【作者】 李琳；

【导师】 刘英志；

【作者基本信息】 青岛大学 ， 麻醉学（专业学位）， 2021， 硕士

【摘要】 研究目的:探讨超声引导下前锯肌平面阻滞联合肋间神经阻滞在机器人辅助胸外科(robot-assisted thoracic surgery,RATS)肺切除术后的镇痛效果。研究方法:选取青岛大学附属医院2019年11月-2020年10月期间60例年龄40-70岁择期全麻下行机器人辅助胸外科(RATS)肺切除术的患者。根据随机数字表法随机将患者分为两组:前锯肌平面阻滞联合肋间神经阻滞组(简称神经阻滞组,B组)和切口局部浸润组(C组)。缝合所有的手术切口后,B组应用0.375%罗哌卡因40ml行超声引导下前锯肌平面阻滞联合肋间神经阻滞;C组应用0.375%罗哌卡因40ml行切口局部浸润。两组患者均在术后出麻醉恢复室(PACU)时使用患者静脉自控镇痛(PCIA)至手术后48h,PCIA药物配方和参数设置:舒芬太尼150ug+氟比洛芬酯150mg+欧贝12mg+生理盐水稀释至150ml,首次剂量2ml,背景剂量为2.0ml/h,自控追加剂量为1ml,锁定时间为15min。手术后采用疼痛数字评分(Numerical Rating Scale,NRS)评价镇痛效果,若静息状态NRS评分>4分或疼痛难以忍受时,则静脉予以50mg氟比洛芬酯进行补救镇痛。记录患者出PACU、术后6h、24h、48h的静息和咳嗽时NRS镇痛评分并记录48h内NRS最高值和出现时间;记录出PACU、术后6h、24h、48h的平均动脉压(MAP)、心率(HR)和脉搏氧饱和度(Sp O2),记录术后48h内镇痛泵药物输注总量和补救药物给药次数,记录心血管不良事件、呼吸抑制、恶心、呕吐等不良反应发生情况。研究结果:(1)两组患者术前一般资料(年龄、体重指数、ASA分级)比较,差异无统计学意义(P>0.05);两组患者术中部分资料(手术时间、麻醉时间、手术切口数、舒芬太尼用量)比较,差异无统计学意义(P>0.05);两组患者术后部分资料(停留PACU时间)比较,差异无统计学意义(P>0.05)。(2)两组患者手术后不同时间点MAP、HR和Sp O2比较差别无统计学意义(P>0.05)。(3)出PACU、术后6h、48h的静息和咳嗽NRS评分两组无统计学差异(P>0.05),术后24h的静息和咳嗽时NRS评分B组明显低于C组(P<0.05),两组术后48h内NRS评分最高值B组明显低于C组(P<0.05),而且B组NRS最高值出现时间明显晚于C组(P<0.05)。(4)手术后48h内镇痛泵药物输注总量、补救镇痛次数和恶心呕吐发生率B组明显低于C组(P<0.05)。两组患者其他不良反应发生情况无统计学差异(P>0.05)。研究结论:与切口局部浸润相比,超声引导下前锯肌平面阻滞联合肋间神经阻滞更有利于缓解机器人辅助胸外科(RATS)肺切除术后疼痛,延长镇痛持续时间,循环呼吸稳定,不增加恶心呕吐等不良反应发生率,适用于RATS肺切除手术后疼痛管理。更多还原

【Abstract】 Objective: To explore the postoperative analgesia effect of ultrasound-guided serratus anterior plane block combined with intercostal nerve block in patients undergoing robot-assisted pulmonary resections.Methods: 60 patients undergoing robot-assisted pulmonary resections in The Affiliated Hospital of Qingdao University from November 2019 to October 2020 were selected and divided into two groups(30 patients pear group)according to randomized digital table:serratus anterior plane block+intercostal nerve block(nerve block group,group B)and incision infiltration of local anesthesia group(group C).After the completion of operation,0.375% ropivacaine 40 ml was used for ultrasound-guided serratus anterior plane block combined with intercostal nerve block in group B,0.375% ropivacaine 40 ml was used for Incision infiltration of local anesthesia in group C.Patient-controlled intravenous analgesia(PCIA)was used in two groups from leaving postoperative anesthesia care unit(PACU)to 48 h after surgery: sufentanil 150μg,flurbiprofen axetil 150 mg,ondansetron 8mg and normal saline were added to 150 ml.The first dose was 2 ml,the background infusion volume was 2 ml/h and 1 ml bolus dose was controlled for 15 min.Pain was evaluated by Numerical Rating Scale(NRS).In order to maintain NRS≤4,flurbiprofen axetil 50 mg were used for remedial analgesia.NRS scores at rest and while coughing were recorded at the time when the patients left PACU and 6h,24 h and 48 h after surgery,the maximum NRS score and occurrence time were recorded as well.MAP,HR and Sp O2 were recorded when the patients left PACU and 6h,24 h and 48 h after surgery.The volume of analgesic drugs,the use of additional analgesic drugs were recorded within 48 h after operation.The incidence of cardiovascular adverse events,respiratory depression,postoperative nausea and vomiting(PONV)were recorded as well.Results:(1)Compared with group C,there were no significant differences in the age,body mass index(BMI),ASA degrade,the time of operation,the time of anesthesia,number of surgical incisions,the amount of sufentanil used intraoperative,the time of PACU(P>0.05).(2)MAP,HR and Sp O2 were no significant differences after surgery between the two groups(P>0.05).(3)NRS scores at rest and while coughing in the group B was significantly lower than group C at 24 h after surgery(P>0.05),while no significant differences were detected in NRS scores at when the patients left PACU、6h、48h after surgery,the maximum NRS score in the group B was significantly lower than group C(P>0.05),and the occurrence time of the maximum NRS score obviously later in group B(P>0.05).(4)The volume of analgesic drugs,the frequency of additional analgesics and the PONV were significantly less in group B(P<0.05).No significant differences were detected in the occurrence of other adverse effects.Conclusion: Compared with incision infiltration of local anesthesia,ultrasound-guided serratus anterior plane block combined with intercostal nerve block can provide better and more durable postoperative analgesia for patients undergoing robot-assisted pulmonary resections,without increasing the incidence of adverse reactions and is suitable for pain management after robot-assisted pulmonary resections.更多还原