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随着老龄化现象日益突出,外科手术中老年腹部手术的病人所占比例越来越高。目前全麻下老年病人围术期并发症的防治越来越受到临床医师的关注,其中减少术后肺部并发症(postoperative pulmonary complications, PPCs)成为围术期麻醉医师的挑战[1]。研究[2-3]表明,腹部手术的围术期镇痛中应用腹横肌平面阻滞,能够减少阿片类药物消耗、术后早期镇痛效果好;肺保护性通气管理策略在全麻手术中的应用效果已得到认可,尤其老年病人。但是联合应用这两种围术期麻醉处理策略探讨减少术后肺部并发症的研究目前很少报道。本研究观察超声引导下腹横肌平面阻滞联合肺保护性通气管理策略对减少老年全麻腹部手术病人术后肺部并发症的效果。
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2组病人一般资料差异均无统计学意义(P>0.05)(见表 1)。
分组 n 男 女 年龄/岁 身高/cm PBW/kg ASA Ⅱ/Ⅲ 高血压 糖尿病 冠心病 脑梗死 慢性支气管炎 手术时间/min 麻醉时间/min C组 50 20 30 72.04±4.72 166.05±3.08 59.88±6.44 37/13 20(40.00) 8(16.00) 4(8.00) 4(8.00) 2(4.00) 151.55±40.32 170.66±35.88 PT组 50 19 31 70.62±4.27 167.54±4.22 59.02±5.90 39/11 18(36.00) 9(18.00) 3(6.00) 5(10.00) 3(6.00) 153.22±39.67 168.56±36.56 χ2 — 0.04 1.58* 2.01* 0.70* 0.22 0.17 0.07 0.15 0 0 0.21* 0.29* P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t值 表 1 2组病人一般资料比较[n; 百分率(%)]
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PT组病人术后下床活动时间、术后住院时间均短于C组(P < 0.05),2组病人气管拔管时间、PACU观察时间、术后胃肠通气时间差异均无统计学意义(P>0.05)(见表 2)。
分组 n 气管拔管时间/min PACU观察时间/min 术后胃肠通气时间/h 术后下床活动时间/d 术后住院时间/d C组 50 22.54±2.48 38.46.04±2.17 39.58±2.06 4.34±0.658 10.50±1.08 PT组 50 21.66±1.98 35.64±2.81 38.06±2.50 3.38±0.490 7.26±0.80 t — 1.96 5.62 3.32 8.27 17.46 P — >0.05 >0.05 >0.05 < 0.05 < 0.05 表 2 2组病人气管拔管时间、PACU观察时间及术后胃肠通气时间、下床活动时间、住院时间比较(x±s)
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PT组术中病人瑞芬太尼用量少于C组(P < 0.05)(见表 3)。
分组 n 瑞芬太尼/g 舒芬太尼/g 诱导 术中追加 C组 50 885.40±28.94 31.90±2.84 18.50±3.81 PT组 50 772.94±34.48 31.32±2.82 16.80±3.75 t — 17.67 1.03 2.25 P — < 0.05 >0.05 >0.05 表 3 2组病人诱导、术中阿片类药物用量比较(x±s)
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PT组病人术后6、12 h VAS评分均低于C组病人(P < 0.05和P < 0.01)(见表 4)。
分组 n 疼痛评分/分 术后6 h 术后12 h 术后24 h 术后48 h C组 50 2.36±0.72 2.62±0.88 2.80±0.89 2.54±0.68 PT组 50 2.22±0.50 2.28±0.65 2.46±0.89 2.14±0.67 t — 1.12 2.21 1.93 2.97 P — < 0.05 < 0.01 >0.05 >0.05 表 4 2组病人术后疼痛评分比较(x±s)
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PT组病人PPCs发生率明显低于C组(P < 0.01)(见表 5)。C组发生谵妄1例,PT组无。
分组 n 肺部并发症 PPCs发生 χ2 P 1级 2级 3级 4级 C组 50 15 5 3 0 23(46.00) PT组 50 8 2 0 0 10(20.00) 7.64 < 0.01 合计 100 23 7 3 0 33(33.00) 表 5 2组病人术后并发症情况的比较n
超声引导腹横肌平面阻滞联合肺保护性通气管理策略对全麻老年腹部手术后肺部并发症的影响
Effect of ultrasound-guided transverse abdominis plane block combined with lung protective ventilation management strategy on postoperative pulmonary complications in elderly patients treated with abdominal surgery under general anesthesia
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摘要:
