摘要
目的 探讨超声引导下菱形肌-肋间肌-低位前锯肌平面(rhomboid intercostal and subserratus plane,RISS)阻滞对微创McKeown食管癌根治术(minimally invasive McKeown esophagectomy,MIE-McKeown)患者术后镇痛的安全性和有效性,以期为微创食管癌手术患者术后镇痛方案选择提供新思路.方法 前瞻性收集2022年3月—2023年6月于重庆大学附属涪陵医院胸心外科行MIE-McKeown术患者的临床资料,采用随机数字表法将入组患者分为A、B、C3组:A组采用持续RISS阻滞+患者自控静脉镇痛(patient-controlled intravenous analgesia,PCIA)策略,B组采用单次RISS阻滞+PCIA策略,C组采用单纯PCIA策略.记录并比较各组主要及次要结局指标:(1)镇痛效果[术后2h、6h、12 h、24 h、48 h的静息和咳嗽视觉模拟量表(visual analogue scale,VAS)疼痛评分];(2)术后镇痛药物使用情况[术后24 h内舒芬太尼用量、镇痛泵有效按压次数和补救性镇痛追加次数];(3)术后镇痛期间不良反应发生情况(头晕、嗜睡、恶心呕吐、低血压、尿潴留等);(4)术中血流动力学指标[不同时间点平均动脉压(mean arterial pressure,MAP)和心率];(5)镇痛满意度.其中(1)(2)(3)为主要结局指标,(4)(5)为次要结局指标.结果 共96例符合纳入和排除标准的患者入选本研究,A、B、C每组各32例.A组患者术后2 h、6 h、12 h、24 h、48 h静息和咳嗽VAS评分均低于C组,且术后2h、24 h的静息VAS评分及术后12 h、24 h的咳嗽VAS评分均低于B组;B组患者术后2h、6h、12 h的静息VAS评分及2h、6h、12 h、24 h、48 h的咳嗽VAS评分均低于C组,差异均具有统计学意义(P均＜0.05).术后24h内舒芬太尼用量、镇痛泵有效按压次数及补救性镇痛的追加次数在A、B、C 3组之间逐渐增加,差异具有统计学意义(P均＜0.001).C组头晕、恶心呕吐发生率均高于A、B组(P均＜0.05).3组患者在麻醉诱导前(T0)、切皮即刻(T1)、切皮后5 min(T2)、拔管后5 min(T3)的MAP和心率差异均无统计学意义(P均＞0.05).A、B、C 3组镇痛满意度依次降低(P＜0.05).结论 超声引导下RISS阻滞可为MIE-McKeown术患者提供良好的术后镇痛,作为多模式镇痛的积极探索,持续RISS镇痛效果更佳,值得临床进一步推广使用.
Abstract
Objective To explore the clinical effect,safety and effectiveness of ultrasound-guided rhomboid intercostal and subserratus plane(RISS)block for postoperative analgesia after minimally invasive McKeown esophagectomy(MIE-McKeown),and provide new ideas for the selection of postoperative analgesia programs for minimally invasive esophageal cancer surgery patients.Methods A prospective randomized con-trolled study design was used to collect data.Patients undergoing MIE-McKeown in the Department of cardiotho-racic surgery of Fuling Hospital of Chongqing University from March 2022 to June 2023 were prospectively col-lected as research objects.They were divided into three groups by random number table method:Group A:con-tinuous RISS plane block+patient controlled intravenous analgesia(PCIA),Group B:single RISS plane block+PCIA,and Group C:control group,simple PCIA.The outcome indicators of each group were recorded and compared:① Analgesic effect[visual analogue scale(VAS)pain score for rest and cough at 2,6,12,24,and 48 hours after surgery],②Postoperative use of analgesics[the amount of sufentanil used within 24 hours after surgery,the number of effective presses of the analgesia pump and the number of additional rescue analge-sia],③Adverse reactions during postoperative analgesia[dizziness,lethargy,postoperative nausea and vomi-ting(PONV),hypotension,respiratory depression,urinary retention,etc.],④Intraoperative hemodynamic indicators[mean arterial pressure(MAP)and heart rate(HR)at different time points],⑤Analgesia satisfac-tion.①②③ were the primary outcome indicators,and ④⑤were the secondary outcome indicators.Results A total of 96 patients who met the inclusion and exclusion criteria were enrolled,with 32 cases in each group.Group A patients had lower resting and cough VAS scores at 2,6,12,24,and 48 hours after surgery compared to Group C.Group A had lower resting VAS scores at 2,24 hours after surgery and lower cough VAS scores at 12,24 hours after surgery compared to Group B.Group B patients had significantly lower resting VAS scores at 2,6,12 hours after surgery and lower cough VAS scores at 2,6,12,24,and 48 hours after surgery compared to Group C(all P＜0.05).The dosage of sufentanil,the number of effective compressions of the analgesic pump,and the additional number of remedial analgesia gradually increased between groups A,B,and C within 24 hours after surgery,with statistical differences(all P＜0.01).The incidence of dizziness and PONV in Group C was higher than that in Groups A and B,respectively(both P＜0.05).There were no statistically sig-nificant differences in MAP and HR among the three groups of patients before anesthesia induction(T0),im-mediately after skin incision(T1),5 minutes after skin incision(T2),and 5 minutes after extubation(T3)(all P＞0.05).The satisfaction with pain relief in Group A,Group B,and Group C decreased sequentially(P＜0.05).Conclusions Ultrasound guided RISS block can provide good postoperative analgesia for MIE-McKeown surgery.As an active exploration of multimodal analgesia,continuous RISS has better analgesic effects.It is safe,effective,and worthy of further clinical promotion and use.
基金项目
重庆市涪陵区科卫联合医学科研项目(2022KWLH002)
维普
万方数据