江仁 張意珍 李 平 李雙月 李紅 楊偉東 和偉易

[摘要] 目的 探討超聲引導(dǎo)腹壁神經(jīng)阻滯聯(lián)合右美托咪定在腹膜透析置管術(shù)中的安全性與有效性。 方法 選取2018年5月至2019年3月我院終末期腎臟病擇期行腹膜透析置管術(shù)患者60例，ASA Ⅲ～Ⅳ，年齡19～69歲，體重45～80 kg，隨機(jī)分為三組（n=20）：局部浸潤(rùn)阻滯組（L組）、超聲引導(dǎo)腹橫肌平面阻滯聯(lián)合腹直肌鞘阻滯組（TR組）、超聲引導(dǎo)腹壁神經(jīng)阻滯聯(lián)合右美托咪定組（TRD組）。觀察三組患者入室（T1）、切皮（T2）、分離（T3）、探查（T4）、置管（T5）、縫皮（T6）和出室（T7）各時(shí)點(diǎn)平均動(dòng)脈壓（MAP）、心率（HR）和視覺(jué)模擬疼痛評(píng)分（VAS）、手術(shù)時(shí)間、術(shù)后24 h靜息/運(yùn)動(dòng)VAS評(píng)分、患者滿意度、醫(yī)生滿意度及麻醉相關(guān)并發(fā)癥。 結(jié)果 與L組比較，TR組患者T3～T5時(shí)點(diǎn)MAP明顯降低（P<0.05），T2～T7時(shí)點(diǎn)HR明顯下降（P<0.05），T3～T6時(shí)點(diǎn)VAS評(píng)分明顯下降（P<0.05），手術(shù)時(shí)間明顯縮短（t=3.680，P=0.001），術(shù)后2 h、6 h、12 h和24 h靜息/運(yùn)動(dòng)VAS評(píng)分均明顯降低（P<0.05），患者滿意度和醫(yī)生滿意度明顯升高（Z=3.351，P=0.001;Z=5.213，P<0.05）;與L組比較，TRD組患者T2～T7 時(shí)點(diǎn)MAP和HR明顯降低（P<0.05），手術(shù)時(shí)間明顯縮短（t=3.250，P=0.002），T2～T6 VAS評(píng)分均明顯降低（P<0.05），患者滿意度和醫(yī)生滿意度明顯升高（Z=4.528，P<0.05;Z=5.213，P<0.05）;與TR組比較，TRD組患者T2 VAS評(píng)分明顯降低（Z=2.670，P=0.007），T4～T7時(shí)點(diǎn)MAP明顯下降（t=2.100，P=0.043;t=2.270，P=0.029;t=2.540，P=0.015;t=2.110，P=0.041），T6和T7時(shí)點(diǎn)HR明顯下降（t=2.450，P=0.019;t=2.150，P=0.038），患者滿意度明顯升高（Z=2.047，P=0.041）;三組患者均未發(fā)生麻醉相關(guān)并發(fā)癥。結(jié)論 超聲引導(dǎo)腹壁神經(jīng)阻滯聯(lián)合右美托咪定用于腹膜透析置管術(shù)安全且麻醉鎮(zhèn)痛更完善，術(shù)中血流動(dòng)力學(xué)波動(dòng)小，術(shù)后鎮(zhèn)痛效果較好，患者滿意度高，是腹膜透析置管術(shù)更為理想的麻醉選擇。

[關(guān)鍵詞] 超聲引導(dǎo);腹橫肌平面阻滯;腹直肌鞘阻滯;腹膜透析置管術(shù);右美托咪定

[中圖分類號(hào)] R692.5? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] B? ? ? ? ? [文章編號(hào)] 1673-9701（2021）25-0121-05

Application of ultrasound-guided abdominal wall nerve block combined with dexmedetomidine in peritoneal dialysis catheterization

JIANG Ren1? ?ZHANG Yizhen2? ?LI Ping1? ?LI Shuangyue1? ?LI Hong1? ?YANG Weidong1? ?HE Weiyi1

1.Department of Anesthesiology， Ningbo Yinzhou No.2 Hospital， Ningbo? ?315100， China; 2.Department of Ultrasound， Ningbo Yinzhou No.2 Hospital， Ningbo? ?315100， China

[Abstract] Objective To investigate the safety and effectiveness of ultrasound-guided abdominal wall nerve block combined with dexmedetomidine in peritoneal dialysis catheterization. Methods A total of 60 end-stage renal disease patients with ASA Ⅲ-Ⅳ， 19-69 years old， 45-80 kg who underwent selective peritoneal dialysis in our hospital from May 2018 to March 2019 were randomly divided into three groups （n=20）：local infiltration block group （L group）， ultrasound guided transverse abdominal muscle plane block combined with rectus sheath block （TR group）， ultrasound guided abdominal wall nerve block combined with dexmedetomidine group （TRD group）. The mean arterial pressure （MAP）， heart rate （HR）and visual analog pain score （VAS）， operation time， 24 h rest/exercise VAS score after surgery， patient satisfaction， doctor satisfaction， and anesthesia-related complications when When entering the room （T1）， cutting the skin （T2）， separating （T3）， exploring （T4）， placing the tube （T5）， suturing the skin （T6） and leaving the room （T7） of the three groups were observed. Results Compared with that of the L group， the MAP of patients in the TR group was significantly lower at T3-T5 （P<0.05）; the HR decreased substantially at T2-T7 （P<0.05）; the VAS score at T3-T6 decreased significantly （P<0.05）; the operation time was significantly shortened （t=3.680， P=0.001）; the rest/exercise VAS scores of 2 h， 6 h， 12 h and 24 h after operation were significantly reduced （P<0.05）; the patient satisfaction and doctor satisfaction were increased considerably （Z=3.351， P=0.001; Z=5.213， P<0.05）. Compared with that of the L group， the MAP and HR of patients in the TRD group at T2-T7 was significantly lower （P<0.05）， and the operation time was shortened obviously （t=3.250， P=0.002）， the intraoperative VAS score was significantly reduced at T2-T6 （P<0.05）， and patient satisfaction and doctor satisfaction was increased considerably （Z=4.528， P<0.05; Z=5.213， P<0.05）. Compared with that of the TR group， the T2 VAS score of the TRD group was significantly reduced （Z=2.670， P=0.007）; the MAP at T4-T7 was significantly decreased （t=2.100， P=0.043; t=2.270， P=0.029; t=2.540， P=0.015; t=2.110， P=0.041）; the HR at T6-T7 decreased significantly （t=2.450， P=0.019; t=2.150， P=0.038）; patient satisfaction at T6-T7 was significantly increased （Z=2.047， P=0.041）. No anesthesia-related complications occurred in the three groups. Conclusion Ultrasound-guided abdominal wall nerve block combined with dexmedetomidine is safe and more perfect for peritoneal dialysis catheterization， with small fluctuations of hemodynamics， better postoperative analgesia， and high patient satisfaction. It is an ideal anesthesia choice for peritoneal dialysis catheterization.