[关键词] 超声引导;腰方肌阻滞;直肠癌根治术;镇痛效果
[Abstract] objective to analyze the analgesic effect of ultrasound-guided lumbar quadrat block after radical resection of abdominal rectal cancer. Methods a total of 86 patients with elective radical resection of abdominal rectal cancer in our hospital from February to August 2018 were selected and randomly divided into the observation group and the control group, with 43 patients in each group. The observation group received ultrasound-guided block of the quadratus lumbar muscle before and after general anesthesia, and 0.375% ropivacaine 20mL was injected between the quadratus lumbar muscle and the major lumbar muscle, while the control group received simple general anesthesia and isovolar physiological saline. The dosages of sufentanil, VAS scores at different time points, number of cases of remedial analgesia, first time out of bed and postoperative satisfaction of patients in the two groups were observed. Results the dosage of sufentanil in the observation group was less than that in the control group at 0-12h and 12-24h after surgery, and the difference was statistically significant (P<0.05). There was no significant difference in the dosage of sufentanil between the two groups at 24-36h and 36-48h after surgery (P>0.05). VAS scores of the observation group were significantly lower than those of the control group at 4, 6, 12 and 24h after surgery, with statistically significant differences (P<0.05). VAS scores of the two groups were not significantly different at 2, 36 and 48h after surgery (P>0.05). The incidence of postoperative remedial analgesia in the observation group was significantly lower than that in the control group, and the time of getting out of bed for the first time was significantly earlier than that in the control group. The postoperative patient satisfaction was high, and the difference was statistically significant (P<0.05). Conclusion ultrasound-guided lumbar quadratus block can significantly improve the postoperative analgesic effect in patients with transabdominal rectal cancer, reduce the amount of postoperative opioids in patients, advance the time of patients' first time out of bed after surgery, and improve patient satisfaction, which is worthy of clinical application and promotion.
[Key words] ultrasonic guidance; Block of quadratus lumbar muscle; Radical resection of rectal cancer; Analgesic effect
