前路腰方肌-阴部神经阻滞对PCNL患者痛敏反应、血流动力学的影响

Effect of anterior quadrate lumbo-pudendal nerve block on pain sensitivity and hemodynamics in patients with PCNL

目的观察前路腰方肌-阴部神经阻滞对经皮肾镜碎石术(PCNL)患者痛敏反应、血流动力学的影响。方法前瞻性选取2022年5月至2023年2月在四川大学华西医院行全身麻醉下PCNL手术治疗的80例患者,按照简单随机法将其分为两组,每组各40例。全麻组单纯行全身麻醉,神经阻滞组全麻诱导后在超声引导下行前路腰方肌-阴部神经阻滞。比较两组手术一般情况(两组麻醉时间、术中出血量、苏醒时间、丙泊酚用量、术中瑞芬太尼用量、术后补救镇痛率、术后艾司洛尔和阿托品使用率、住院时间),麻醉诱导前(T_(0))、建立工作通道(T_(1))、取石即刻(T_(2))、手术结束(T_(3))的血流动力学指标[心率、平均动脉压(MAP)],术后3、6、12、24、48 h的咳嗽和静息视觉模拟评分法(VAS)评分,检测两组术前、术后1 d应激指标[皮质醇、促肾上腺皮质激素(ACTH)、去甲肾上腺素(NE)、肾素]的差异,记录并比较两组术后24、48 h术后恢复质量(QoR40)评分。结果两组的麻醉时间、术中出血量、苏醒时间、术后艾司洛尔和阿托品使用率、住院时间比较,差异均无统计学意义(P>0.05);神经阻滞组的丙泊酚用量、术中瑞芬太尼用量均少于全麻组,术后补救镇痛率低于全麻组,差异均有统计学意义(P<0.05)。神经阻滞组T1时心率低于全麻组,差异有统计学意义(P<0.05);神经阻滞组T_(0)、T_(2)、T_(3)时的心率及T_(0)、T_(1)、T_(2)、T_(3)时的MAP与同时间点全麻组比较,差异均无统计学意义(P>0.05)。神经阻滞组术后3、6、12、24、48 h的咳嗽和静息VAS评分均低于全麻组,差异均有统计学意义(P<0.05)。术后1 d,两组的皮质醇、ACTH、NE、肾素水平均较术前升高,且神经阻滞组的皮质醇、ACTH、NE、肾素水平均低于全麻组,差异均有统计学意义(P<0.05)。神经阻滞组术后24 h的QoR40评分高于全麻组,差异有统计学意义(P<0.05);神经阻滞组术后48 h的QoR40评分与全麻组比较,差异无统计学意义(P>0.05)。结论前路腰方肌-阴部神经阻滞可降低PCNL患者痛敏反应,稳定血流动力学,术后应激反应较小。

Objective To observe the effect of anterior quadrate lumbo-pudendal nerve block on pain sensitivity and hemodynamics in patients undergoing percutaneous nephrolithotripsy(PCNL).Methods Eighty patients who underwent PCNL surgery under general anaesthesia at West China Hospital,Sichuan University from May 2022 to February 2023 were prospectively selected and divided into two groups according to the simple random method,with 40 cases in each group.In the general anaesthesia group,general anaesthesia was performed alone,and in the nerve block group,an anterior lumbarflexor-pubic nerve block was performed under ultrasound guidance after induction of general anaesthesia.The general conditions(anesthesia time,intraoperative blood loss,recovery time,propofol dosage,intraoperative remifentanil dosage,postoperative remedial analgesia rate,postoperative esmolol and atropine usage rate,hospitalization time),hemodynamic indexes[heart rate,mean arterial pressure(MAP)]before anesthesia induction(T_(0)),establishment of working channel(T_(1)),immediate stone removal(T_(2))and end of operation(T_(3)),cough and resting visual analogue scale(VAS)scores at 3,6,12,24 and 48 h after operation were compared between the two groups,the stress indicators[cortisol,adrenocorticotropic hormone(ACTH),norepinephrine(NE),and renin]before operation and 1 d after operation were detected,and the quality of postoperative recovery(QoR40)scores were recorded and compared.Results There were no statistically significant differences in anesthesia time,intraoperative blood loss,recovery time,postoperative use rate of esmolol and atropine,and hospitalization time between the two groups(P>0.05).The dosage of propofol and intraoperative remifentanil dosage in the nerve block group were less than those in the general anesthesia group,and the postoperative remedial analgesia rate was lower than that in the general anesthesia group,the differences were statistically significant(P<0.05).The heart rate at T_(1)in the nerve block group was lower than that in the general anesthesia group,and the difference was statistically significant(P<0.05).There was no statistically significant difference in heart rate at T_(0),T_(2)and T_(3)and MAP at T_(0),T_(1),T_(2)and T_(3)between the nerve block group and the general anesthesia group at the same time point(P>0.05).The cough and resting VAS scores of the nerve block group were lower than those of the general anesthesia group at 3,6,12,24 and 48 h after operation,and the differences were statistically significant(P<0.05).At 1 day after operation,the levels of cortisol,ACTH,NE and renin in the two groups were higher than those before operation,and the levels of cortisol,ACTH,NE and renin in the nerve block group were lower than those in the general anesthesia group,the differences were statistically significant(P<0.05).The QoR40 score of the nerve block group at 24 h after operation was higher than that of the general anesthesia group,and the difference was statistically significant(P<0.05);there were no statistically significant differences in QoR40 score between the nerve block group and the general anesthesia group at 48 h after operation(P>0.05).Conclusion Anterior quadrate lumbo-pudendal nerve block can reduce pain sensitivity,stabilize hemodynamics and reduce postoperative stress reaction in PCNL patients.