裴晴晴 黃巧波 王明
[摘要] 目的 探討超聲引導(dǎo)肋緣下腹橫肌平面(TAP)阻滯對(duì)腹腔鏡膽囊切除術(shù)后早期恢復(fù)質(zhì)量的影響。 方法 選擇2018年1~12月我院擇期腹腔鏡膽囊切除手術(shù)患者62例,隨機(jī)分為觀察組和對(duì)照組。手術(shù)結(jié)束后,觀察組患者予以超聲引導(dǎo)雙側(cè)肋緣下腹橫肌平面阻滯,對(duì)照組不予干預(yù),術(shù)后觀察兩組患者各時(shí)間點(diǎn)HR、MAP、SpO2、疼痛評(píng)分、惡心嘔吐、肛門排氣時(shí)間、下床活動(dòng)時(shí)間、術(shù)后補(bǔ)救鎮(zhèn)痛次數(shù);記錄術(shù)后24 h QoR-40評(píng)分,比較兩組患者的舒適度。 結(jié)果 與對(duì)照組相比,觀察組術(shù)后4 h、8 h的HR均顯著低于對(duì)照組(P<0.05);觀察組患者拔管后5 min、術(shù)后2 h、4 h及術(shù)后8 h的VAS評(píng)分,均顯著低于對(duì)照組(P<0.05);觀察組患者肛門排氣時(shí)間顯著縮短,下床活動(dòng)時(shí)間及術(shù)后補(bǔ)救鎮(zhèn)痛次數(shù)也優(yōu)于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);與對(duì)照組相比,觀察組QoR-40總分較高,主要體現(xiàn)在情緒狀態(tài)、身體舒適度和疼痛等主觀感受方面,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。 結(jié)論 超聲引導(dǎo)肋緣下腹橫肌平面阻滯用于腹腔鏡膽囊術(shù)后鎮(zhèn)痛,可以降低患者術(shù)后疼痛評(píng)分,減少術(shù)后惡心、嘔吐等不良反應(yīng)的發(fā)生率,維持血流動(dòng)力學(xué)平穩(wěn),有效提升腹腔鏡膽囊切除術(shù)后患者早期恢復(fù)質(zhì)量。
[關(guān)鍵詞] 超聲;腹橫肌平面阻滯;腹腔鏡膽囊切除術(shù);早期恢復(fù)質(zhì)量
[中圖分類號(hào)] R657.4;R445.1 ? ? ? ? ?[文獻(xiàn)標(biāo)識(shí)碼] B ? ? ? ? ?[文章編號(hào)] 1673-9701(2020)26-0127-05
[Abstract] Objective To investigate the effect of ultrasound-guided subcostal transversus abdominis plane (TAP) block on early recovery quality after laparoscopic cholecystectomy. Methods A total of 62 patients undergoing elective laparoscopic cholecystectomy from January to December 2018 were randomly divided into observation group and control group. After the operation, patients in the observation group were given ultrasound-guided bilateral subcostal transversus abdominis plane block. The control group did not receive the intervention. The HR, MAP, SpO2, pain score, nausea and vomiting, anal exhaust time, the time of getting out of bed, and number of additional pain medications after surgery in the two groups were observed and recorded after surgery. QoR-40 score was recorded 24 hours after surgery. The comfort between the two groups was compared. Results The HR of the observation group at 4 h and 8 h after surgery was significantly lower than that of the control group. The VAS scores of the observation group at 5 min after the extubation, at 2 h, 4 h and 8 h after surgery were significantly lower than those of the control group. The anal exhaust time was significantly shorter in the observation group, and the time of getting out of bed and the number of postoperative remedial analgesia were better than those of the control group, and the differences were statistically significant(P<0.05). The total analgesic QoR-40 score in the observation group was higher than that in the control group, mainly in the subjective experience such as emotional state, physical comfort and pain, and the differences were statistically significant(P<0.05). Conclusion Ultrasound-guided subcostal transversus abdominis plane block for analgesia after laparoscopic gallbladder surgery can reduce patients' postoperative pain score, reduce the incidence of postoperative nausea, vomiting and other adverse reactions, maintain stable hemodynamics, and effectively improve early recovery quality of patients after laparoscopic cholecystectomy.
