超声引导下腹横肌平面阻滞联...康复外科中的有效性和安全性_雷碧波.pdf

介入放射学杂志2023年2月第32卷第2期J Intervent Radiol 2023,Vol.32,No.2 临床研究Clinical research 超声引导下腹横肌平面阻滞联合喉罩通气在原发性肝癌患者加速康复外科中的有效性和安全性雷碧波，樊飞，张明强，王小琦【摘要】目的探计超声引导下腹横肌平面（TAP）阻滞联合喉罩通气在原发性肝癌患者加速康复外科中的有效性和安全性。方法选择2018年6月至2020年11月成都中医药大学附属医院行腹腔镜肝切除术治疗的患者189例，根据麻醉方法不同分为观察组96例和对照组93例。观察组行超声引导下TAP阻滞联合全身麻醉喉罩通气，对照组行单纯气管内插管全麻，记录术后总住院时间、术后48 h内的镇痛需求、首次排气时间、麻醉药物及血管活性药物消耗量等术中一般情况。记录麻醉诱导前（T0）、手术开始（T1）、手术结束（T2）和离开手术室时（T3）的血糖和乳酸水平；采用40项恢复质量评分量表（QoR-40）及数字评定量表（NRS）评价两组患者早期恢复质量及手术切口疼痛情况，并记录不良反应情况。结果观察组术后住院时间、首次下床时间、出血量、术后舒芬太尼消耗量、首次排气时间、输液量、七氟烷、瑞芬太尼、罗库溴铵、多巴酚丁胺与去甲肾上腺素消耗量与对照组相比明显降低（均P0.05）。观察组T1及T2时血糖水平明显低于对照组，T2及T3时血清乳酸水平明显低于对照组（均P0.05）。观察组术后2、6、24和48 h时，NRS评分均明显低于对照组（均P0.05）；而术后1 d和3 d时，QoR-40评分均明显高于对照组（均P0.05）。2组患者均有多种不良反应出现，但发生率差异均无统计学意义（均P0.05）。结论超声引导下TAP阻滞联合喉罩通气在原发性肝癌患者围手术期有良好的镇痛效果，安全性高，且可减少术中、术后镇痛药物的使用，有利于快速康复。【关键词】腹横肌平面阻滞；喉罩通气；原发性肝癌；加速康复外科；有效性；安全性中图分类号：R735.7文献标志码：B文章编号:1008-794X（2023）-02-0149-05The effectiveness and safety of ultrasound-guided transversus abdominis plane block combinedwith laryngeal mask ventilation general anesthesia in enhanced recovery after surgery for patientswith primary liver cancerLEI Bibo,FAN Fei,ZHANG Mingqiang,WANG Xiaoqi.Department ofAnesthesiology,Affiliated Hospital of Chengdu University of Traditional Chinese Medicine,Chengdu,SichuanProvince 610072,ChinaCorresponding author:WANG Xiaoqi,E-mail:【Abstract】ObjectiveTo explore the effectiveness and safety of ultrasound-guided transversusabdominis plane（TAP）block combined with laryngeal mask ventilation general anesthesia in enhancedrecovery after surgery（ERAS）for patients with primary hepatocellular carcinoma（HCC）.Methods A totalof 189 patients with primary HCC,who underwent laparoscopic hepatectomy at the Affiliated Hospital ofChengdu University of Traditional Chinese Medicine of China between June 2018 and November 2020,wereenrolled in this study.According to the used anesthesia method,the patients were divided into study group（n=96）and control group（n=93）.TAP block combined with laryngeal mask ventilation general anesthesiawas employed for the patients of the study group,while pure endotracheal intubation general anesthesia wasadopted for the patients of the control group.The postoperative hospitalization time,postoperative need ofDOI：10.3969/j.issn.1008-794X.2023.02.010基金项目：四川省卫生健康委员会科研课题（17PJ492）作者单位：610072四川成都成都中医药大学附属医院麻醉科（雷碧波、樊飞、张明强）；四川省妇幼保健院麻醉科（王小琦）通信作者：王小琦E-mail：149介入放射学杂志2023年2月第32卷第2期J Intervent Radiol 2023,Vol.32,No.2加速康复外科（enhanced recovery after surgery，ERAS）是指采用一系列围术期处理的优化措施以促进患者术后加速康复，目前已经应用于多个外科领域1-3。