【作者】 王凯；

【导师】 陈胜阳；

【作者基本信息】 新乡医学院 ， 麻醉学， 2020， 硕士

【摘要】 背景腹腔镜子宫切除术（Laparoscopic hysterectomy,LAH）属于微创手术,临床认为与传统开腹手术相比,该术式术后无需进行术后镇痛。但越来越多的研究报告以及反馈调查显示,即使是侵袭性较小的腹腔镜手术,术后切口疼痛、气腹造成的腹腔镜术后疼痛综合征,均可导致患者术后急性疼痛,其疼痛程度不亚于传统开腹手术。腰方肌阻滞（Quadratus lumborum block,QLB）作为术后多模式镇痛的有效方法之一,在腹部手术术后镇痛方面已得到广泛应用。目的研究不同浓度罗哌卡因行腰方肌阻滞（QLB）对腹腔镜子宫切除术术后镇痛效果,以期为腹腔镜子宫切除术术后镇痛提供临床依据。方法选取2019年2月²019年10月我院（新乡医学院第四临床学院）实际纳入临床研究的择期行腹腔镜子宫切除术120例患者,随机分为A、B、C、D四组,每组30例。四组均采用静脉全身麻醉,其中B、C、D组术后行超声引导下双侧QLB,每侧20 ml。A组（对照组）,B组（0.15%罗哌卡因）,C组（0.25%罗哌卡因）,D组（0.33%罗哌卡因）。观察并记录四组:1.术毕6 h（T₁）、12 h（T₂）、24 h（T₃）、48 h（T₄）时刻静息及运动时视觉模拟疼痛评分（VAS）;2.T_1-4时刻主观舒适度评分（BCS）;3.术毕48h内纳布啡追加率;4.术毕时（T₀）、T_1-4时刻外周血P物质（SP）和5-羟色胺（5-HT）浓度;5.术毕48h内头晕、恶心呕吐发生率。6.镇痛满意度。结果1.静息及运动时视觉模拟疼痛评分（VAS）比较组内比较:A组VAS随时间延长而升高,差异有统计学意义（P<0.05）,B、C、D组VAS T_1-3时刻两两间比较,差异无统计学意义（P>0.05）;四组VAS T₄时刻较T₃时刻升高,差异有统计学意义（P<0.05）。组间比较:四组间VAS B、C、D组T_1-4时刻低于A组,C、D组低于B组,差异有统计学意义（P<0.05）;C、D组组间T_1-4时刻比较,差异无统计学意义（P>0.05）。2.主观舒适度评分（BCS）比较组内比较:A组BCS随时间延长而降低,差异有统计学意义（P<0.05）,B、C、D组BCS T_1-3时刻两两间比较,差异无统计学意义（P>0.05）;四组BCS T₄时刻较T₃时刻降低,差异有统计学意义（P<0.05）。组间比较:四组间BCS B、C、D组T_1-4时刻高于A组,C、D组高于B组,差异有统计学意义（P<0.05）;C、D组组间T_1-4时刻比较,差异无统计学意义（P>0.05）。3.术毕48 h内纳布啡追加率比较组间比较:四组间两两比较,差异有统计学意义（P<0.05）;B、C、D组少于A组,C、D组少于B组,差异有统计学意义（P<0.05）;C、D组组间比较,差异无统计学意义（P>0.05）。4.外周血P物质（SP）和5-羟色胺（5-HT）浓度比较组内比较:四组T₀时刻相比,差异无统计学意义（P>0.05）;A组随时间延长而升高,差异有统计学意义（P<0.05）;B、C、D组T_1-3时刻两两间比较,差异无统计学意义（P>0.05）;四组T₄时刻较T₃时刻升高,差异有统计学意义（P<0.05）。组间比较:B、C、D组T_1-4时刻低于A组,C、D组低于B组,差异有统计学意义（P<0.05）;C、D组组间T_1-4时刻比较,差异无统计学意义（P>0.05）。5.术毕48h内头晕、恶心呕吐发生率比较组间比较:四组间两两比较,差异无统计学意义（P>0.05）。6.镇痛满意度比较组间比较:四组间两两比较,差异有统计学意义（P<0.05）;B、C、D组高于A组,C、D组高于B组,差异有统计学意义（P<0.05）;C、D组组间比较,差异无统计学意义（P>0.05）。结论0.25%、0.33%罗哌卡因行双侧QLB对腹腔镜子宫切除术术后镇痛效果显著。更多还原

