超声引导下不同神经阻滞复合全身麻醉在腹腔镜胆囊切除术中的应用

Application of three ultrasound-guided nerve blocks combined with general anesthesia in laparoscopic cholecystectomy

目的探讨超声引导下不同神经阻滞复合全身麻醉在腹腔镜胆囊切除术(LC)中的应用。方法开展前瞻性随机对照试验。选取2022年10月至2023年11月于西安交通大学第一附属医院榆林医院收治的60例行择期LC患者作为研究对象,采用随机数字表法分为竖脊肌平面阻滞(ESPB)组(20例)、椎旁神经阻滞(PVB)组(20例)和肋横突神经阻滞(MTPB)组(20例),所有患者均在超声引导下行神经阻滞复合全身麻醉。ESPB组男9例、女11例,年龄(49.85±10.58)岁;PVB组男8例、女12例,年龄(54.40±10.51)岁;MTPB组男7例、女13例,年龄(49.95±11.61)岁。记录术中瑞芬太尼、丙泊酚用量,术中、术后平均动脉压(MAP),并比较术后2 h、8 h、24 h视觉模拟评分法(VAS)评分、C反应蛋白(CRP)、去甲肾上腺素(NE)、血糖浓度及术后不良反应情况。统计学方法采用t检验、F检验、χ^(2)检验。结果3组患者丙泊酚用量、术前和术后MAP、术后24 h的VAS评分比较,差异均无统计学意义(均P>0.05);MTPB组和PVB组瑞芬太尼用量、术中MAP、术后2 h及8 h的VAS评分[(1.09±0.50)mg、(89.96±4.56)mmHg(1 mmHg=0.133 kPa)、(4.95±3.14)分、(3.55±2.50)分及(0.84±0.47)mg、(90.42±5.08)mmHg、(4.60±2.56)分、(4.00±2.55)分]均低于ESPB组[(1.77±0.29)mg、(93.00±3.90)mmHg、(7.75±1.89)分、(5.95±2.87)分],差异均有统计学意义(F=25.04、4.06、8.94、4.65,均P<0.05)。术后2 h、8 h、24 h,3组患者血糖浓度比较,差异均无统计学意义(均P>0.05);术后2 h、8 h、24 h,MTPB组和PVB组CRP、NE水平[(2.83±0.82)ng/dl、(3.34±0.99)ng/dl、(2.75±1.10)ng/dl、(361.89±44.43)ng/L、(351.01±56.17)ng/L、(358.16±43.28)ng/L及(1.84±0.93)ng/dl、(2.14±1.09)ng/dl、(1.70±0.90)ng/dl、(303.31±55.97)ng/L、(302.45±47.87)ng/L、(297.46±44.68)ng/L]均低于ESPB组[(3.87±1.15)ng/dl、(3.89±0.82)ng/dl、(3.92±1.11)ng/dl、(400.77±55.38)ng/L、(407.11±58.59)ng/L、(403.27±51.48)ng/L],差异均有统计学意义(F=21.62、16.96、22.75、17.67、18.54、25.94,均P<0.05)。3组患者术后24 h不良反应发生情况比较,差异无统计学意义(P>0.05)。结论LC患者应用MTPB或PVB复合全身麻醉,术后镇痛效果佳,可减少术中瑞芬太尼用量,延长镇痛时间,抑制术后机体应激反应,无严重术后不良反应,但MTPB操作简单、安全。

Objective To investigate the application of three ultrasound-guided nerve blocks in conjunction with general anesthesia in laparoscopic cholecystectomy(LC).Methods Sixty patients taking selective LC at Yulin Hospital,First Hospital,Xi'an Jiaotong University from October 2022 to November 2023 were selected for the randomized controlled trial,and were divided into an erector spinae plane block(ESPB)group,a paravertebral nerve block(PVB)group,and a transversal-midpleural nerve block(MTPB)group by the random number table method,with 20 cases in each group.All the patients received ultrasound-guided nerve blocks combined with general anesthesia.There were 9 males and 11 females in the ESPB group;they were(49.85±10.58)years old.There were 8 males and 12 females in the PVB group;they were(54.40±10.51)years old.There were 7 males and 13 females in the MTPB group;they were(49.95±11.61)years old.The intraoperative remifentanil and propofol dosages,intraoperative and postoperative mean arterial pressures(MAP),scores of Visual Analogue Scale(VAS),and levels of C-reactive protein(CRP),norepinephrine concentrations,and blood glucose levels at various time points after surgery,as well as postoperative adverse reactions,were recorded and compared.t,F,and χ^(2) tests were applied.Results There were no statistical differences in the propofol dosage,MAP's before and after the surgery,and score of VAS 24 h after the surgery between the 3 groups(all P>0.05).The remifentanil dosages,MAP's during the surgery,and scores of VAS 2 and 8 h after the surgery in the MTPB group and the PVB group[(1.09±0.50)mg,(89.96±4.56)mmHg(1 mmHg=0.133)kPa,(4.95±3.14),and(3.55±2.50);(0.84±0.47)mg,(90.42±5.08)mmHg,(4.60±2.56),and(4.00±2.55)]were lower than those in the ESPB group[(1.77±0.29)mg,(93.00±3.90)mmHg,(7.75±1.89),and(5.95±2.87)],with statistical differences(F=25.04,4.06,8.94,and 4.65;all P<0.05).There were no statistical differences in the blood glucose levels 2,8,and 24 h after the surgery between the 3 groups(P>0.05).Two,8,and 24 h after the surgery,the levels of CRP and NE in the MTPB group and the PVB group[(2.83±0.82)ng/dl,(3.34±0.99)ng/dl,(2.75±1.10)ng/dl,(361.89±44.43)ng/L,(351.01±56.17)ng/L,and(358.16±43.28)ng/L;(1.84±0.93)ng/dl,(2.14±1.09)ng/dl,(1.70±0.90)ng/dl,(303.31±55.97)ng/L,(302.45±47.87)ng/L,and(297.46±44.68)ng/L]were lower than those in the ESPB group[(3.87±1.15)ng/dl,(3.89±0.82)ng/dl,(3.92±1.11)ng/dl,(400.77±55.38)ng/L,(407.11±58.59)ng/L,and(403.27±51.48)ng/L],with statistical differences(F=21.62,16.96,22.75,17.67,18.54,and 25.94;all P<0.05).There was no statistical difference in the incidence of adverse reactions between the 3 groups(P>0.05).Conclusion Application of MTPB or PVB combined with general anesthesia in patients taking LC provides effective postoperative analgesia,reduces intraoperative remifentanil dosage,prolongs analgesic effect,inhibits postoperative stress responses without causing serious adverse reactions,but MTPB is simple and safe.