【摘要】：腹橫肌平面阻滯(Transversus abdominis plane block,TAPB)是一種針對腹部的區(qū)域阻滯鎮(zhèn)痛技術(shù),其通過對腹壁的腹橫肌平面腔隙的神經(jīng)阻滯,可提供前腹壁皮膚、肌肉和腹膜壁層的有效鎮(zhèn)痛。目前,隨著超聲影像技術(shù)在臨床麻醉上的應(yīng)用,采用超聲引導(dǎo)下行小兒TAPB也逐漸增多,成為小兒多模式鎮(zhèn)痛的重要組成部分之一。本研究從超聲影像學(xué)變化、藥物有效劑量、穿刺入路等方面對嬰幼兒TAPB進(jìn)行探討。第一部分嬰幼兒不同容量1%利多卡因TAP阻滯后術(shù)中鎮(zhèn)痛效果的比較及藥物擴(kuò)散的超聲影像變化目的:比較嬰幼兒不同容量1%利多卡因行腹橫肌平面阻滯后的術(shù)中鎮(zhèn)痛效果及藥物擴(kuò)散超聲影像變化。方法:選擇符合入選標(biāo)準(zhǔn)擬行擇期單側(cè)腹股溝斜疝或鞘膜積液手術(shù)嬰幼兒60例,男40例,女20例。按隨機(jī)數(shù)子法將所有患兒分為L_(0.3)、L_(0.5)和C三組,每組各20例。全部患兒均采用七氟烷吸入誘導(dǎo)后,超聲引導(dǎo)下用側(cè)入腋中線法行TAP穿刺成功后,L_(0.3)組患兒注入1%利多卡因0.3ml/kg,L_(0.5)組患兒注入1%利多卡因0.5ml/kg,C組患兒注入生理鹽水0.3ml/kg或0.5ml/kg。完成患兒TAP穿刺及注藥后,在咪達(dá)唑侖維持鎮(zhèn)靜下,用針刺法測試?yán)嗫ㄒ蚱鹦r間及阻滯范圍。測試完成后,患兒吸入七氟烷麻醉誘導(dǎo)后置入喉罩,以3%七氟烷吸入維持麻醉,術(shù)中根據(jù)患兒心率及血壓變化,調(diào)整瑞芬太尼連續(xù)或間斷輸注的用量,術(shù)后測試TAP阻滯作用消失時間。通過超聲影像在腋中線處測量注藥后、阻滯起效時及術(shù)畢時局麻藥液在TAP內(nèi)向頭尾端、前后側(cè)擴(kuò)散距離、TAP內(nèi)腹內(nèi)斜肌與腹橫肌之間(I-T)最大間距以及藥液距最下肋緣、髂脊之間的距離,觀察TAP阻滯作用消失后藥液的殘留情況。記錄L_(0.3)、L_(0.5)兩組患兒TAP阻滯起效時間、阻滯范圍、作用時間及不同時間點(diǎn)超聲影像的變化。結(jié)果:(1)L_(0.3)、L_(0.5)兩組患兒TAPB起效時間及持續(xù)作用時間相同(P0.05),L_(0.5)組患兒的TAP阻滯平面可達(dá)T10水平,而L_(0.3)組患兒的TAP阻滯平面低于L_(0.5)組(P0.01)。L_(0.3)、L_(0.5)兩組患兒術(shù)中瑞芬太尼的用量均較C組減少(P0.01),而L_(0.3)、L_(0.5)兩組間術(shù)中瑞芬太尼的用量并無差異(P0.05)。(2)嬰幼兒不同容量1%利多卡因TAP阻滯后藥物擴(kuò)散的超聲影像學(xué)變化:給予患兒TAP內(nèi)注藥后,超聲影像顯示為梭形或勺狀TAP藥液腔隙。注藥后至藥物起效時藥液向前后雙向擴(kuò)散距離、頭尾端擴(kuò)散距離加大,藥液距肋下緣距離減小,但至術(shù)畢時,藥液上述擴(kuò)散距離較起效時均無明顯變化。在不同時間點(diǎn),L_(0.5)組與L_(0.3)相比,藥液距肋下緣距離更近,向其它方向擴(kuò)散距離更大。藥液向后側(cè)擴(kuò)散均較向前擴(kuò)散為多,但兩組患兒藥液向前或向后單向擴(kuò)散距離卻無明顯差異。注藥后I-T間距隨著時間逐漸下降,L_(0.3)組較L_(0.5)組患兒I-T間距更為窄小。在TAP阻滯作用消失時,超聲影像顯示兩組均有部分患兒TAP腔內(nèi)仍有小量殘液存在,腹內(nèi)斜肌后鞘膜及腹橫肌筋膜被藥液浸潤后,可見明顯的增厚和膨脹。結(jié)論:(1)0.3ml/kg和0.5ml/kg的1%利多卡因均能為腹股溝斜疝及鞘膜積液手術(shù)的嬰幼兒提供可靠的TAP阻滯效果,并可減少術(shù)中阿片類藥物的使用。(2)嬰幼兒TAP內(nèi)注藥后,隨時間變化,超聲影像顯示藥物擴(kuò)散特點(diǎn)不同:注藥后至藥物起效時藥液向前后雙向擴(kuò)散、頭尾端擴(kuò)散明顯;而至術(shù)畢時藥物擴(kuò)散穩(wěn)定于藥物起效時水平,無明顯變化。藥物容量對其在TAP內(nèi)的擴(kuò)散影響明顯,容量加大后藥液向各方向擴(kuò)散距離增加,距肋下緣縮短,有利于提高下腹部支配神經(jīng)的阻滯范圍。第二部分左旋布比卡因用于嬰幼兒下腹部手術(shù)TAP阻滯的有效濃度和有效容量目的:測定0.5ml/kg左旋布比卡因用于嬰幼兒超聲引導(dǎo)下TAP阻滯對下腹部手術(shù)的有效濃度和0.25%左旋布比卡因的有效容量。方法:(1)選擇符合入選標(biāo)準(zhǔn)的嬰幼兒100例,男75例,女25例,行單側(cè)腹股溝斜疝手術(shù)或下腹壁腫物切除手術(shù)患兒各50例。將患兒隨機(jī)分為L_(0.1)、L_(0.125)、L_(0.15)、L_(0.2)及L_(0.25)五個濃度劑量組,每組各20例。全部患兒均采用七氟烷吸入誘導(dǎo)后,超聲引導(dǎo)下行TAP穿刺,按分組不同TAP內(nèi)分別給予濃度為0.1%、0.125%、0.15%、0.20%及0.25%左旋布比卡因0.5ml/kg。給藥后,測試阻滯側(cè)T10~L1皮區(qū)的針刺體動反應(yīng),反應(yīng)陰性的患兒繼續(xù)觀察切皮時患兒有無體動反應(yīng)及心率或血壓變化,若出現(xiàn)體動反應(yīng),或心率或血壓較切皮前升高20%持續(xù)超過1min,則認(rèn)為TAP阻滯無效。記錄并比較五組患兒一般情況、TAPB有效人數(shù),TAPB有效患兒神經(jīng)阻滯平面及術(shù)TAPB術(shù)后鎮(zhèn)痛作用時間。用Probit單位回歸法測算0.5ml/kg左旋布比卡因用于嬰幼兒TAPB的EC50、EC95及95%可信區(qū)間。(2)選擇符合入選標(biāo)準(zhǔn)的嬰幼兒100例,男77例,女23例,行單側(cè)腹股溝斜疝手術(shù)或臍下單側(cè)腹壁腫物切除手術(shù)患兒各50例。