[Key words] Ultrasound; Transversus abdominis plane block; Laparoscopic cholecystectomy; Early quality recovery
腹腔鏡手術(shù)是微創(chuàng)手術(shù)的代表之一,現(xiàn)已廣泛應(yīng)用于臨床各專業(yè)領(lǐng)域。其突出優(yōu)勢(shì)在于手術(shù)創(chuàng)傷較傳統(tǒng)手術(shù)大大減小,術(shù)后疼痛也相應(yīng)減輕,故術(shù)后疼痛往往不能引起手術(shù)醫(yī)師充分重視。但事實(shí)上由于二氧化碳(CO2)氣腹刺激、腹膜牽拉等因素,腔鏡手術(shù)術(shù)后急性疼痛及其產(chǎn)生的一系列應(yīng)激反應(yīng)仍可以影響患者的康復(fù)[1],是患者術(shù)后延遲出院的重要原因之一,有效的圍術(shù)期鎮(zhèn)痛能降低術(shù)后疼痛評(píng)分,減少疼痛引起的相關(guān)并發(fā)癥,優(yōu)化手術(shù)轉(zhuǎn)歸。
腹橫肌平面(Transversus abdominis plan,TAP)阻滯是圍術(shù)期多模式鎮(zhèn)痛的方法之一[2],局麻藥物主要作用于前腹壁的皮膚、肌肉和壁層腹膜[3],可為腔鏡手術(shù)圍術(shù)期提供良好鎮(zhèn)痛,降低術(shù)后疼痛評(píng)分及不良反應(yīng)的發(fā)生率。本研究對(duì)擇期腹腔鏡膽囊切除術(shù)患者進(jìn)行臨床觀察,研究超聲引導(dǎo)肋緣下腹橫肌平面阻滯對(duì)腹腔鏡膽囊切除術(shù)后疼痛及早期恢復(fù)質(zhì)量的影響,為臨床診療提供參考,現(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料
本臨床試驗(yàn)獲得我院醫(yī)學(xué)倫理學(xué)委員會(huì)批準(zhǔn)。連續(xù)納入2018年1~12月我院擇期腹腔鏡膽囊切除術(shù)患者62例,年齡40~70歲,性別不限,體質(zhì)量指數(shù)18~24 kg/m2,美國麻醉醫(yī)師協(xié)會(huì)(ASA)分級(jí)Ⅰ~Ⅲ級(jí),心功能Ⅰ~Ⅱ級(jí)(NYHA分級(jí));呼吸系統(tǒng)無明顯異常,無合并心腦等重要臟器疾病、無皮膚感染破損、無局麻藥、無過敏史、無藥物濫用史。將其分為觀察組和對(duì)照組,每組各31例。術(shù)前所有患者簽署知情同意書。其中2例患者因外科原因中轉(zhuǎn)開腹,退出實(shí)驗(yàn),最終納入統(tǒng)計(jì)分析60例。排除標(biāo)準(zhǔn):不愿配合納入臨床研究者;對(duì)局麻藥物存在過敏反應(yīng)者;穿刺部位有瘢痕或局部感染者;嚴(yán)重心、腎功能障礙,重要器官功能不全,難以耐受手術(shù)者。
1.2 方法
1.2.1 手術(shù)方法 ?兩組患者均在氣管插管全身麻醉下行腹腔鏡膽囊切除術(shù),無術(shù)前用藥,入室后予面罩吸氧,開放上肢靜脈通道,常規(guī)心電監(jiān)護(hù),準(zhǔn)備搶救藥物。麻醉誘導(dǎo):依托咪酯 0.2 mg/kg,舒芬太尼0.8 μg/kg,順式阿曲庫銨2.5 mg/kg,氣管插管后行機(jī)械通氣;術(shù)中給予靜脈泵注丙泊酚+瑞芬太尼維持麻醉,維持循環(huán)穩(wěn)定,血壓波動(dòng)<20%術(shù)前,BIS監(jiān)測(cè)值為40~60。手術(shù)結(jié)束前30 min,予托烷司瓊5 mg,地佐辛5 mg。待患者意識(shí)清醒,自主呼吸恢復(fù),吞咽嗆咳反應(yīng)正常后拔除氣管導(dǎo)管。術(shù)后患者VAS評(píng)分>3分時(shí),靜脈注射氟比洛芬酯50 mg,24 h不超過4次。
1.2.2 術(shù)后復(fù)蘇 ?觀察組:手術(shù)結(jié)束后,行超聲引導(dǎo)雙側(cè)腹橫肌平面阻滯后轉(zhuǎn)入PACU復(fù)蘇;對(duì)照組:不予干預(yù),直接轉(zhuǎn)入PACU復(fù)蘇。
