超声引导下双侧腹横肌平面阻滞复合全身麻醉在老年患者妇科开腹手术中的应用

Application of ultrasound-guided transverses abdominis plane block combined with general anesthesia in laparotomy of senile female patients

摘要:

目的：探讨超声引导下双侧腹横肌平面（transversus abdominis plane，TAP）阻滞复合全身麻醉在老年妇科开腹手术应用中的安全性和有效性。方法：纳入择期行妇科良性疾病开腹手术的老年患者（年龄>65岁）60例，美国麻醉医师协会（Ameri－can Association of Anesthesiologists，ASA）分级Ⅰ~Ⅲ级，随机分为对照组（C组）和腹横肌平面阻滞组（TAP组），每组30例。TAP组采用超声引导下双侧腹横肌平面阻滞复合全身麻醉，C组采用全身麻醉。观察2组患者麻醉诱导前（T0）、麻醉诱导后（T1）、切皮时（T2）、手术结束时（T3）、术后30 min（T4）时的平均动脉血压（mean arterial pressure，MAP）、心率（heart rate，HR）等血流动力学参数，测定血清肾上腺素（adrenaline，A）、去甲肾上腺素（noradrenaline，NA）水平。随访记录患者术后2、4、8、12、24 h视觉模拟评分（visual analogue scale，VAS）、镇痛泵按压次数、舒芬太尼补救例数及术后不良事件（恶心、呕吐、低血压、心动过缓和尿潴留等）的发生情况。结果：2组患者一般情况无统计学差异。与T0时刻[（122.8±7.0） mmHg]相比，C组MAP值在T1[（111.7±9.4） mmHg]，T2[（102.2±8.0） mmHg]，T3[（101.1±11.9）mmHg]，T4[（105.0±5.3） mmHg]时刻均有所下降；TAP组MAP值在T1[（113.3±10.9） mmHg]，T2[（110.1±9.4） mmHg]，T3[（109.1±11.2） mmHg]，T4[（116.5±7.2） mmHg]有所降低（P<0.05），但是TAP组在T2~T4血压较C组平稳（两组比较P<0.05）；T2、T3和T4时点TAP组血清肾上腺素[T2：（192.3±22.6） pg/mL，T3：（221.7±16.5） pg/mL，T4：（166.4±14.1） pg/mL]和去甲肾上腺素水平[T2：（140.4±17.0） pg/mL，T3：（149.6±14.4） pg/mL，T4：（116.7±21.1） pg/mL]明显降低（P<0.05）；术后2~12 h VAS评分TAP组（2 h：2.40±0.50，4 h：2.27±0.45，8 h：2.06±0.71，12 h：2.03±0.61）低于C组（P<0.05），且TAP组镇痛泵按压次数[（15.3±4.1）次]及舒芬太尼补救例数（3例）均低于C组[分别为（36.5±6.9）次，12例]。2组患者术后不良事件发生情况无明显差别（P>0.05）。重复测量的方差分析结果显示，经校正后，2组间不同时间的MAP、HR、A、NA、VAS均不同（P<0.05），且HR、A、NA、VAS在时间因素和组别之间有交互作用（P<0.05）。结论：超声引导下双侧腹横肌平面阻滞复合全身麻醉能有效降低老年妇科开腹手术中的应激反应，围术期血流动力学更平稳，且术后镇痛效果好，是一种安全有效的麻醉方法。

Abstract:

Objective：To explore the safety and effectiveness of transverses abdominis plane block combined with general anesthesia in senile female patients undergoing laparotomy. Methods：Sixty senile women diagnosed as benign diseases were recruited in the study according to certain criteria（ASAⅠ-Ⅲ）. The patients were randomly divided into Group C（30 cases） and Group TAP（30 cases）. The patients in Group C were treated with single general anesthesia during the induction and maintenance periods of anesthesia. The patients in Group TAP received TAP block as anesthesia induction and general anesthesia as maintenance. The mean arterial pressure（MAP），heart rate（HR），adrenaline（A） and noradrenaline（NA） level at the following time：before anesthesia induction（T0），after anesthesia induction（T1），skin incision（T2），suture abdominal cavity（T3），30 minutes after surgery（T4） were recorded. The VAS score，analgesic pump pressure times，the number of sufentanil reme－dies and adverse effects（including nausea，vomit，hypotension，bradycardia，uroschesis and traction reaction） were recorded at following time after surgery 2，4，8，12，24 hours. Results：Com－pared with MAP at T0[（122.8±7.0） mmHg] in Group C，MAP of T1[（111.7±9.4） mmHg]，T2[（102.2±8.0） mmHg]，T3[（101.1±11.9） mmHg] and T4[（105.0±5.3） mmHg] were decreased. Meanwhile the MAP of Group TAP at T1[（113.3±10.9） mmHg]，T2[（110.1±9.4） mmHg]，T3[（109.1±11.2） mmHg] and T4[（116.5±7.2） mmHg] were lower than that at T0[（121.3±9.3） mmHg]. However，during T2-T4，MAP of Group TAP was relatively stable than that of Group C. Additionally，compare with that of Group C，the adrenaline level in serum of Group TAP during T2-T4 [T2：（192.3±22.6） pg/mL，T3：（221.7±16.5） pg/mL，T4：（166.4±14.1） pg/mL] were lower，while noradrenaline level of serum in Group TAP[T2：（140.4±17.0） pg/mL，T3：（149.6±14.4） pg/mL，T4：（116.7±21.1） pg/mL] were also lower. Furthermore，the average VAS scores of Group TAP at 2-12 h after surgery（2 h：2.40±0.50，4 h：2.27±0.45，8 h：2.06±0.71，12 h：2.03±0.61） were lower. Additionally，analgesic pump pressure times[（15.3±4.1） times] and sufentanil remedies cases（3 cases） of group TAP were lower than that of Group C[（36.5±6.9） times，12 cases]. There was no difference between two groups at post-operation. Repeated-measures analysis of variance showed that MAP，HR，A，NA，and VAS at different times were different between the TAP and C groups after correction（P<0.05）. Furthermore，time and group factors of HR，A，NA，VAS were interacted（P<0.05）. Conclusion：Compared to single general anesthesia，ultrasound-guided TAP block combined with general anesthesia has better effect on maintaining stable hemodynamics，reducing stress reaction during operation and relieving post-operative pain on senile female patients undergoing laparotomy.