將患兒隨機(jī)分為L_(0.2)、L_(0.25)、L_(0.3)、L_(0.3)5及L0.4五個容量組,每組各20例,TAPB給予的0.25%左旋布比卡因容量分別為0.2ml/kg、0.25ml/kg、0.30ml/kg、0.35ml/kg及0.4ml/kg,其余方法和評估同上,記錄并比較五組患兒一般情況、TAPB有效人數(shù),TAPB有效患兒神經(jīng)阻滯平面及術(shù)TAPB術(shù)后鎮(zhèn)痛作用時間。用Probit單位回歸法測算0.25%左旋布比卡因用于嬰幼兒超聲引導(dǎo)下TAP阻滯的EV50、EV95及95%可信區(qū)間。結(jié)果:(1)超聲引導(dǎo)下嬰幼兒給予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50為0.13%(95%可信區(qū)間為0.118%~0.148%),,EC95為0.23%(其95%可信區(qū)間為0.20%~0.31%);Probit量效關(guān)系方程為:Probit=5.84+6.682X。各劑量組TAP阻滯有效的患兒,其組間術(shù)后鎮(zhèn)痛作用時間有統(tǒng)計(jì)學(xué)差異(P0.01),每兩組之間比較也均有不同(P均0.05)。TAP阻滯有效的患兒,其術(shù)后鎮(zhèn)痛作用時間與濃度有顯著的正相關(guān)(P0.01),并呈線性關(guān)系(P0.01),其線性方程為:術(shù)后鎮(zhèn)痛時間=-3.316+68.03X。(2)超聲引導(dǎo)下嬰幼兒給予0.25%左旋布比卡因行下腹部TAPB的EV50為0.27ml,其95%可信區(qū)間為(0.248~0.284),EC95為0.37ml,其95%可信區(qū)間為(0.339~0.435),量效關(guān)系方程為:Probit=6.57+11.43X。各容量組TAP阻滯有效的患兒,其組間術(shù)后鎮(zhèn)痛作用時間無統(tǒng)計(jì)學(xué)差異(P0.01)結(jié)論:(1)超聲引導(dǎo)下嬰幼兒給予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50為0.13%,EC95為0.23%;各劑量組TAP阻滯有效的患兒,其術(shù)后鎮(zhèn)痛作用時間與濃度正相關(guān)并呈線性關(guān)系。(2)超聲引導(dǎo)下嬰幼兒給予0.25%左旋布比卡因行下腹部手術(shù)TAPB的EV50為0.27ml,EV95為0.37ml;各容量組TAP阻滯有效的患兒,其術(shù)后鎮(zhèn)痛作用時間無差異同。第三部分羅哌卡因用于嬰幼兒腋中線法和后路法TAP阻滯效果的比較目的:比較羅哌卡因腋中線法和后路法TAP阻滯對嬰幼兒下腹部手術(shù)的鎮(zhèn)痛效果。方法:選擇符合入選標(biāo)準(zhǔn)的嬰幼兒60例,男44例,女16例,根據(jù)TAP阻滯方法的不同,按隨機(jī)數(shù)子法將患兒分為A、B和C三組,每組各20例。全部患兒均采用七氟烷吸入誘導(dǎo),A組患兒行超聲引導(dǎo)下腋中線法TAP阻滯,B組患兒行超聲引導(dǎo)下后路法TAP阻滯,注入藥物均為0.25%羅哌卡因0.4ml,C組為全麻對照組,僅行外周靜脈穿刺,不行TAP阻滯。完成患兒TAP穿刺及注藥后,在咪達(dá)唑侖維持鎮(zhèn)靜下,用針刺法測試羅哌卡因起效時間及阻滯范圍。測試完成后,患兒吸入七氟烷麻醉誘導(dǎo)后置入喉罩,以3%七氟烷吸入維持麻醉,術(shù)中根據(jù)患兒心率及血壓變化,調(diào)整給予瑞芬太尼連續(xù)或間斷輸注的用量。記錄所有患兒一般情況、手術(shù)時間、麻醉時間、拔除喉罩時間、患兒在PACU停留時間及A、B兩組患兒TAP阻滯起效時間、阻滯范圍,觀察各組患兒手術(shù)切皮前后血壓和心率變化,計(jì)算術(shù)中鎮(zhèn)痛藥物瑞芬太尼的使用總量;在PACU期間對所有患兒進(jìn)行躁動評分,對躁動程度進(jìn)行評估;對術(shù)后2h、4h、8h、12h、16h、24h時的疼痛情況進(jìn)行FLACC評分。注意觀察TAP阻滯過程有無操作相關(guān)并發(fā)癥及局麻藥毒性不良反應(yīng)。術(shù)后24h隨訪,記錄惡心嘔吐、頭暈頭痛、心悸、呼吸抑制、嗜睡等不良反應(yīng)的發(fā)生情況。結(jié)果:A、B兩組患兒的起效時間分別為:(12±2.10)min及(11.6±2.08)min,兩組間起效時間無統(tǒng)計(jì)學(xué)差異(P0.05);A組所有患兒阻滯范圍下端均達(dá)L1神經(jīng)平面,上端均達(dá)T10神經(jīng)平面,B組所有患兒阻滯范圍下端均達(dá)L1神經(jīng)平面,上端達(dá)T9~T7神經(jīng)平面。三組患兒間切皮前后平均血壓、心率無統(tǒng)計(jì)學(xué)差異,A、B兩組術(shù)中瑞芬太尼使用總量少于全麻對照組(P0.01);在PACU停留期間,A、B兩組患兒躁動發(fā)生率、PAED評分均較對照組降低(P0.05);A、B兩組患兒術(shù)后2h、4h、8h和12h的FLACC評分均顯著降低(P0.05);B組患兒術(shù)后16h的FLACC評分較A、C兩組患兒均明顯降低(P0.05)。結(jié)論:采用腋中線法和后路法給予0.25%羅哌卡因0.4ml/kg行TAP阻滯,均能為下腹部手術(shù)的嬰幼兒提供滿意的TAP阻滯效果,其起效時間相同,但后路法TAPB所達(dá)平面更高,術(shù)后鎮(zhèn)痛時間也更長,明顯優(yōu)于腋中線法;兩種方法均可明顯減少嬰幼兒術(shù)中瑞芬太尼的用量,降低其麻醉恢復(fù)期躁動的發(fā)生。小結(jié)1.0.3ml/kg和0.5ml/kg的1%利多卡因均能為腹股溝斜疝及鞘膜積液手術(shù)的嬰幼兒提供可靠的TAP阻滯效果。2.超聲影像顯示,嬰幼兒TAP內(nèi)注入1%利多卡因后至藥物起效時藥液擴(kuò)散明顯;而至術(shù)畢時藥物擴(kuò)散穩(wěn)定于藥物起效時水平;藥物容量對其在TAP內(nèi)的擴(kuò)散影響明顯。3.超聲引導(dǎo)下嬰幼兒給予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50為0.13%,EC95為0.23%。4.超聲引導(dǎo)下嬰幼兒給予0.25%左旋布比卡因行下腹部手術(shù)TAPB的EV50為0.27ml,EV95為0.37ml。5.腋中線法和后路法0.25%羅哌卡因0.4ml/kg行嬰幼兒TAPB,起效時間相同,但后路法TAPB的阻滯范圍更高,術(shù)后鎮(zhèn)痛時間也更長長,明顯優(yōu)于腋中線法。