1.2.3 腹橫肌平面阻滯 ?麻醉醫(yī)師在便攜超聲儀(美國索諾聲公司)引導(dǎo)下進(jìn)行腹橫肌平面阻滯。選擇高頻(頻率6~13 MHz)探頭,用一次性無菌腔鏡保護(hù)套保護(hù)超聲探頭,貼著肋緣下,探及三層肌肉結(jié)構(gòu):腹外斜肌、腹內(nèi)斜肌和腹橫?。▓D1),從Mark點(diǎn)進(jìn)針,利用平面內(nèi)技術(shù),沿著超聲顯像平面推入神經(jīng)阻滯針(22 G駝人公司)超聲顯影下推進(jìn)至腹橫肌平面,回抽無血、水及氣體后,利用水分離技術(shù),邊推注藥液邊推進(jìn)針體,觀察組兩側(cè)均勻注射0.25% 鹽酸羅哌卡因(宜昌人福藥業(yè))各20 mL,給藥后腹內(nèi)斜肌與腹橫肌之間可出現(xiàn)邊界清楚的梭形暗區(qū),注射成功(圖2)。
1.3 觀察指標(biāo)
觀察兩組患者超聲神經(jīng)阻滯后的血流動(dòng)力學(xué)變化,記錄患者PACU拔管后5 min、術(shù)后2 h、4 h、8 h、24 h的HR、MAP、SpO2,同時(shí)運(yùn)用視覺模擬評(píng)分量表(VAS)對(duì)兩組患者的疼痛程度進(jìn)行評(píng)定,觀察記錄兩組患者疼痛評(píng)分、惡心嘔吐情況、肛門排氣時(shí)間、下床活動(dòng)時(shí)間、術(shù)后追加止痛藥的次數(shù)。記錄術(shù)后24 h QoR-40評(píng)分,比較患者的舒適度。QoR-40量表包括5個(gè)指標(biāo):情緒狀態(tài)、身體舒適度、心理支持、自理能力和疼痛,總分最低分為40分,最高分為200分,總分越高代表患者恢復(fù)質(zhì)量越好。
1.4 統(tǒng)計(jì)學(xué)分析
采用SPSS19.0統(tǒng)計(jì)學(xué)軟件統(tǒng)計(jì)分析所有數(shù)據(jù),符合正態(tài)分布的計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示;偏態(tài)分布結(jié)果以中位數(shù)(M)、四分位數(shù)間距(Q25,Q75)表示。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組患者一般情況及術(shù)前指標(biāo)的比較
本研究共選入患者62例,其中對(duì)照組31例,觀察組31例。除去中轉(zhuǎn)開腹的2例患者,全部入選患者60例,其中男 34例,女 26例,年齡40~70歲,平均 (52.90±9.57)歲,體質(zhì)量45~75 kg,平均(62.00±8.93)kg,其中術(shù)前高血壓5例,術(shù)前糖尿病4例。兩組患者術(shù)前一般情況比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),見表1。
2.2 兩組患者術(shù)后血流動(dòng)力學(xué)變化比較
觀察組術(shù)后4 h、8 h的HR均顯著低于對(duì)照組(P<0.05);其他各時(shí)間點(diǎn)的HR及兩組患者術(shù)后各時(shí)間點(diǎn)MAP、SpO2比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),見表2。
2.3兩組患者術(shù)后各時(shí)間點(diǎn)的VAS評(píng)分及不良反應(yīng)比較
觀察組患者拔管后5 min、術(shù)后2 h、4 h及術(shù)后8 h的VAS評(píng)分,均顯著低于對(duì)照組(P<0.05),但兩組患者術(shù)后24 h的VAS評(píng)分比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。對(duì)照組中,術(shù)后8 h出現(xiàn)惡心嘔吐6例,而觀察組2例,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見表3。