超声引导下三点阻滞与椎旁阻滞用于剖腹肝胆手术术后镇痛的比较

目的观察术前给予超声引导下三点法阻滞(低位前锯肌阻滞、肋缘下腹横肌平面阻滞和腹直肌后鞘阻滞)或单侧胸椎旁阻滞对肝胆手术患者术后镇痛及相关围术期转归的影响。方法选择择期右上腹部切口行肝胆手术的患者95例,男69例,女26例,年龄18~65岁,ASAⅠ或Ⅱ级。随机分为三点组(n=48)和椎旁组(n=47)。三点组患者入室后采用0.375%罗哌卡因行超声引导下低位前锯肌阻滞(10 ml)、肋缘下腹横肌平面阻滞(15 ml)复合腹直肌后鞘阻滞(15 ml),椎旁组采用0.375%罗哌卡因20 ml行超声引导下T7-9椎旁阻滞。记录术后24 h舒芬太尼用量;记录切皮前、切皮后1和5 min时HR和SBP的变化、麻醉后恢复室内和术后24 h VAS疼痛评分,以及患者过敏、局麻药中毒、穿刺损伤等不良反应发生情况。结果两组患者术后24 h内舒芬太尼用量差异无统计学意义(0.98±0.33)μg/kg vs (0.95±0.28)μg/kg]。患者麻醉后恢复室内和术后24 h VAS疼痛评分差异无统计学意义。椎旁组术中低血压发生率31例(66.0%) vs 11例(22.9%)和去甲肾上腺素用量(3.5±1.6)μg/kg vs (1.2±0.4)μg/kg]明显高于三点组(P<0.01)。两组患者均未见过敏、局麻药中毒、穿刺损伤等不良反应。结论低位前锯肌阻滞、肋缘下腹横肌平面阻滞、腹直肌后鞘阻滞三点阻滞复合可以产生与单侧椎旁阻滞相当的术中和术后镇痛作用,而且前者的低血压发生率明显低于椎旁阻滞,是一种可供临床选择的上腹部神经阻滞方式。

Comparison of the post-operative analgesic effect of ultrasound-guided three-point block and paravertebral block in patients undergoing open hepatobiliary surgery

Objective To observe the effect of three-point block(lower serratus plane block,subcostal transversus abdominis plane block and rectus sheath block)and unilateral paravertebral block on postoperative pain and other outcomes in patients undergoing open hepatobiliary surgery.Methods A total of 95 patients scheduled for open hepatobiliary surgery were randomly assigned to three-point group(n=48)and paravertebral group(n=47).Three-point group received three-point block at lower serratus plane,subcostal transversus abdominis plane and rectus sheath with ropivacaine of 0.375%,while group paravertebral received unilateral paravertebral block with ropivacaine of 0.375%.The primary concern was sufentanil consumption in 24 h after surgery.The secondary outcomes included hemodynamic stability before and after incision,and during surgery,VAS pain scores in PACU and at 24 h after surgery,and side effects.Results Sufentanil consumption in 24 h after surgery was comparable between the two groups(0.98±0.33)μg/kg vs(0.95±0.28)μg/kg].And no significant difference was observed as to pain scores in PACU and at 24 h after surgery,number of patient-controlled analgesia bolus.Incidence of hypotension31(66.0%)vs 11(22.9%)]and dose of norepinephrine(3.5±1.6)μg/kg vs(1.2±0.4)μg/kg)]was significantly higher in paravertebral group compared with that in three-point group(P<0.01).Conclusion Combined lower serratus plane block,subcostal transversus abdominis plane block and rectus sheath block can induce comparable postoperative analgesic effect to unilateral paravertebral block with less intraoperative hypotension.