[Abstract]:Transversus abdominal dominis plane block (TAPB) is a regional analgesia technique for abdominal anesthesia. It can provide effective analgesia for anterior abdominal skin, muscle and peritoneal wall through nerve block in the plane lacuna of transverse abdominal muscle. In this study, TAPB in infants and young children was studied by ultrasound imaging, effective dosage of drugs, puncture approach and so on. Part one: Comparison of analgesic effect and drug expansion in infants and young children with different volume of 1% lidocaine TAP. Objective: To compare the analgesic effect and drug diffusion of 1% lidocaine in transverse abdominal plane block in infants and young children.Methods: 60 infants, 40 males and 20 females, who were selected to undergo selective unilateral indirect inguinal hernia or hydrocele surgery according to the selected criteria, were selected. All the patients were induced by sevoflurane inhalation. After successful TAP puncture by transaxillary midline under ultrasound guidance, the children in L_ (0.3) group were injected with 1% lidocaine 0.3 ml/kg, the children in L_ (0.5) group were injected with 1% lidocaine 0.5 ml/kg, the children in C group were injected with 0.3 ml/kg or 0.5 ml/kg saline. After TAP puncture and injection, the onset time and blocking range of lidocaine were measured by acupuncture under midazolam sedation. After induction of sevoflurane anesthesia, laryngeal mask was inserted and 3% sevoflurane was inhaled to maintain anesthesia. Remifentanil was continuously or intermittently infused during operation according to the changes of heart rate and blood pressure. Ultrasound images were used to measure the distance of local anesthetic solution from the middle axillary line to the end of the head and tail of TAP, the distance between the internal oblique and transverse abdominal muscles (I-T) and the distance between the liquid and the lowest costal margin, the iliac spine. Result: (1) The onset time and duration of TAPB in two groups were the same (P 0.05). The level of TAP blockade in L_ (0.5) group was up to T10. The level of TAP blockade in L_ (0.3) group was lower than that in L_ (0.5) group (P 0.01). L_ (0.3) and L_ (0.5) group were lower than that in C group (P 0.01). There was no difference in the amount of remifentanil