目的探讨超声引导下腹横肌平面阻滞联合肺保护性通气管理策略对全麻老年腹部手术病人术后肺部并发症的影响。 方法选取择期全麻下行腹部手术的老年病人100例,随机分成对照组(C组)和超声下腹横肌平面阻滞联合肺保护性通气策略组(PT组),每组50例。观察记录2组病人术后肺部并发症发生率,气管拔管时间、PACU停留时间、术后胃肠通气时间、术后下床活动时间、术后住院时间、麻醉诱导、术中阿片类药物用量,术后6、12、24、48 h的VAS评分。 结果PT组病人术后肺部并发症发生率明显低于C组病人(P < 0.01),术后下床活动时间、术后住院时间均短于C组病人(P < 0.05),术中瑞芬太尼用量,术后6、12 h的VAS评分低于C组病人(P < 0.05和P < 0.01),2组病人的气管拔管时间,PACU观察时间,术后胃肠通气时间,麻醉诱导、术中舒芬太尼用量,术后24、48 h的VAS差异均无统计学意义(P>0.05)。 结论腹横肌平面阻滞联合肺保护性通气管理策略可显著减少全麻老年腹部手术病人术后肺部并发症的发生。 Abstract:ObjectiveTo investigate the effects of ultrasound-guided transverse abdominis plane block combined with lung protective pulmonary ventilation management strategy on postoperative pulmonary complications in elderly patients treated with abdominal surgery under general anesthesia. MethodsA total of 100 elderly patients treated with abdominal surgery under general anesthesia were randomly divided into the control group(group C) and group PT(treated with ultrasound transabdominal muscle plane block combined with lung protective ventilation strategy)(50 cases each in group).The incidence rates of postoperative pulmonary complications in two groups were observed and recorded.The tracheal extubation time, PACU residence time, postoperative gastrointestinal ventilation time, postoperative activity time out of bed, postoperative hospitalization time, anesthesia induction, intraoperative opioid dosage, and VAS scores after 6 h, 12 h, 24 h and 48 h of surgery were analyzed in two groups. ResultsThe incidence rate of postoperative pulmonary complications in group PT was lower than that in group C(P < 0.01), the postoperative activity time out of bed and postoperative hospital stay in group PT were shorter than those in group C(P < 0.05), and the intraoperative fentanyl dosage and VAS scores after 6 h and 12 h of operation in PT group were lower than those in group C(P < 0.05 and P < 0.01).The differences of the tracheal extubation time, PACU observation time, postoperative gastrointestinal ventilation time, anesthesia induction, intraoperative sufentanil dosage, and VAS scores after 24 h and 48 h of operation between two groups were not statistically significant(P>0.05). ConclusionsTransverse abdominis plane muscle block combined with lung protective ventilation management strategy can significantly reduce the incidence of postoperative pulmonary complications in elderly patients treated with abdominal surgery under general anesthesia. -
表 1 2组病人一般资料比较[n; 百分率(%)]
分组 n 男 女 年龄/岁 身高/cm PBW/kg ASA Ⅱ/Ⅲ 高血压 糖尿病 冠心病 脑梗死 慢性支气管炎 手术时间/min 麻醉时间/min C组 50 20 30 72.04±4.72 166.05±3.08 59.88±6.44 37/13 20(40.00) 8(16.00) 4(8.00) 4(8.00) 2(4.00) 151.55±40.32 170.66±35.88 PT组 50 19 31 70.62±4.27 167.54±4.22 59.02±5.90 39/11 18(36.00) 9(18.00) 3(6.00) 5(10.00) 3(6.00) 153.22±39.67 168.56±36.56 χ2 — 0.04 1.58* 2.01* 0.70* 0.22 0.17 0.07 0.15 0 0 0.21* 0.29* P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t值 表 2 2组病人气管拔管时间、PACU观察时间及术后胃肠通气时间、下床活动时间、住院时间比较(x±s)
