内侧腹横肌平面阻滞在腹股沟疝修补术中的镇痛研究

目的探讨单侧腹股沟疝修补术的患者中，超声引导下的内侧腹横肌平面阻滞的镇痛效果。 方法对2017年1月至2018年4月在新疆维吾尔自治区人民医院治疗的年龄≥18岁、ASA麻醉分级为Ⅰ~Ⅱ级的100例男性患者进行前瞻性随机对照双盲试验。患者前瞻性随机分为2组，分别接受切口前同侧髂腹股沟-髂腹下神经阻滞50例（对照组）、内侧腹横肌平面阻滞50例（试验组）。观察2组术后24 h镇痛剂的消耗量、疼痛评分、术后副作用等。 结果试验组患者第1次要求镇痛剂的时间、术后24 h镇痛剂用量、麻醉满意度方面与对照组比较，差异无统计学意义（P>0.05）；试验组在时间节点8、12 h的术后疼痛数字评分低于对照组，差异有统计学意义（P<0.05）；术后其他时间点1、4、18、24 h与对照组比较，差异无统计学意义（P>0.05）。 结论内侧腹横肌平面阻滞是一种简单易行的麻醉方法，可用作腹股沟-髂腹下神经阻滞的替代方案，用于腹股沟疝修补术后患者的术后疼痛缓解。     

超声引导下双侧腹横肌平面阻滞对产妇术后镇痛及血清PRL水平的影响

目的探讨超声引导下双侧腹横肌平面阻滞对产妇术后镇痛及血清PRL水平的影响。方法选取2015-09—2016-09间在商丘市妇幼保健院实施剖宫产的60例产妇。随机分为2组,每组30例。对照组未实施双侧腹横肌平面阻滞,观察组在超声引导下行双侧腹横肌平面阻滞。对2组产妇的初乳时间、不同时间点VAS评分和血清PRL浓度进行测定,同时观察并发症发生情况。结果观察组产妇的初乳时间明显早于对照组,术后24、48 h血清PRL浓度明显高于对照组,差异有统计学意义(P0.05)。观察组患者静息状态下2、4、12、24 h时VAS评分明显低于对照组,差异有统计学意义(P0.05)。观察组未发生腹壁血肿或脏器损伤等并发症。结论超声引导下双侧腹横肌平面阻滞可有效缓解产妇术后疼痛,改善血清PRL水平。     

B超引导腹横肌平面阻滞联合腹直肌鞘阻滞在腹膜透析置管术中应用的临床研究

目的研究B超引导腹横肌平面阻滞联合腹直肌鞘阻滞在腹膜透析置管术中应用的临床效果。方法选取惠州市第三人民医院2018年5月1日到2018年10月30日期间收治的24例拟行腹膜透析置管术患者,依据随机数字表法将其分为腹横肌平面阻滞联合腹直肌鞘阻滞组(TR组,n=12)、局部浸润麻醉组(L组,n=12),TR组采用超声引导下腹横肌平面阻滞联合腹直肌鞘阻滞麻醉,L组采用局部浸润麻醉,对两组患者的临床效果进行比较。结果 TR组分离腹直肌、荷包缝合、置管、结扎荷包及缝合腹壁时点VAS评分低于L组(P0.05),切皮时间点VAS评为高于L组,但差异无统计学意义(P0.05);TR组患者术中静脉用镇痛药剂量低于L组[(1.39±0.09)μg vs.(3.05±0.07)μg],TR组术后镇痛药使用低于L组(0.00%vs. 41.67%),差异均具有统计学意义(P0.05);TR组不良事件发生率低于L组(8.33%vs. 58.32%),差异具有统计学意义(P0.05)。结论 B超引导腹横肌平面阻滞联合腹直肌鞘阻滞在腹膜透析置管术中应用具有良好效果,值得推广。     