【Abstract】 BackgroundCompared with the traditional open operation,laparoscopic hysterectomy（LAH）which belongs to the minimally invasive surgery,has none-postoperative pain.However,a growing number of research reports and feedback surveys show that even with less invasive laparoscopic surgery,postoperative incision pain and pneumoperitoneum pain syndrome can lead to acute postoperative pain in patients,which is no less than traditional open surgery.Quadratus lumborum block（QLB）,as one of the effective methods of postoperative multi-mode analgesia,has been widely used in postoperative analgesia after abdominal surgery.ObjectiveTo explore the analgesic effect of different concentrations of ropivacaine in quadratus lumborum block（QLB）in laparoscopic hysterectomy（LAH）,in order to provide a basis for analgesia after LAH.MethodsFrom February 2019 to December 2019,120 patients who were from the four hospital of Xinxiang Medical University underwent laparoscopic hysterectomy were randomly divided into four groups:A,B,C,and D,30 cases in each group.All groups underwent intravenous general anesthesia,among them,groups B,C,and D underwent bilateral QLB under ultrasound guidance,20 ml ropivacaine on each side.Group A（control group）,group B（0.15%ropivacaine）,group C（0.25%ropivacaine）,and group D（0.33%ropivacaine）.The four groups were observed and recorded for:（1）Pain severity（VAS）scores of rest and exercise at 6 h（T₁）,12 h（T₂）,24 h（T₃）,and 48 h（T₄）after surgery.（2）Comfort level（BCS）score at T_1-4.（3）Additional numbers of nalbuphine within 48h after surgery.（4）Concentrations of substance P（SP）and serotonin（5-HT）in peripheral blood at the end of the operation（T₀）and T_1-4.（5）Incidence of postoperative dizziness,nausea and vomiting.（6）Satisfaction degree of analgesia.Results1.There was no significant difference in the VAS scores of group B,C and D at rest and exercise at T_1-3（P>0.05）,with the extension of time in group A,the higher the VAS score at rest and during exercise,the difference was statistically significant（P<0.05）;the VAS scores of the four groups at time T₄ at rest and during exercise were higher than those at time T₃,and the differences were statistically significant（P<0.05）,the VAS scores of group B,C and D at rest and exercise at T_1-4-4 were lower than those of group A,and those of group C and D were lower than those of group B（P<0.05）,but there was no significant difference in the VAS scores of group C and D at rest and exercise at T_1-4（P>0.05）.2.There was no significant difference in BCS score between groups B,C and D at T_1-3-3 time（P>0.05）,with the extension of time in group A,the lower the BCS score,the difference was statistically significant（P<0.05）;the BCS scores at time T₄ in the four groups were lower than those at time T₃,and the difference was statistically significant（P<0.05）;the BCS scores of groups B,C,and D at T_1-4-4 were higher than those of group A,and those of groups C and D were higher than those of group B,the difference was statistically significant（P<0.05）,but there was no significant difference in the BCS scores at time T_1-4-4 between groups C and D（P>0.05）.3.The number of additions of nalbuphine within 48 hours after surgery was less in groupB,C,and D than in group A,and the number of additions of nalbuphine within 48hours after surgery in groups C and D was less than that in group B,the difference was statistically significant（P<0.05）;there was no significant difference in the number of additions of nalbuphine within 48 hours after surgery between groups C and D（P>0.05）.4.There was no significant difference in the concentration of SP and 5-HT at the time of T₀ between the four groups（P>0.05）;there was no significant difference in the concentration of SP and 5-HT at the time of T_1-3-3 among groups B,C and D（P>0.05）,but the concentration of SP and 5-HT in group A was higher with time prolonging（P<0.05）;the concentration of SP and 5-HT at T₄ was higher than that at T₃ in the four groups,and the difference was statistically significant（P<0.05）,the concentrations of SP,5-HT in groups B,C and D at time T_1-4-4 were lower than those in group A,and those in groups C and D were lower than those in group B,the difference was statistically significant（P<0.05）,but there was no significant difference in SP and 5-HT concentrations between groups C and D at time T_1-4（P>0.05）.5.There was no significant difference in the incidence of dizziness,nausea and vomiting within 48 h after operation among the four groups（P>0.05）.6.Compared with the analgesia satisfaction of the four groups,the difference was statistically significant（P<0.05）,the analgesia satisfaction of B,C and D was higher than that of group A,and the analgesia satisfaction of groups C and D was higher than that of group B,and the difference was statistically significant（P<0.05）,there was no significant difference in analgesia satisfaction between groups C and D（P>0.05）.ConclusionAfter laparoscopic hysterectomy,bilateral QLB with 0.25%and 0.33%ropivacain-e showed significant analgesic effect.更多还原