between L_ (0.3) and L_ (0.5) groups (P 0.05). After TAP injection, the ultrasonic image showed a spindle-shaped or spoon-shaped cavity of TAP solution. After TAP injection, the liquid diffused forward and backward, the diffused distance between head and tail increased, the distance between the liquid and the lower costal margin decreased, but at the end of surgery, the above-mentioned diffused distance of the liquid did not change significantly. Compared with L_ (0.3), the distance between L_ (0.3) and subcostal margin was shorter, and the distance to other directions was wider. When the TAP blockade disappeared, ultrasound images showed that some of the children in both groups still had a small amount of residual TAP fluid in the cavity. The posterior sheath of the internal oblique muscle and the transverse abdominal muscle fascia were significantly thickened and swelled after being infiltrated by the liquid. Conclusion: (1) 0.3ml/kg and 0.5ml/kg of 1% lidocaine can be used to lift the oblique inguinal hernia and hydrocele in infants. To provide reliable TAP blockade effect and reduce the use of opioids during operation. (2) After TAP injection in infants and young children, changes with time, ultrasound imaging shows that drug diffusion characteristics are different: after injection to the drug onset of two-way diffusion, head-tail diffusion is obvious; and at the end of the operation, drug diffusion is stable at the level of drug onset, not clear. The volume of the drug has a significant effect on the diffusion of TAP. When the volume increases, the diffusion distance increases in all directions and the distance from the infracostal margin shortens, which is conducive to increasing the blocking range of the innervating nerve in the lower abdomen. Methods: (1) 100 infants, 75 males and 25 females, were selected to undergo unilateral oblique inguinal hernia surgery or excision of lower inguinal mass. The children were randomly divided into two groups. Twenty children in each group were treated with sevoflurane inhalation, and TAP puncture was performed under the guidance of ultrasound. The concentrations of 0.1%, 0.125%, 0.15%, 0.20% and 0.25% levobupivacaine in different TAP groups were given 0.5 ml/kg. If the body movement reaction occurs, or the heart rate or blood pressure increases by 20% for more than 1 minute, the TAP block is considered ineffective. The general condition of the five groups of children, the effective number of TAPB and the effective nerve block of TAPB were recorded and compared. The EC50, EC95 and 95% confidence intervals of 0.5ml/kg levobupivacaine for infantile TAPB were measured