老年腹股沟疝患者在超声引导下髂腹下与髂腹股沟腹横肌平面阻滞的麻醉效果分析

目的探讨老年腹股沟疝患者应用超声引导下横肌平面阻滞（TAPB）联合髂腹下及髂腹股沟神经阻滞的临床效果。 方法选取2017年10月至2018年10月平罗县人民医院收治的老年腹股沟疝患者60例,采用随机数字表法将患者分为试验组和对照组,各30例,对照组行常规硬膜外麻醉,试验组行超声引导下TAPB联合髂腹下及髂腹股沟神经阻滞。比较2组手术相关临床参数、围手术期血流动力学变化,记录术后苏醒躁动及追加镇痛药情况,并进行患者躁动及疼痛的评估。 结果试验组术后苏醒时间短于对照组（P<0.05）;从手术麻醉前至手术结束,试验组患者心率（HR）、平均动脉压（MAP）、血氧饱和度（SpO₂）水平均无变化（P>0.05）,对照组患者HR、MAP水平在切皮前、切皮后10 min、手术结束时均高于手术麻醉前（P<0.05）;试验组患者在上述时间点的HR、MAP水平均低于对照组（P<0.05）;试验组苏醒躁动发生率、追加镇痛药发生率和Cravero评分均低于对照组（P<0.05）;试验组患者苏醒时,术后2、4、8 h的视觉模拟量表评分（VAS）均显著低于对照组（P<0.05）。 结论老年腹股沟疝患者应用超声引导下TAPB联合髂腹下及髂腹股沟神经阻滞可明显缩短苏醒时间,减少术后疼痛感,围手术期患者的血流动力学更稳定,且镇静效果好。     

超声引导腹横肌平面阻滞在患儿腹股沟区手术的应用

<正>患儿腹股沟区手术为了快速苏醒及术后镇痛,常采用全麻复合髂腹下/髂腹股沟神经(iliohypogastric/ilioinguinal nerve,IIN)阻滞。IIN在腹股沟区解剖变异较普遍,失败率高达30%[1]。应用超声引导行IIN阻滞已有报道[2,3],但患儿神经较纤细,超声定位较困难。IIN在髂嵴上方穿过腹横肌,进入腹横肌与腹内斜肌之间的腹横肌平面(transversus abdominis plane,TAP),位置相对固定。在此部位行TAP     

腹横肌平面阻滞在乳房再造术后镇痛中的临床研究

目的：探讨腹横肌平面阻滞在腹壁皮瓣乳腺癌患者乳房再造术后镇痛的临床效果。方法回顾性分析腹横肌平面阻滞置管间断注射局部麻醉药术后镇痛和术后患者自控静脉镇痛48 h 镇痛效果、阿片类药物的使用量及术后镇痛相关并发症的发生率。结果腹横肌平面阻滞组术后镇痛效果与患者自控静脉镇痛组相当,但阿片类药物使用量和术后镇痛相关并发症发生率却远低于患者自控静脉镇痛组。结论腹壁皮瓣乳腺癌患者乳房再造术后应用腹横肌平面阻滞置管镇痛可提供与传统术后镇痛方法相当的镇痛效果,同时又具有传统术后镇痛方法所不具备的优势,值得临床应用。     

纳布啡联合双侧腹横肌平面阻滞用于妇科腹腔镜术后静脉自控镇痛的效果观察

目的评价纳布啡联合双侧腹横肌平面阻滞用于妇科腹腔镜手术后静脉自控镇痛(PCIA)的镇痛效果。方法选取2017-12—2018-08间在本院接受妇科腹腔镜手术的120例患者,随机分为对照组和实验组,每组60例。分别使用氢吗啡酮(对照组)和纳布啡(实验组)联合双侧腹横肌平面阻滞用于术后静脉自控镇痛。术后记录2组患者不同时间点的疼痛程度、用药总量及患者术后不良反应的发生情况。结果术后12 h实验组疼痛评分(VAS)低于对照组,差异有统计学意义(P0.05),其他时间2组疼痛评分及用药总量比较,差异无统计学意义(P0.05);实验组术后呕吐发生率低于对照组,差异有统计学意义(P0.05),其他不良反应的发生率差异无统计学意义(P0.05)。结论纳布啡联合双侧腹横肌平面阻滞应用于PCIA术后镇痛能够提供有效镇痛,并减少阿片受体相关的不良反应的发生率,有较高的临床价值。     

