右美托咪定不同给药方式复合腹横肌平面阻滞在结直肠肿瘤手术中的临床应用研究-现代医学

右美托咪定不同给药方式复合腹横肌平面阻滞在结直肠肿瘤手术中的临床应用研究

单位：1. 东南大学附属中大医院溧水分院(南京市溧水区人民医院) 麻醉科, 江苏南京 211200;
2. 江苏省肿瘤医院麻醉科, 江苏南京 210000

分类号：R614;R735.3

出版年·卷·期（页码）：2020·48·第九期（1117-1123）

摘要：

目的：观察右美托咪定不同给药方式联合腹横肌平面阻滞（TAPB）对结直肠癌根治性切除术患者术后镇痛及早期恢复的影响。方法：择期行结直肠癌根治性切除术的患者100例，随机分为右美托咪定静脉泵注联合罗哌卡因TAPB组（DV-T组）、右美托咪定混合罗哌卡因TAPB组（DR-T组）、罗哌卡因TAPB组（R-T组）、生理盐水TAPB对照组（C组），每组25例。DV-T组于麻醉诱导前10 min开始静脉泵注右美托咪定0.5 μg·kg^-1（10 min内泵注完毕），随后按0.5 μg·kg^-1·h^-1的速度持续泵注至手术结束前30 min。各组患者均于麻醉诱导后行超声引导下TAPB，DR-T组给予右美托咪定1 μg·kg^-1混合0.375%罗哌卡因共40 ml，DV-T组和R-T组给予0.375%罗哌卡因40 ml，C组注入生理盐水40 ml，每侧各20 ml。记录麻醉诱导前10 min（T₀）、TAPB后10 min（T₁）、手术开始时（T₂）、手术开始30 min（T₃）、手术开始60 min时（T₄）、手术结束时（T₅）收缩压（SBP）、舒张压（DBP）及心率（HR）；观察术后2、6、12、24及48 h静息状态和运动状态下VAS评分；记录术中严重心动过缓、低血压以及术后恶心、呕吐发生率，术后首次下床时间、肛门排气时间、住院天数，记录术后24 h内舒芬太尼用量及镇痛泵有效按压次数。结果：与C组比较，DR-T组、DV-T组于T₂~T₅时点SBP、DBP均显著降低（P<0.05）。与C组及R-T组比较，DR-T组和DV-T组于T₁~T₅时点HR显著减慢（P<0.05）。与C组比较，R-T组、DV-T组于术后6、12 h，DR-T组于术后6、12、24 h活动时视觉模拟评分法（VAS）评分均显著降低（P<0.05）；与R-T组比较，DR-T组术后12 h活动时VAS评分均显著降低（P<0.05）。与C组比较，R-T组、DR-T组、DV-T组术后24 h舒芬太尼用量及术后24 h镇痛泵按压次数均显著减少（P<0.05），且DR-T组术后24 h舒芬太尼用量和术后24 h镇痛泵按压次数均少于R-T组、DV-T组（P<0.05）。R-T组、DR-T组、DV-T组术后下床时间均显著早于C组（P<0.05）；DR-T组、DV-T组肛门首次排气时间亦显著早于C组（P<0.05）。而DV-T组术中严重心动过缓发生率明显高于C组（P<0.05）。结论：右美托咪定两种给药方式联合TAPB用于结直肠癌根治术均可显著减轻手术应激引起的血压升高、心率增快，促进患者早期恢复，其中右美托咪定混合罗哌卡因TAPB镇痛作用时间更长，可减少术后阿片类药物的用量，严重心动过缓等不良反应发生率更低。

Objective: To observe the effects of dexmedetomidine given by different methods of administration combined with transversus abdominis plane block(TAPB) on postoperative analgesia and early recovery in patients undergoing radical colorectal resection. Methods: A total of 100 patients scheduled for elective radical colorectal resection were randomly divided into four groups(n=25 in each group): dexmedetomidine intravenous plus TAPB group(group DV-T), dexmedetomidine mixed with ropivacaine TAPB group(group DR-T), ropivacaine TAPB group(group R-T) and control group(group C). In group DV-T, dexmedetomidine was given intravenously at 0.5 μg/kg over 10 minutes before anesthesia induction, followed by intravenous infusion at the rate of 0.5 μg/kg.h. Ultrasound guided bilateral TAPB was performed in all patients after anesthesia induction, group DR-T with dexmedetomidine 1μg/kg plus 0.375% ropivacaine of 40 ml and group DV-T, group R-T with 0.375% ropivacaine of 40 ml, and equal volume of saline was used in group C. Systolic blood pressure(SBP), diastolic blood pressure(DBP), and heart rate (HR) were recorded before induction(T₀), 10 minutes after TAPB(T₁), at the beginning of operation(T₂), 30 min(T₃), 60 min(T₄) after the beginning of operation, at the end of operation (T₅). VAS score at rest and on movement at 2, 6, 12, 24and 48 h after operation were assessed. The requirements of sufentanil and the total times of pressing the analgesia pump on the first day after operation, the frequency of severe hypotension, bradycardia, nausea and vomiting, the first off-bed time, the first flatus time and the length of postoperative hospital stay were also recorded. Results: Compared with group C, SBP, DBP in group DR-T and group DV-T were significantly decreased at T₂-T₅ (P<0.05). Compared with group C and group R-T, HR in group DR-T and group DV-T were obviously decreased at T₁-T₅ (P<0.05). Compared with group C, VAS scores on movement at 6 h, 12 h after operation in group R-T and group DV-T, at 6, 12 and 24 h after operation in group DR-T were decreased (P<0.05). VAS scores on movement at 12 h after operation in group DR-T were significantly lower than those in group R-T(P<0.05).Compared with group C, the requirements of sufentanil and the total times of pressing the analgesia pump in the first day after operation in group R-T, group DR-T and group DV-T were significantly decreased(P<0.05), and the requirements of sufentanil and the total times of pressing the analgesia pump in the first day after operation in group DR-Twere obviously less than those of in group R-T and group DV-T(P<0.05). In group R-T, group DR-T and group DV-T, the first time ofgetting down from bed was significantly shorter than that in group C(P<0.05). The first flatus time in group DR-T and group DV-T was also earlier than that in group C. Compared with group C, the frequency of severe bradycardia in group DV-T was obviously increased(P<0.05). Conclusion: Both of dexmedetomidine intravenous plus TAPB and dexmedetomidine mixed with ropivacaine for TAPB can significantly reduce the increase of blood pressure and heart rate caused by surgical stress, and promote earlier recovery. But dexmedetomidine mixed with ropivacaine can prolong the time of postoperative analgesia with a lower incidence of severe bradycardia.

