不同时机超声引导腹直肌鞘阻滞对术后镇痛的影响

目的 探讨单孔腹腔镜妇科手术超声引导腹直肌鞘阻滞的最佳时机。方法 选取2021年8月至2022年1月温州医科大学附属第二医院妇科病房63例择期行单孔腹腔镜下妇科良性肿物切除手术的患者为研究对象，根据随机数字表法将其分为E组（32例）和O组（31例），剔除3例，最终纳入60例，每组各30例。E组患者采用术前超声引导腹直肌鞘阻滞，O组患者采用术后超声引导腹直肌鞘阻滞。比较两组患者拔管后即刻（T1）、术后12h（T2）、术后24h（T3）静息、活动状态的数字疼痛量表（numerical rating scale，NRS）评分；比较两组患者术中切皮前后的平均动脉压及心率；比较两组患者术中瑞芬太尼使用量、术后羟考酮使用量、术后镇痛补救率；比较两组患者入室时长及手术时长；记录两组患者神经阻滞并发症的发生情况。结果 整体分析发现：两组患者静息NRS评分时间点比较及交互作用差异均有统计学意义（P<0.05），活动NRS评分时间点比较差异有统计学意义（P<0.05）。进一步两两比较，组内比较：O组患者T2、T3时点静息NRS和活动NRS评分均显著低于T1时点（P<0.05）；E组患者T3时点静息NRS评分显著低于T1时点，T2、T3时点活动NRS评分均显著低于T1时点（P<0.05）。组间比较：E组患者T1时点静息NRS和活动NRS评分均显著低于O组（P<0.05）。切皮后，O组患者的平均动脉压显著高于本组切皮前，心率显著快于本组切皮前（P<0.05）。两组均无腹腔穿刺、穿刺点感染、局部麻醉药中毒等情况发生。结论 单孔腹腔镜妇科手术中，术前超声引导下腹直肌鞘神经阻滞，在术后早期可为患者提供更佳的镇痛效果，且患者术中切皮前后心率和平均动脉压变化更小，值得推荐。

Effect of different timing ultrasound-guided rectus sheath block on postoperative analgesia

Objective To investigate best timing of ultrasound-guided rectus sheath block in single-site laparoendoscopic surgery. Methods A total of 63 patients underwent elective single-site laparoendscopic surgery for benign gynecological tumors in Gynecology Ward of the Second Affiliated Hospital of Wenzhou Medical University from August 2021 to January 2022 were selected as study subjects. They were divided into Group E (32 cases) and Group O (31 cases) by using a random number table method. After excluding three cases, 60 patients were finally admitted, with 30 cases in each group. Group E underwent preoperative ultrasound-guided rectus sheath block, and group O underwent postoperative ultrasound-guided rectus sheath block. Numerical rating scale (NRS) score of immediately after extubation (T1), 12-hour after surgery (T2), and 24-hour after surgery (T3) in resting and active status were compared between two groups; mean arterial pressure and heart rate before and after incision were compared between two groups; intraoperative dose of remifentanil, postoperative oxycodone and rate of postoperative analgesic relief were compared between two groups; time of entry and operation were compared between two groups; and occurrence of nerve block complications in two groups was recorded. Results Overall analysis found that there were significant differences in comparison of time points and interaction of resting NRS scores in two groups(P<0.05), as well as there were significant differences in comparison of time points of active NRS scores in two groups (P<0.05). Further pairwise comparison, within-group comparison: NRS scores of rest status and active status at T2 and T3 in group O were significantly lower than those at T1 (P<0.05); NRS scores for rest status at T3 was significantly lower than that at T1 in group E, and NRS scores for active status at T2 and T3 were significantly lower than those at T1 in group E (P<0.05). Comparison between groups: NRS scores for rest and active status at T1 were significantly lower in group E than that in group O (P<0.05). After skin incision, mean arterial pressure in group O was significantly higher than before skin incision, and heart rate in group O was significantly faster than before skin incision (P<0.05). No abdominal puncture, puncture site infection, local anesthetic poisoning, or other complications occurred in either group. Conclusion In single-site laparoendoscopic gynecological surgery, ultrasound-guided preoperative rectus sheath block can provide better analgesic effect for patients in the early postoperative stage, and changes in heart rate and mean arterial pressure before and after incision are smaller, which is worthy of recommendation.