by Probit unit regression method. (2) 100 infants, 77 males and 23 females, were selected for unilateral indirect inguinal hernia or 50 infants for unilateral subumbilical abdominal mass resection. The children were randomly divided into five volume groups: L_ (0.2), L_ (0.25), L_ (0.3), L_ (0.3), L_ (0.3) 5 and L_ (0.4). Each group had 20 cases. The volume of levobupivacaine given by TAPB was 0.2 ml/kg, 0.25 ml/kg, 0.30 ml/kg, 0.35 ml/kg and 0.4 ml/kg, respectively. EV50, EV95 and 95% confidence intervals of 0.25% levobupivacaine for ultrasound-guided TAP block in infants and young children were measured by Probit unit regression. Results: (1) EC50 of 0.13% (95% confidence interval 0.118% ~ 0.148% for ultrasound-guided TAP block in infants and young children was 0.5 ml/kg levobupivacaine. EC95 was 0.23% (95% confidence interval was 0.20% ~ 0.31%); Probit dose-response relationship equation was: Probit = 5.84 + 6.682X. There were significant differences in postoperative analgesic time between the groups (P 0.01), and there were also differences between the two groups (P 0.05). There was a significant positive correlation (P 0.01) and a linear relationship (P 0.01). The linear equation was: postoperative analgesia time = - 3.316 + 68.03X. (2) EV50 of 0.25% levobupivacaine for TAPB was 0.27 ml, 95% confidence interval was (0.248 ~ 0.284), EC95 was 0.37 ml, 95% confidence interval was (0.339 ~ 0.435), and dose-effect relationship formula was established. There was no significant difference in postoperative analgesic time between the two groups (P 0.01). Conclusion: (1) EC50 and EC95 of 0.5 ml/kg levobupivacaine for TAPB in lower abdomen were 0.13% and 0.23% respectively under ultrasound guidance in infants and young children with effective TAP blockade in each dose group. (2) EV50 and EV95 of 0.25% levobupivacaine were 0.27 ml and 0.37 ml for TAPB in lower abdominal surgery under ultrasound guidance. There was no difference in the postoperative analgesic time between the patients with effective TAP block in each volume group. Objective:To compare the analgesic effects of ropivacaine axillary midline block and posterior TAP block in infants undergoing lower abdominal surgery.Methods:Sixty infants, 44 males and 16 females, were selected and divided into three groups according to the different methods of TAP block. Methane inhalation was induced in group A, axillary midline TAP block under ultrasound guidance was performed in group B, posterior TAP block under ultrasound guidance was performed in group B, and 0.25% ropivacaine 0.4 ml was injected into group C. The control group was given general anesthesia only