参考文献：

[1] NYGREN J,THACKER J,CARLI F,et al.Guidelines for perioperative care in elective rectal/pelvic surgery:Enhanced Recovery After Surgery (ERAS) Society recommendations[J].Clin Nutr,2012,31(6):801-816.
[2] GUSTAFSSON U O,SCOTT M J,SCHWENK W,et al.Guidelines for periopera tive care in elective colonic surgery:Enhanced Recovery After Surgery (ERAS) Society recommendations[J].World J Surg,2013,37(2):259-284.
[3] CHEN P,LIN Q S,LIN X Z.Optimal concentration of the transversus abdominis plane block in enhanced recovery after surgery protocols for patients of advanced age undergoing laparoscopic rectal cancer surgery[J].J Int Med Res,2018,46(11):4437-4446.
[4] MATULEWICZ R S,PATEL M,JORDAN B J,et al.Transversus abdominis plane blockade as part of a multimodal postoperative analgesia plan in patients undergoing radical cystectomy[J].Bladder Cancer,2018,4(2):161-167.
[5] SINGH P M,BORLE A, MAKKAR J K,et al.Evaluation oftransversus abdominis plane block for renal transplant recipients-a meta analysis and trial sequential analysis of published studies[J].Saudi J Anaesth,2018,12(2):261-271.
[6] VARSHNEY A,PRABHU M,PERIYADKA B,et al.Transversus abdominis plane(TAP) block with levobupivacaine versus levobupivacaine with dexmedetomidine for postoperative analgesia following cesarean delivery[J].J Anaesthesiol Clin Pharmacol,2019,35(2):161-164.
[7] MARHOFER D,KETTNER S C,MARHOFER P,et al.Dexmedetomidine as an adjuvant to ropivacaine prolongs peripheral nerve block:a volunteer study[J].Br J Anaesth,2013,110(3):438-442.
[8] RAFI A N.Abdominal field block:a new approach via the lumbar triangle[J].Anaesthesia,2001,56(10):1024-1026.
[9] GAO T,ZHANG J J,XI F C et al.Evaluation of transversus abdominis plane(TAP) block in hernia surgery:a meta analysis[J].Clin J Pain,2017,33(4):369-375.
[10] CHAMPANERIA R,SHAH L,GEOGHEGAN J,et al.Analgesic effectiveness of transversus abdominis plane blocks after hysterectomy:a meta-analysis[J].Eur J Obstet Gynecol Reprod Biol,2013,166,(1):1-9.
[11] SMITH SR,DRAGANIC B,POCKNEY P,et al.Transversus abdominis plane blockade in laparoscopic colorectal surgery:a double-blind randomized clinical trial[J].Int J Colorectal Dis,2015,30(9):1237-1245.
[12] OH TK,YIM J,KIM J,et al.Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer:a double-blind randomized controlled trial[J].Surg Endosc,2017,31(1):127-134.
[13] LIU L,XIE Y H,ZHANG W,et al.Effect of transversus abdominis plane block on postoperative pain after colorectal surgery:a meta-analysis of randomized controlled trials[J].Med Princ Pract,2018,27(2):158-165.
[14] FRITSCH G,DANNINGER T,ALLERBERGER K,et al.Dexmedetomidine added to ropivacaine extends the duration of interscalene brachial plexus blocks for elective shoulder surgery when compared with ropivacaine alone:a single-center,prospective,triple-blind, randomized contolled trial[J].Reg Anesth Pain Med,2014,39(1):37-47.
[15] CHEN Q,LIU X,ZHONG X,et al.Addition of dexmedetomidine or fentanyl to ropivacaine for transversus abdominis plane block:evaluation of effect on postoperative pain and quality of recovery in gynecological surgery[J].J Pain Res, 2018,11(2):2897-2903.
[16] OBAYAH GM,REFAIE A,ABOUSHANAB O,et al.Addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair[J].Eur J Anaesthesiol,2010,27(3):280-284.
[17] ESMAOGLU A,YEGENOGLU F,AKIN A,et al.Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block[J].Anesth Analg,2010,111(6):1548-1551.

服务与反馈：

【文章下载】【发表评论】【查看评论】【加入收藏】

提示：您还未登录，请登录！点此登录