连续菱形肌-肋间肌平面阻滞对胸腔镜肺叶切除术患者镇痛效果的评价

Effects of continuous rhomboid intercostal block on postoperative analgesia in patients undergoing thoracoscopic lobectomy

目的评价连续菱形肌-肋间肌平面阻滞(RIB)对胸腔镜肺叶切除术患者术后镇痛的效果。方法选择2020年10月—2021年5月择期行胸腔镜肺叶切除术患者60例,男23例、女37例,ASA分级Ⅰ或Ⅱ级。采用随机数字表法将患者分为连续RIB镇痛组和常规患者静脉自控镇痛(常规PCIA)组,每组各30例。连续RIB镇痛组患者在超声引导下行RIB并置管,后实施全身麻醉气管插管,术后予0.2%罗哌卡因自控镇痛;PCIA组患者直接行全身麻醉气管插管,不实施神经阻滞,术后予舒芬太尼常规静脉自控镇痛。记录连续RIB镇痛组行RIB后30 min时的感觉平面。分别于术后1、6、12、24、48 h记录两组患者静息和咳嗽时疼痛VAS评分,分别于术前、术后24 h、术后48 h记录40项术后恢复质量量表(QoR-40)评分。记录两组患者术中丙泊酚、瑞芬太尼用量,术后48 h内补救镇痛药物(布桂嗪)用量、行补救镇痛患者例数,术后不良反应发生情况,以及胸腔引流管拔除时间和术后住院时间。术后48 h进行患者满意度评分。结果连续RIB镇痛组、PCIA组分别有1、3例被剔除本研究。与PCIA组比较,连续RIB镇痛组患者术后各时间点的静息、咳嗽时疼痛VAS评分均显著降低(P值均<0.01)。两组间术前QoR-40总分,以及各项评分的差异均无统计学意义(P值均>0.05)。术后24 h,连续RIB镇痛组QoR-40总分和身体舒适度、情绪状态、自理能力、疼痛控制评分均显著高于PCIA组(P值分别<0.01或0.05);术后48 h,连续RIB镇痛组QoR-40总分和身体舒适度、情绪状态、疼痛控制评分均显著高于PCIA组(P值分别<0.01或0.05)。两组间术中丙泊酚用量的差异无统计学意义(P>0.05)。连续RIB镇痛组术中瑞芬太尼用量和术后补救镇痛药物布桂嗪用量均显著少于PCIA组(P值均<0.05),术后行补救镇痛的患者比例显著低于PCIA组(P<0.05)。连续RIB镇痛组患者术后恶心、呕吐发生率均显著低于PCIA组(P值均<0.05),两组间术后皮肤瘙痒、嗜睡、头晕发生率的差异均无统计学意义(P值均>0.05)。两组间患者引流管拔除时间和术后住院时间的差异均无统计学意义(P值均>0.05)。连续RIB镇痛组术后患者满意度评分显著高于PCIA组(P<0.05)。结论与PCIA相比,连续RIB可为胸腔镜肺叶切除术患者提供更好的镇痛效果,减少术后不良反应发生,提高短期恢复质量,改善患者预后。

Objective To evaluate the effects of continuous rhomboid intercostal block(RIB)on postoperative analgesia in patients undergoing thoracoscopic lobectomy.Methods Sixty patients with American Society of Anesthesiologists(ASA)physical status I or II who were scheduled for thoracoscopic lobectomy between October 2020 and May 2021 were randomly allocated into continuous RIB group and patient-controlled intravenous analgesia(PCIA)group,with 30 patients in each group.Patients in continuous RIB group received ultrasound-guided RIB and tube placement before induction of general anesthesia,followed by continuous RIB analgesia after surgery.In PCIA group,no block interventions were performed and all patients received sufentanil PCIA after surgery.The sensory plane of continuous RIB group was recorded 30 min after RIB treatment.Visual analogue scale(VAS)score of pain at rest and cough at 1 h,6 h,12 h,24 h,and 48 h after operation were recorded.QoR-40 scale scores were recorded before surgery,and 24 h and 48 h after surgery.The intraoperative dosage of propofol and remifentanil were recorded.The dosage of rescue analgesic drugs(bucinnazine)and the number of rescue analgesia within 48 h postoperatively,as well as the incidence of adverse reactions,extubation time and postoperative hospital stay were also recorded.The degree of patient’s satisfaction was assessed at 48 h postoperatively.Results One participant in the continuous RIB group and three participants in the PCIA group were excluded from this study.The VAS score of pain at rest and cough in the continuous RIB group were significantly lower than that in the PCIA group at each time point after surgery(all P<0.01).There were no significant differences in the total score of QoR-40 scale or each item score before surgery between the two groups(all P>0.05).At 24 h after surgery,the total score of QoR-40 scale and scores for physical comfort,emotional state,self-care ability,and pain control in the continuous RIB group were significantly higher than those in the PCIA group(all P<0.01 or 0.05).At 48 h after surgery,the total score of QoR-40 scale and the scores for physical comfort,emotional state and pain control in the continuous RIB group were significantly higher than those in the PCIA group(all P<0.01 or 0.05).There was no significant difference in the intraoperative dosage of propofol between the two groups(P>0.05).The intraoperative dosage of remifentanil,the postoperative dosage of bucinnazine,and the proportion of patients receiving postoperative rescue analgesia in the continuous RIB group were significantly lower than those in the PCIA group(all P<0.05).The continuous RIB group had lower incidence of nausea and vomiting than the PCIA group(all P<0.05).There was no significant difference in the incidence of pruritus,drowsiness or dizziness between the two groups(all P>0.05).There was no significant difference in the extubation time or the length of postoperative hospital stay between the two groups(both P>0.05).The continuous RIB group had higher satisfaction scores than the PCIA group(P<0.05).Conclusion Compared with PCIA,continuous RIB can provide better postoperative analgesia,reduce postoperative adverse reactions,and improve short-term recovery quality and the prognosis of patients undergoing thoracoscopic lobectomy.