超声引导腹横肌平面阻滞联合喉罩全身麻醉在小儿疝囊高位结扎术的镇痛效果

目的探究超声引导下腹横肌平面阻滞联合喉罩全麻下小儿疝囊高位结扎术的镇痛效果。 方法选取2016年1月至2018年1月,湖北省洪湖市人民医院150例接受疝囊高位结扎术的患儿,随机分为观察组（75例）和对照组（75例）。对照组采用单纯喉罩全身麻醉,而观察组在对照组基础上进行超声引导下腹横肌平面阻滞。比较2组患儿的平均动脉压（MAP）、心率（HR）、躁动及疼痛评分、苏醒时间、手术时间及并发症发生状况。 结果观察组的并发症发生率（6.7%）低于对照组（17.3%）,差异有统计学意义（P<0.05）。观察组患儿手术时间、苏醒时间、躁动评分、12 h小儿疼痛量表（12 h FLACC）评分均低于对照组（P<0.05）。观察组插入喉罩后、手术开始时、拔除喉罩时与麻醉诱导前比较,MAP、HR差异均无统计学意义（P>0.05）;对照组插入喉罩后、拔除喉罩时与麻醉诱导前比较,MAP、HR差异均无统计学意义（P>0.05）,手术开始时MAP、HR高于麻醉诱导前（P<0.05）。麻醉诱导前、插入喉罩后、拔除喉罩时2组间的MAP、HR差异均无统计学意义（P>0.05）,手术开始时,观察组的MAP、HR均低于对照组（P<0.05）。 结论小儿疝囊高位结扎术中应用超声引导下腹横肌平面阻滞联合喉罩全麻的麻醉效果较好,术后苏醒快,可以缓解患儿术后疼痛及躁动,降低并发症的发生率,具有临床应用价值。     

腹横肌平面阻滞的临床应用进展

正研究表明腹横肌平面(transversus abdominis plane,TAP)阻滞可以成功阻滞腹部的外周疼痛信号的传导,有效缓解疼痛,超声技术的辅助使这一技术得以定形[1]。现将TAP阻滞用于术后镇痛的相关问题综述如下。TAP阻滞的解剖学基础腹部前外侧的肌肉由外及里依次为腹外斜肌、腹内斜肌、腹横肌,肌肉之间为筋膜层;腹内斜肌与腹横肌之间的平     

超声引导下腹横筋膜平面阻滞与腹横肌平面阻滞在剖宫产术后镇痛中的效果比较

目的 比较超声引导下腹横筋膜平面(TFP)阻滞与腹横肌平面(TAP)阻滞在剖宫产术后镇痛中的效果。
方法 择期蛛网膜下腔阻滞下行剖宫产术产妇60例,年龄20～35岁,体重50～75 kg,ASA Ⅰ或Ⅱ级,采用随机数字表法分为两组：腹横筋膜平面阻滞组（TFP组）和腹横肌平面阻滞组（TAP组）,每组29例。术毕TFP组行超声引导下双侧腹横筋膜平面阻滞,TAP组行超声引导下双侧腹横肌平面阻滞,两组均每侧注射0.375%罗哌卡因1.25 mg/kg。术后均行曲马多PCIA,若VAS疼痛评分≥4分,肌肉注射曲马多100 mg行补救镇痛。记录术后6、12、24、36、48 h PCIA中曲马多累积用量;记录术后48 h内曲马多补救镇痛情况;记录镇痛期间恶心呕吐、局麻药中毒、呼吸抑制、穿刺部位血肿、穿刺部位感染、腹膜刺穿造成腹腔内注射等不良反应的发生情况。
结果 与TAP组比较,TFP组术后6、12、24、36、48 h PCIA中曲马多累积用量明显减少 （P＜0.05）,术后48 h内曲马多补救镇痛率明显降低 （P＜0.05）。两组镇痛期间恶心呕吐发生率差异统计学意义。两组均无其他不良反应发生。
结论 与超声引导下腹横肌平面阻滞比较,腹横筋膜平面阻滞可减少剖宫产术后阿片类药物用量,镇痛效果更佳。     

Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks

The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of injection and pattern of spread within the plane. There are currently a number of ultrasound-guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary approach and a more recently proposed posterior approach. We wished to determine whether the site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast solution in four groups of volunteers. The first group underwent the classical landmark-based transversus abdominis plane block whereby two different volumes of injectate were studied: 0.3 ml.kg(-1) vs 0.6 ml.kg(-1). The second group underwent transversus abdominis plane block using the anterior subcostal approach. The third group underwent transversus abdominis plane block using the mid-axillary approach. The fourth group underwent transversus abdominis plane block using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time. The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches resulted in a predominantly anterior spread of the contrast solution within the transversus abdominis plane and relatively little posterior spread. There was no spread to the paravertebral space with the anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast enhancement in the paravertebral space at T12-L2. In contrast, the posterior approaches, using both landmark and ultrasound identifications, resulted in predominantly posterior spread of contrast around the quadratus lumborum to the paravertebral space from T5 to L1 vertebral levels. We concluded that the pattern of spread of local anaesthetic differs depending on the site of injection into the transversus abdominis plane. This may have important implications for the extent of analgesia produced with each approach.     

Continuous lumbar transversus abdominis plane block may spread to supraumbilical dermatomes

Purpose

The transversus abdominis plane block is an interfascial block intended to target nerves supplying the abdominal wall. It has been shown to reduce pain and postoperative opioids in abdominal surgeries. We present the case of a high-risk patient in whom bilateral continuous lumbar transversus abdominis plane blocks provided effective postoperative analgesia following infraumbilical midline laparotomy.

