【摘要】 目的 观察微创冠状动脉旁路移植术(MIDCABG)后应用前锯肌平面阻滞镇痛的效果，探讨其在促进术后恢复中的作用。方法 2024年3—12月郑州大学第一附属医院经左胸小切口行MIDCABG的冠心病患者56例，术中均用左乳内动脉与左前降支吻合，随机分为观察组和对照组各28例。2组均采用快通道麻醉技术，麻醉诱导依次静脉注射艾司氯胺酮0.3 mg/kg、咪达唑仑0.02 mg/kg、瑞芬太尼2μg/kg、依托咪酯0.1 mg/kg、罗库溴铵1.0 mg/kg;麻醉维持采用静脉持续泵注丙泊酚4～8 mg/(kg·h)、瑞芬太尼0.2～0.4μg/(kg·min),每50 min追加罗库溴铵0.3 mg/kg维持肌肉松弛。术毕，对照组静脉注射盐酸羟考酮0.1 mg/kg,然后行静脉自控镇痛(盐酸羟考酮50 mg+质量分数0.9%生理盐水100 mL),观察组在对照组基础上行超声引导下前锯肌平面阻滞(质量分数0.3%罗哌卡因30 mL+地塞米松5 mg)。比较2组年龄、性别、体质量指数、手术时间、麻醉时间和拔管时间；比较2组术后48 h镇痛泵按压次数、盐酸羟考酮用量；记录2组术后2、4、6、8、12、24、48 h时静息及运动状态下的疼痛数字评分(NRS),术后24、48 h时15项恢复质量量表(QoR-15)评分，术后48 h内恶心、呕吐、头晕、瘙痒、呼吸抑制、肠梗阻等不良反应发生情况。结果 (1)观察组性别、年龄、体质量指数、手术时间、麻醉时间和拔管时间与对照组比较差异均无统计学意义(P>0.05)。(2)观察组镇痛泵按压次数[(4.36±0.68)次]、盐酸羟考酮用量[(40.13±3.56)mg]均少于对照组[(4.96±0.43)次、(55.47±2.79)mg](t=4.00、17.95,P均<0.001)。(3)观察组术后2、4、8、12 h时静息NRS评分[0、0、1.00(0, 1.00)、2.00(2.00, 2.00)分]和运动NRS评分[0、1.00(0.75, 2.00)、2.00(1.00, 2.00)、3.00(2.00, 3.25)分]均低于对照组[静息：1.00(0, 2.00)、1.00(1.00, 2.00)、2.00(2.00, 2.25)、2.00(2.00, 3.00)分；运动：2.00(1.00, 2.25)、3.00(2.00, 3.00)、3.00(3.00, 4.00)、4.00(4.00, 4.00)](U=-5.84～-3.79,P均<0.05),术后24、48 h时QoR-15评分[(115.00±5.48)、(125.11±4.47)分]均高于对照组[(101.21±6.36)、(116.04±6.92)分](t=8.69、4.54,P均<0.001),术后24、48 h时静息和运动NRS评分与对照组比较差异均无统计学意义(P>0.05)。(4)2组术后48 h均无肠梗阻、呼吸抑制病例；观察组发生恶心3例、呕吐1例、头晕2例，排气时间>24 h者4例；对照组发生恶心4例、呕吐2例、头晕2例、瘙痒1例，排气时间>24 h者5例。观察组不良事件发生率(35.7%)与对照组(50.0%)比较差异无统计学意义(χ~2=1.17,P=0.280)。结论 冠心病患者MIDCABG后应用质量分数0.3%罗哌卡因30 mL行超声引导下前锯肌平面阻滞可减轻术后12 h内的静息和运动疼痛，减少阿片类药物用量，提高术后恢复质量，不增加不良反应。更多还原

【Abstract】 Objective To observe the analgesic effect of serratus anterior plane block(SAPB)after minimally invasive direct coronary artery bypass grafting (MIDCABG)in order to explore its role in promoting postoperative recovery.Methods Fifty-six patients with coronary artery disease underwent MIDCABG via left anterolateral mini-thoracotomy in the First Affiliated Hospital of Zhengzhou University from March to December 2024,during which left internal mammary artery to left anterior descending artery anastomosis was performed in all patients.These 68patients were randomly divided into an observation group (n=28)and a control group (n=28),and received fast-track anesthesia including anesthesia induction with intravenous sequential injection of esketamine (0.3 mg/kg),midazolam (0.02 mg/kg),remifentanil(2μg/kg),etomidate (0.1 mg/kg)and rocuronium (1.0 mg/kg),and anesthesia maintenance with continuous infusion of propofol[4-8mg/（kg·h)]and remifentanil[0.2-0.4μg/（kg·min)]and subsequent supplement with rocuronium (0.3mg/kg every 50min)for muscle relaxation.Postoperatively,the control group was intravenously injected with oxycodone hydrochloride(0.1mg/kg)followed by patient-controlled intravenous analgesia with oxycodone50mg+0.9%normal saline 100mL.The observation group received additional ultrasound-guided SAPB with 0.3%ropivacaine 30mL+dexamethasone 5mg.The age,gender,body mass index,operation time,anesthesia duration and extubation time were compared between two groups.The number of analgesic pump presses and oxycodone consumption were compared 48hafter operation between two groups.The numeric rating scale (NRS)scores at rest and during movement at 2,4,6,8,12,24and 48hpostoperatively,Quality of Recovery-15(QoR-15)scores at 24and 48h,and incidence of adverse events (nausea,vomiting,dizziness,pruritus,respiratory depression,ileus)within 48h were recorded.Results(1)No significant differences were observed between groups in the gender,age,body mass index,operation time,anesthesia duration or extubation time(P>0.05).(2)The observation group had fewer analgesic pump presses(4.36±0.68 vs.4.96±0.43)and less oxycodone consumption[(40.13±3.56)mg vs.(55.47±2.79)mg]compared to the control group (t=4.00,P<0.001;t=17.95,P<0.001).(3)The NRS scores at rest[0,0,1.00(0,1.00),2.00(2.00,2.00)]and during movement[0,1.00(0.75,2.00),2.00(1.00,2.00),3.00(2.00,3.25)]in the observation group at 2,4,8and 12hafter operation were lower than those in the control group[1.00(0,2.00),1.00(1.00,2.00),2.00(2.00,2.25),2.00(2.00,3.00);2.00(1.00,2.25),3.00(2.00,3.00),3.00(3.00,4.00),4.00(4.00,4.00)](U=-5.84to-3.79,all Pvalues<0.05).The QoR-15scores at 24and 48hafter operation were higher in the observation group(115.00±5.48,125.11±4.47)than those in the control group(101.21±6.36,116.04±6.92)(t=8.69,P<0.001;t=4.54,P<0.001).At 24and 48hafter operation,there was no statistically significant differences in the NRS scores at rest and during movement between two groups(P>0.05).(4)No respiratory depression or ileus occurred 48hafter operation.The adverse events included nausea in 3patients,vomiting in 1,dizziness in 2and delayed flatus(>24h)in 4in the observation group,and nausea in4,vomiting in 2,dizziness in 2,pruritus in 1and delayed flatus(>24h)in 5in the control group.The incidences of adverse event rates were comparable between the observation group (35.7%)and control group (50.0%）（χ~2=1.17,P=0.280).Conclusion Ultrasound-guided SAPB with 0.3%ropivacaine (30 mL)after MIDCABG alleviates early postoperative pain(within 12h),reduces opioid use,enhances recovery quality,and does not increase adverse events.更多还原