(VAS)评分,记录患者围手术期指标和术后48 h内镇痛泵按压次数,以及不良反应发生情况。结果不同时点间心率、收缩压、舒张压、SpO_(2)、MAP的主效应差异有统计学意义(P<0.01),不考虑测量时间,心率、收缩压、舒张压、MAP组间的主效应差异有统计学意义(P<0.01),SpO_(2)组间的主效应差异无统计学意义(P>0.05),心率、收缩压、舒张压、MAP组间和时点间存在交互作用(P<0.01),SpO_(2)组间和时点间无交互作用(P>0.05);诱导时、手术开始后20 min,联合组心率、收缩压、舒张压、MAP高于对照组(P<0.05)。术后不同时点间VAS评分的主效应差异有统计学意义(P<0.01),不考虑测量时间,组间的主效应差异有统计学意义(P<0.01),组间和时点间存在交互作用(P<0.01);术后12、24 h,联合组患者VAS评分低于对照组(P<0.05)。联合组瑞芬太尼消耗量、镇痛泵按压次数少于对照组[(2.34±0.18)mg比(4.25±0.31)mg、(12.3±2.3)次比(17.4±3.6)次](P<0.01)。联合组不良反应总发生率低于对照组[11.54%(6/52)比31.03%(18/58)](χ^(2)=6.110,P=0.013)。结论对行肝切除术治疗的老年患者在全身麻醉的基础上应用TAPB联合TPVB可获得更优的镇痛效果,术中患者循环情况也更为稳定,且安全性佳。

Objective To analyze the efficacy and safety of transverse abdominis plane block(TAPB)combined with thoracic paravertebral block(TPVB)in elderly patients undergoing hepatectomy.Methods A total of 110 elderly patients undergoing hepatectomy in Shandong Provincial Third Hospital from Feb.2022 to Apr.2023 were included.According to different anesthesia methods,they were divided into a control group(58 cases)and a combination group(52 cases).The control group was given general anesthesia;on the basis of the control group,the combination group was given TAPB(15-20 ml injection of 0.3% ropivacaine in each lateral abdominal transverse muscle plane)and TPVB(10-15 ml injection of 0.5% ropivacaine in the paravertebral space).The hemodynamic indexes[heart rate,systolic blood pressure,diastolic blood pressure,pulse oxygen saturation(SpO_(2))and mean arterial pressure(MAP)]of the two groups were compared before anesthesia induction,during induction,20 min after surgery,at extubation,and 30 min after extubation.Visual analogue scale(VAS)score at 6,12,24,and 48 h postoperatively were compared;the perioperative indexes,the number of analgesic pump compressions in 48 h and the occurrence of adverse reactions at postoperative recovery.Results The main effect differences of the heart rate,systolic blood pressure,diastolic blood pressure,SpO_(2),and MAP in different time points were statistically significant(P<0.01);regardless of the measurement time,the main effect differences of the heart rate,systolic blood pressure,diastolic blood pressure and MAP were statistically significant between groups(P<0.01),and no significant difference in SpO_(2) between groups(P>0.05);there were interactions between groups and time points of the heart rate,SBP,DBP and MAP(P<0.01),and no interaction of SpO_(2) between groups and time points(P>0.05);at induction,20 min after starting surgery,the heart rate,SBP,DBP and MAP in the combination group were higher than those in the control group(P<0.05).The main effect differences of the VAS score between different postoperative time points were statistically significant(P<0.01),regardless of the measurement time,the main effect difference of VAS score was statistically significant between groups(P<0.01),and there was an interaction between groups and time points(P<0.01);at 12 and 24 h after surgery,VAS score of the combination group was lower than the control group(P<0.05).The amount of remifentanil consumption and analgesic pump press times in the combination group were less than those in the control group[(2.34±0.18)mg vs(4.25±0.31)mg,(12.3±2.3)times vs(17.4±3.6)times](P<0.01).The overall incidence of adverse effects in the combination group was lower than that in the control group[11.54%(6/52)vs 31.03%(18/58)](χ^(2)=6.110,P=0.013).Conclusion For elderly patients undergoing hepatectomy,TAPB combined with TPVB on the basis of general anesthesia can obtain better analgesic effect,and the patient intraoperative circulation is more stable and safe.