Clinical features

A 59-yr-old woman with coronary artery disease, severe peripheral vascular disease, and mild to moderate obstructive sleep apnea underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection via an infraumbilical midline laparotomy. Bilateral ultrasound-guided lumbar transversus abdominis plane blocks with catheters were sited intraoperatively. Using only a continuous local anesthetic infusion in the postoperative period, the patient required no systemic opioids or acetaminophen for 81 hr. A sensory block level of T6-L1, higher than that reported following a single-shot technique, remained for 24 hr following infusion discontinuation and finally normalized after 33 hr.

Conclusions

Lumbar transversus abdominis plane blocks with continuous infusions may offer an effective alternative to epidural blockade and systemic opioids in high-risk patients. Additionally, given the extensive somatosensory block, this technique may have an analgesic role following abdominal incisions involving not only the infraumbilical region but also supraumbilical sites.     

Transversus abdominis plane block: a cadaveric and radiological evaluation

BACKGROUND AND OBJECTIVES: The abdominal wall is a significant source of pain after abdominal surgery. Anterior abdominal wall analgesia may assist in improving postoperative analgesia. We have recently described a novel approach to block the abdominal wall neural afferents via the bilateral lumbar triangles of Petit, which we have termed a transversus abdominis plane block. The clinical efficacy of the transversus abdominis plane block has recently been demonstrated in a randomized controlled clinical trial of adults undergoing abdominal surgery. METHODS: After institutional review board approval, anatomic studies were conducted to determine the deposition and spread of methylene blue injected into the transversus abdominis plane via the triangles of Petit. Computerized tomographic and magnetic resonance imaging studies were then conducted in volunteers to ascertain the deposition and time course of spread of solution within the transversus abdominis fascial plane in vivo. RESULTS: Cadaveric studies demonstrated that the injection of methylene blue via the triangle of Petit using the "double pop" technique results in reliable deposition into the transversus abdominis plane. In volunteers, the injection of local anesthetic and contrast produced a reliable sensory block, and demonstrated deposition throughout the transversus abdominis plane. The sensory block produced by lidocaine 0.5% extended from T7 to L1, and receded over 4 to 6 hours, and this finding was supported by magnetic resonance imaging studies that showed a gradual reduction in contrast in the transversus abdominis plane over time. CONCLUSIONS: These findings define the anatomic characteristics of the transversus abdominis plane block, and underline the clinical potential of this novel block.     

甲哌卡因腹横筋膜阻滞对瑞芬太尼引起的痛觉超敏反应的影响

［摘要］ 目的 观察甲哌卡因腹横筋膜阻滞对瑞芬太尼引起的痛觉超敏反应的影响。方法 收集择期下行腹式全宫手术患者50例，分为甲哌卡因组（25例）和对照组（25例）。甲哌卡因组在麻醉诱导后在超声引导下用1.5%甲哌卡因行腹横筋膜阻滞，每侧20 mL，对照组不予腹横筋膜阻滞。麻醉维持均采用七氟烷0.8-1.1 MAC，瑞芬太尼0.05~0.3 μg/kg·min，监测脑电双频指数（BIS），根据BIS值和血流动力学情况调整麻醉用药。观察并比较患者术中瑞芬太尼总的消耗量，术后1 h（VAS 1），3 h（VAS 2），6 h（VAS 3），12 h（VAS 4），24 h（VAS 5）的视觉模拟评分（VAS评分），术后病房镇痛药物的追加量及相关并发症。结果 甲哌卡因组术中瑞芬太尼用量显著小于对照组（P<0.05），术后各时间点VAS评分小于对照组（均P<0.05），而术后镇痛药物追加次数小于对照组（P<0.05）。结论 术前使用甲哌卡因腹横筋膜阻滞可明显减少术中瑞芬太尼用量，减轻瑞芬太尼引起的痛觉超敏反应。     

腹横肌平面阻滞在腹式全子宫切除术中的应用经验

目的探讨腹横肌平面阻滞(TAP)技术在腹式全子宫切除术中的应用。方法选择择期行开腹全子宫切除术患者50例,分为两组(n=25),腹横肌平面阻滞组(TAP组)和对照组。TAP组患者在全麻插管后实施B超引导下双侧腹横肌平面阻滞,对照组患者不行阻滞,两组患者术后均采用相同静脉自控镇痛方案。比较两组患者术后各项监测指标的差异。结果 TAP组患者术毕清醒时间,术后VAS疼痛评分、排气时间、早期下床时间、出院时间均较对照组显著降低。结论腹横肌平面阻滞(TAP)技术在开腹全子宫切除术中能使患者早期苏醒,减少术后疼痛,提早下床活动及减少住院时间等作用,有益于患者术后快速康复。     