实际上麻醉方法及管理在ERAS中发挥重要的作用4，作为多模式镇痛管理方法的一种，超声引导下腹横肌平面（transversus abdominis plane，TAP）阻滞可以有效缓解术后疼痛并减少阿片类药物的应用剂量，且具有定位精准、操作简单等优点5-6。气管插管常用于全身麻醉术中气道管理，但会导致强烈的刺激反应，甚至引发气道损伤，而喉罩作为声门上通气装置，对气道的伤害性刺激较小，可增加全麻术中患者的舒适度7。本研究探讨TAP阻滞联合喉罩通气在原发性肝癌患者ERAS中的有效性和安全性。1材料和方法1.1一般资料选择2018年6月至2020年11月成都中医药大学附属医院行腹腔镜肝切除术的患者189例，根据麻醉方法不同分为观察组96例和对照组93例。观察组行超声引导下TAP阻滞联合全麻喉罩通气，对照组行单纯气管内插管全麻。纳入标准：年龄为1865 岁；BMI 为 18.528.0 kg/m2；ASA 分级为级；肿瘤病灶数目3；肿瘤最大直径或总直径小于10 cm；Child-Pugh分级为A级或B 级；肿瘤临床分期为期或期；剩余肝容量/标准肝体积比40%；气管插管或喉罩置入无困难。排除标准：CT或MRI显示肝内血管侵犯或肝外转移；临床资料不完整或失访；术前接受过化疗或放疗；酗酒或阿片类药物滥用史；腹部手术史。本研究经医院伦理委员会审核批准，所有患者均知情并签署同意书。1.2麻醉方法开放患者静脉通道，行心电图、心率、指脉血氧饱和度和无创血压检测。使用丙泊酚23 mg/kg、舒芬太尼 0.20.4 g/kg 和罗库溴铵 0.6 mg/kg 麻醉诱导。应用 1.0 MAC 七氟烷、瑞芬太尼 0.2 g/（kg min）和丙泊酚4.0 mg/（kgh）维持麻醉。对照组面罩给氧待肌松满意、意识消失后行气管内插管，确认气管导管位置及深度后转为机械通气，以68 mL/kg 的潮气量进行正压通气，并调整呼吸频率以维持呼气末 CO2分压为 3545 mmHg。平均动脉压、心率控制在基础值的20%内，变化范围过大时给予血管活性药物对症处理。观察组在全麻诱导前行超声引导下双侧TAP阻滞，麻醉药物为 0.2%罗哌卡因 20 mL。采用 GE 便携式彩色超声仪行超声引导下双侧TAP阻滞，超声探头（高频线阵探头 512 MHz）置于腋中线与脐水平相交处，自腹中线向外侧缓慢移动后腹横肌平面图像可清晰显影，穿刺针经前内侧腹壁，当针尖到达腹内斜肌与腹横肌之间的筋膜层后回抽，确认无血、无气、无液体后缓慢注入 0.2%罗哌卡因 10 mL。手术结束时静脉注射舒芬太尼 0.1 g/kg，托吡司琼4 mg。analgesic drugs within 48 hours,postoperative first exhaust time,consumption of anesthetic drug andvascular active drug,etc.were recorded.Blood glucose and lactate levels were determined at the followingtime points:before anesthesia induction（T0）,starting operation（T1）,end of the operation（T2）and leavingoperating room（T3）.By using 40-quality items of restore scale（QoR-40）score and numerical rating scale（NRS）score,the quality of early recovery and surgical incision pain were evaluated in both groups,and theadverse reactions were recorded.Results The postoperative hospitalization time,first time to get out of bed,amount of blood loss,postoperative sufentanil consumption,first exhaust time,infusion volume,andconsumption amount of sevoflurane,remifentanil,rocuronium,dobutamine and norepinephrine in the studygroup were significantly lower than those in the control group（all P0.05）.The postoperative 2-,6-,24-,and48-hour NRS scores in the study group were obviously lower than those in the control group（all P0.05）.The postoperative 1-day and 3-day QoR-40 scores in the study group were remarkably lower than those inthe control group（both P0.05）.A variety of adverse reactions occurred in both groups,but there was nosignificant difference between the two groups（all P0.05）.ConclusionUltrasound-guided TAP blockcombined with laryngeal mask ventilation general anesthesia has a good