peripheral venipuncture without TAP block. Ropivacaine onset time and blockade range. After induction of anesthesia with sevoflurane inhalation, the patient was given a laryngeal mask and maintained anesthesia with 3% sevoflurane inhalation. During the operation, the dosage of remifentanil was adjusted according to the changes of heart rate and blood pressure. The duration of laryngeal mask, the duration of stay in PACU, the onset time of TAP block in group A and B, the range of block, the changes of blood pressure and heart rate before and after skin incision were observed, and the total amount of remifentanil was calculated. FLACC score was used to assess the pain at 6 and 24 hours. Operational complications and toxic side effects of local anesthetics were observed during TAP blockade. The occurrence of nausea and vomiting, dizziness and headache, palpitation, respiratory depression and somnolence were recorded 24 hours after operation. There was no significant difference in onset time between the two groups (P 0.05) at 6 65 The total amount of remifentanil used in operation was less than that in general anesthesia control group (P 0.01); during the stay in PACU, the incidence of restlessness and PAED scores in group A and B were lower than those in control group (P 0.05); FLACC scores in group A and B were significantly lower than those in group A, 4, 8 and 12 hours after operation (P 0.05); FLACC scores in group B were significantly lower than those in group A and C at 16 hours after operation (P 0.05). Conclusion: TAP block with 0.25% ropivacaine 0.4ml/kg by midaxillary route and posterior route can provide satisfactory results for infants undergoing lower abdominal surgery. The onset time of TAP block is the same, but the level of TAPB by posterior route is higher and the postoperative analgesia time is longer, both methods can significantly reduce the operation of infants and young children. Conclusion 1.0.3 ml/kg and 0.5 ml/kg of 1% lidocaine can provide reliable TAP blocking effect for infants undergoing indirect inguinal hernia and hydrocele surgery. The EC50 of TAPB was 0.13% and EC95 was 0.23% under ultrasound guidance. 4. EV50 of TAPB was 0.27 ml and E was 0.25% under ultrasound guidance. V95 was 0.37ml.5.The onset time of TAPB was the same in infants and young children treated with 0.25% ropivacaine 0.4ml/kg in axillary midline and posterior route, but the blockade range of TAPB in posterior route was higher and the postoperative analgesia time was longer than that of axillary midline.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R726.1

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