Audit of initial use of the ultrasound-guided transversus abdominis plane block in children

The extent of dermatomal block post transversus abdominis plane block is described in adults as T7-L1; other authors argue extent above T10 is infrequent (supra-iliac 20 ml injection). A paediatric guideline recommends this block for upper and lower abdominal surgery using 0.2 ml/kg. We aimed (through prospective audit) to document the multi-level block achieved with ultrasound-guided transversus abdominis plane block in children having abdominal surgery, during a departmental training period. Data included patient, anaesthetic and surgical details, transversus abdominis plane block characteristics (anterior supra-iliac injections) and dermatomal blockade to ice. Twenty-seven children received 38 blocks performed by 58% consultant and 42% trainee operators (90% novices): 16 unilateral/11 bilateral for umbilical (1), inguinal (13), laparoscopic (8) and laparotomy (5) surgery. Dermatomal assessment for 35 blocks (mean local anaesthetic volume 0.4 ml/kg [SD 0.2]) revealed the median blockade achieved was 3 dermatomes (interquartile range 3 to 4) involving T10 to L1 in 75% of patients. Eight blocks (six patients) also involved T8 and T9, following 0.31 to 0.81 ml/kg. One patient (3% of assessed blocks) had no block to ice at 60 minutes, but required no postoperative analgesia. Ultrasound-guided transversus abdominis plane blocks performed by supra-iliac approach and novice operators produced lower abdominal sensory blockade in children of usually 3 to 4 dermatomes, and should be offered for lower abdominal surgery only, as only 25% had upper abdominal block extension. The optimal local anaesthetic dose/volume, duration of effect and utility for these blocks in relation to peripheral and neuraxial blockade needs clarification.     

Epidural vs. transversus abdominis plane block for abdominal surgery – a systematic review,meta-analysis and trial sequential analysis

Traditionally, pain relief for abdominal surgery has centred on epidural analgesia, but transversus abdominis plane block is increasingly being used. Our aim was to compare the analgesic efficacy and the side-effect profile of transversus abdominis plane block with epidural analgesia in a systematic review with meta-analysis and trial sequential analysis. After a systematic search of the electronic databases, we identified 18 randomised controlled trials with 1220 patients. Confirmed by trial sequential analysis, our first co-primary outcome, postoperative pain score at rest at 12 h, was decreased by a mean difference (95%CI) of 0.69 (0.12–1.27; p = 0.02) with epidural analgesia compared with transversus abdominis plane block, with the quality of evidence graded as low. No difference was found for the second co-primary outcome, postoperative pain score at rest at 24 h, with the quality of evidence rated as very low. Relative to transversus abdominis plane block, epidural analgesia further reduced the need for intravenous morphine-equivalent consumption during the 0–24 h interval by a mean difference (95%CI) of 5.91 mg (2.34–9.49; p = 0.001) at the expense of an increased incidence of hypotension at 72 h, with a risk ratio (95%CI) of 5.88 (2.08–16.67; p < 0.001). Our meta-analysis was limited by detection and performance bias, significant statistical heterogeneity and publication bias. In view of the minimal clinically important difference in postoperative pain scores, epidural analgesia was interpreted to not be clinically different to transversus abdominis plane block after abdominal surgery. With transversus abdominis plane block, the increase in intravenous morphine-equivalent consumption at 24 h should be balanced against the decreased risk of hypotension at 72 h. In choosing between epidural analgesia and transversus abdominis plane block, potential benefits should be balanced against the reported risk of harm, although the confidence in the evidence varied, underlining the uncertainty in our estimates.     

The analgesic efficacy of transversus abdominis plane (TAP) block

The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. It was described for the first time in 2007 by McDonnell et al. We applied the technique after the original methodology of the authors. We evaluated its analgesic efficacy first 24 postoperative hours of patients, undergoing to surgical and urological interventions. After induction of anesthesia, 20 ml of 0.375% levobupivacaine was deposited into the transversus abdominis neuro-fascial plane via the bilateral lumbar triangles of Petit. Each patient was evaluated by VAS in the postanesthesia care unit at the 2, 4, 6, 12 and 24 h postoperatively. Despite the results were more unsatisfactory than those of McDonnel, they were good. Our first impression is that the TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery.     

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis*

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4–6 h, 8–12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.