疼痛是影响患者术后康复的主要原因,研究表明,全世界89%患者因疼痛而延迟治愈时间。腹部手术疼痛主要由于腹壁的皮肤、内脏等受到刺激性伤害,导致肠麻痹、交叉神经活动亢进,严重影响胃肠道功能,单纯的静脉自控镇痛容易发生镇静过度导致患者出现恶心、头晕不良反应,因此临床多采取多模式术后镇痛,有利于患者更早恢复[1]。腰方肌阻滞能够稳定地阻滞T6-L1神经根,腰方肌阻滞药物可以通过胸腰筋膜扩散到胸椎旁间隙,基本覆盖直肠癌手术区域,阻断交感神经,有利于改善患者术后的镇痛效果[2]。本研究旨在探究超声引导下腰方肌阻滞对经腹直肠癌根治术后的镇痛效果,为临床提供更多方法和思路,现报告如下。
1资料与方法
1.1一般资料
选取2018年2月-8月来我院行择期经腹直肠癌根治术患者86例,随机分为观察组和对照组各43例。其中观察组男22例,女21例,年龄48-70岁,平均年龄(58.4±8.3)岁,BMI(28.4±3.7)kg/m,ASA(美国麻醉师协会) 分级Ⅰ级30例,Ⅱ级13例;对照组男20例,女23例,年龄45-75岁,平均年龄(59.2±7.6)岁,BMI(26.4±3.4)kg/m,ASA 分级Ⅰ级24例,Ⅱ级19例。纳入标准:术前所有患者进行肿瘤定位和分期。排除标准:罗哌卡因过敏患者;长期服用阿片类药物;患有严重心、脑、肺、肝和肾等脏器功能障碍;患有服用抗抑郁药物、单胺氧化酶抑制剂史;严重的精神疾病患者;语言障碍患者;局部麻醉药过敏患者;术前1d简易精神量表(MMSE)评分<23。两组患者在性别、年龄等一般资料方面比较差异无统计学意义(P>0.05)。
1.2麻醉方法
所有患者术前常规禁食8h,禁饮2h,除抗生素以外未使用其他药物。入室后开放静脉通路,例行监测无创血压、SpO2、心电和BIS 值。两组患者均采用快速诱导法诱导气管内插管全麻,麻醉诱导药物:丙泊酚1.5mg/kg、咪达唑仑0.05mg/kg、舒芬太尼 0.4μg/kg、顺苯磺酸阿曲库铵0.3mg/kg。在BIS值达到50时,行经口明视气管插管,确保插管后麻醉剂行机械通气,术中麻醉维持:瑞芬太尼0.2μg/(kg·h),丙泊酚3-4mg/(kg·h),间断注入顺苯磺酸阿曲库铵,根据BIS值变化,调节丙泊酚剂量。术中若BP、HR的波动大于基础值20%,给予芬太0.05静脉推注,若BP、HR的波动小于基础值20%,给予阿托品 0.5 mg 静脉推注,以平稳血流[3]。
观察组患者在全麻后在穿刺侧臀下垫一薄垫,便于更清晰观测穿刺部位,患者保持平卧位,局部消毒铺巾,采用BLS型超声仪,选用2-5MHz低频凸阵探头,将探头置于无菌镜头套内,内涂超声耦合剂,探头置于Petit三角,显示典型的三层腹部结构,选用QL2入路,随后逐渐向后移动,腹横肌逐渐消失出现腹横肌腱膜,略微倾斜探头显示出腰方肌,腰方肌一般位于腹横肌腱膜的内侧,再往背侧略微移动探头,使用平面内技术和100 mm的穿刺针,从腹部向背侧插入穿刺针,注射生理盐水2mL确认穿刺位置,每侧注射0.375%罗哌卡因20mL,可见药物在腰方肌后的胸腰筋膜间隙扩散表示注射成功[4],所有麻醉注射操作均由一名资深的麻醉师完成。
两组患者术后均采用PCIA,配方为:舒芬太尼400μg,昂丹司琼3mg,氯化钠液稀释至100mL。镇痛泵参数设置:背景剂量2mL/h,单次按压剂量2mL,负荷剂量4mL,锁定15min。当患者VAS评分>3时,开启PCIA,进行补救性镇痛。
1.3观察指标
观察和记录两组患者不同时间段舒芬太尼的用量和术后不同时间点(第2/4/6/12/24/36/48h)静息VAS评分,补救性镇痛例数,有效镇痛例数定义为局麻药注射至开启 PCIA ,首次下床时间和术后满意度(分为3个层次:非常满意、一般满意和不满意,共10分,>9分表示非常满意,6-9分表示一般满意,<6分表示不满意)。
1.4统计学分析
采用统计学软件SPSS21.0对数据进行处理,计量类资料采用(x±s)表示,使用t检验,计数类资料采用(%)表示,使用2检验,当P<0.05时表示差异具有统计学意义。
2结果
2.1两组患者术后不同时间段舒芬太尼的用量比较
术后0-12h和12-24h,观察组舒芬太尼的用量明显少于对照组,差异具有统计学意义(P<0.05),而在术后24-36h和36-48h,两组舒芬太尼用量无显著差异(P>0.05),见表1。
3讨论
超声引导下腰方肌阻滞是一种新型的神经阻滞办法,对于其他阻滞办法,阻滞范围更加广泛,能够保证患者及早下床,减少并发症,促进患者及早康复。超声引导下腰方肌阻滞注射药物后,药物在腰方肌后的胸腰筋膜间隙扩散,阻断交感神经,缓解内脏的疼痛感。
本研究应用0.375%罗哌卡因20mL于双侧行超声引导下腰方肌阻滞,取得了确切效果,选用QL2入路,相对于其他入路方法,更加安全可靠。根据以往研究显示,与TAP阻滞比较,腰方肌阻滞能够提供更长的镇痛时间,且能够有效的减少吗啡的使用,延长镇痛时间至48h。目前,超声引导下腰方肌阻滞已经成为手术期重要的镇痛方法之一,广泛应用于腹部手术后的镇痛中[5]。
综上所述,超声引导下经腰方肌滞能够较好地缓解经腹直肠癌根治术患者术后镇痛,使得患者下床时间提前,提高患者满意度,有利于患者术后康复。
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论文作者:李诚
论文发表刊物:《总装备部医学学报》2019年第10期
论文发表时间:2019/12/10
标签:术后论文; 患者论文; 超声论文; 直肠癌论文; 统计学论文; 两组论文; 用量论文; 《总装备部医学学报》2019年第10期论文;