超声引导下胸壁神经阻滞与胸椎旁神经阻滞用于乳腺癌改良根治术的镇痛效果  

Effect of the perioperative analgesia effect between ultrasound-guided thoracic wall nerve block and thoracic paravertebral block in patients undergoing modified radical mastectomy

作　　者：赵赢 邵安民[2] 冯树全 张代玲[2] 雷月[2] 姚俊岩 ZHAO Ying;SHAO Anmin;FENG Shuquan;ZHANG Dailing;LEI Yue;YAO Junyan(Shanghai General Hospital of Nanjing Medical University,Shanghai 200080,China)

机构地区：[1]南京医科大学附属上海一院临床医学院,200080 [2]江苏省昆山市中医医院麻醉科

出　　处：《临床麻醉学杂志》2020年第1期58-62,共5页Journal of Clinical Anesthesiology

基　　金：昆山市社会发展科技专项项目(ks18037);上海市浦江人才计划资助课题(17PJD035)。

摘　　要：目的比较超声引导下胸壁神经阻滞[胸横肌平面-胸神经阻滞(transversus thoracic muscle plane-pectoral nerves,TTP-PECS)]与胸椎旁神经阻滞(thoracic paravertebral block,TPVB)用于乳腺癌改良根治术围术期的镇痛效果与安全性。方法择期行乳腺癌改良根治术的女性患者64例,年龄35~72岁,BMI 20~26 kg/m^2,ASAⅠ或Ⅱ级。所有患者随机均分为两组:TTP-PECS组(A组)和TPVB组(B组)。麻醉诱导前A组在超声引导下行患侧TTP-PECS,B组在超声引导下行患侧TPVB,均注入0.5%罗哌卡因30 ml,分别于操作结束后30 min测定痛觉减退范围。术毕两组患者均给予PCIA,并静注氟比洛芬酯50 mg补救镇痛,维持静息VAS评分≤3分或运动VAS评分≤5分。记录神经阻滞操作时间、阻滞范围、阻滞相关并发症的发生情况;记录术中芬太尼消耗量、阻滞镇痛维持时间、镇痛泵有效按压次数及补救镇痛例数;评估术后2、6、12、24及48 h的静息及运动状态下的VAS评分;记录术中血管活性药物使用量、术后不良反应的发生情况。结果A组阻滞范围主要为T 2—T 6,B组主要为T 3—T 7,A组T 2皮区的阻滞者明显多于B组,T 6、T 7皮区的阻滞者少于B组(P<0.05);与B组比较,A组阻滞操作时间缩短,阻滞镇痛时间延长,镇痛泵有效按压次数和补救镇痛例数明显减少,术后12 h的VAS评分明显降低(P<0.05);A组术中血管活性药物使用量明显减少,术后低血压和心动过缓发生率明显低于B组(P<0.05)。结论超声引导下TTP-PECS用于乳腺癌改良根治术的围术期镇痛效果和安全性优于TPVB。Objective To campare the perioperative analgesia effect between ultrasound-guided thoracic wall nerve block(TTP-PECS)and thoracic paravertebral block(TPVB)in patients undergoing modified radical mastectomy.Methods Sixty-four patients,aged 35-72 yr,with a BMI 20-26 kg/m^2,falling into ASA physical statusⅠorⅡcategory,scheduled for elective modified radical mastectomy were randomly divided into thoracic wall nerve block group(group A)and thoracic paravertebral block group(group B).Before general anesthesia induction,TTP-PECS and TPVB were performed with 0.5%ropivacaine 30 ml respectively.30 min after block,the range of sensory block was assessed.Patient-controlled intravenous analgesia(PCIA)was provided to all the patients in both groups when the operation was over.Flurbiprofen 50 mg was injected intravenously as a rescue analgesic to maintain the VAS score less than 3 at quiescence or less than 5 at motion.Time-consuming,area-blocking,adverse reaction of each nerve block were recored.Fentanil consumption,analgesia duration,the effective pressing times of PCA pump and cases of remedial analgesia were also recorded;VAS scores at quiescence and at motion were evaluated at 2,6,12,24 and 48 h after operation.Meanwhile,the intraoperative usage of vasoactive agents were recorded,as well as the postoperative adverse reactions.Results The main blocking area was T 2-T 6 in group A and T 3-T 7 in group B,T 2 dermatomal spread was significantly increased but T 6and T 7 dermatomal spread decreased in group A(P<0.05).Compared with group B,the nerve block time-consuming was shorter,the duration of block analgesia was longer,the effective pressing times and postoperative remedial analgesia cases were reduced,the 12 h postoperative VAS scores of quiescence and motion were lowered in group A(P<0.05).In group A,the usage of vasoactive agents and the incidence of postoperative hypotension and bradycardia were decreased(P<0.05).Conclusion Ultrasound-guided thoracic wall nerve block can provide better perioperative analgesia effect

关 键 词：超声 神经传导阻滞 乳腺癌 镇痛安全性 

分 类 号：R614[医药卫生—麻醉学] R737.9[医药卫生—外科学]