分组 n 气管拔管时间/min PACU观察时间/min 术后胃肠通气时间/h 术后下床活动时间/d 术后住院时间/d C组 50 22.54±2.48 38.46.04±2.17 39.58±2.06 4.34±0.658 10.50±1.08 PT组 50 21.66±1.98 35.64±2.81 38.06±2.50 3.38±0.490 7.26±0.80 t — 1.96 5.62 3.32 8.27 17.46 P — >0.05 >0.05 >0.05 < 0.05 < 0.05 表 3 2组病人诱导、术中阿片类药物用量比较(x±s)
分组 n 瑞芬太尼/g 舒芬太尼/g 诱导 术中追加 C组 50 885.40±28.94 31.90±2.84 18.50±3.81 PT组 50 772.94±34.48 31.32±2.82 16.80±3.75 t — 17.67 1.03 2.25 P — < 0.05 >0.05 >0.05 表 4 2组病人术后疼痛评分比较(x±s)
分组 n 疼痛评分/分 术后6 h 术后12 h 术后24 h 术后48 h C组 50 2.36±0.72 2.62±0.88 2.80±0.89 2.54±0.68 PT组 50 2.22±0.50 2.28±0.65 2.46±0.89 2.14±0.67 t — 1.12 2.21 1.93 2.97 P — < 0.05 < 0.01 >0.05 >0.05 表 5 2组病人术后并发症情况的比较n
分组 n 肺部并发症 PPCs发生 χ2 P 1级 2级 3级 4级 C组 50 15 5 3 0 23(46.00) PT组 50 8 2 0 0 10(20.00) 7.64 < 0.01 合计 100 23 7 3 0 33(33.00) -
[1] 中国医师协会麻醉学医师分会. 促进术后康复的麻醉管理专家共识(2015)[J]. 中华麻醉学杂志, 2015, 35(2): 141. doi: 10.3760/cma.j.issn.0254-1416.2015.02.001 [2] KAGWA S, HOEFT MA, FIRTH PG, et al. Ultrasound guided transverses abdominis plane versus sham blocks after caesarean section in an Ugandan village hospital: a prospective, randomised, double-blinded, single-centre study[J]. Lancet, 2015, 385(Suppl2): S36. [3] 中华医学会外科分会, 中华医学会麻醉学分会. 加速康复外科中国专家共识暨路径管理指南(2018)[J]. 中华麻醉学杂志, 2018, 38(1): 8. [4] HULZEBOS EH, HELDERS PJ, FAVIÉ NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a rangdomized clinical trial[J]. JAMA, 2006, 296(15): 263. [5] SABATE S, MAZO V, CANET J. Predicting postoperative pulmonary complications: implications for outcomes and costs. Current opinion[J]. Anaesthesioiogy, 2014, 27(2): 201. [6] NETO A, HEMMES S, BARBAS C, et al. Protective versus conventional ventilation for surgery. A systematic review and individual patient data meta-analysis[J]. Anesthesiology, 2015, 123(1): 66. doi: 10.1097/ALN.0000000000000706 [7] 彭晓慧, 顾尔伟, 郑立山, 等. 小潮气量肺保护通气对老年合并肺功能不全胃肠手术病人术后转归的影响[J]. 临床麻醉学杂志, 2017, 33(4): 364. [8] KOEPKE EJ, MANNING EL, MILLER TE, et al. The rising tide of opioid use and abuse: the role of the anesthesiologist[J]. Perioper Med, 2018, 7(1): 16. doi: 10.1186/s13741-018-0097-4 [9] KUMAR K, KIRKSEY MA, DUONG S, et al. A Review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively[J]. Anesth Analg, 2017, 125(5): 1749. doi: 10.1213/ANE.0000000000002497 [10] BORGLUM J, JENSEN K, CHRISTENSEN AF, et al. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis planeblock[J]. Reg Anesth Pain Med, 2012, 37(3): 294. doi: 10.1097/AAP.0b013e31824c20a9 [11] CHONG MA, BERBENETZ NM, LIN C, et al. Perineural versus intravenous dexametasone as an adjuvant for peripheral nerve blocks: a systematic review and meta-analysis[J]. Reg Anesth Pain Med, 2017, 42(3): 319. doi: 10.1097/AAP.0000000000000571