本文選題：胸壁神經(jīng)阻滯 + 右美托咪定　； 參考：《廣州中醫(yī)藥大學(xué)》2017年碩士論文

【摘要】：目的:觀察乳腺手術(shù)患者術(shù)后在超聲引導(dǎo)下行胸壁神經(jīng)阻滯(pectoral nerves,Pecs)對(duì)患者術(shù)后恢復(fù)的影響,同時(shí)觀察術(shù)后給予患者胸壁神經(jīng)阻滯后慢性疼痛的發(fā)生情況,對(duì)比單純使用羅哌卡因阻滯和使用右美托咪定(Dexmedetomidine,DEX)加羅哌卡因阻滯的恢復(fù)情況,探討胸壁神經(jīng)阻滯對(duì)此類手術(shù)患者術(shù)后的慢性疼痛的發(fā)生率及其恢復(fù)的影響,為臨床術(shù)后鎮(zhèn)痛提供參考依據(jù)。方法:將135例擇期在全麻下行乳腺區(qū)段切除術(shù)患者隨機(jī)分為3組:對(duì)照組(C組)、單純羅哌卡因Pecs組(P組)、右美托咪定加羅哌卡因Pecs組(D組)。干預(yù)措施:P組患者在手術(shù)結(jié)束后行Pecs阻滯(即分別在胸大肌和胸小肌之間筋膜層,胸小肌和前鋸肌之間的筋膜層給予局麻藥注射),給予0.16%濃度的羅哌卡因30ml;D組患者在手術(shù)結(jié)束后行Pecs阻滯,給予0.16%濃度的羅哌卡因加1.0 μg/kg右美托咪定30ml;C組患者不予Pecs阻滯,由病房常規(guī)按需鎮(zhèn)痛(VAS4,予鹽酸曲馬多緩釋片100mg 口服)。術(shù)后在手術(shù)室時(shí)的補(bǔ)救措施為若試驗(yàn)組患者接受Pecs阻滯后或者對(duì)照組患者術(shù)后未離開手術(shù)室時(shí)VAS評(píng)分大于4分,則給予舒芬太尼5μg靜脈注射;記錄術(shù)中患者生命體征、用藥、輸液、手術(shù)時(shí)間、腫物情況等。評(píng)估乳腺術(shù)后患者術(shù)后6h(T1)、術(shù)后1d(T2)、術(shù)后2d(T3)、術(shù)后1周(T4)、術(shù)后1月(T5)、術(shù)后3月(T6)的視覺模擬評(píng)分(visual analogue scale,VAS);術(shù)后 6h Ramsay 鎮(zhèn)靜評(píng)分、惡心嘔吐(post operative nausea and vomiting,PONV)情況及病房鎮(zhèn)痛用藥情況;術(shù)后1d睡眠干擾DSIS評(píng)分;術(shù)前1d及術(shù)后1d的QoR-40評(píng)分。結(jié)果:三組患者年齡、身高、體重、體重指數(shù)(body mass index,BMI)、ASA分級(jí)及腫物情況比較差異無顯著性(P0.05)。三組患者阿片類用藥及手術(shù)時(shí)間比較差異無顯著性(P0.05)。三組患者術(shù)后6h、術(shù)后1d、術(shù)后2d、術(shù)后1周、術(shù)后1月的VAS評(píng)分各時(shí)間點(diǎn)組間比較結(jié)果顯示差異有統(tǒng)計(jì)學(xué)意義(P0.05),術(shù)后3月的VAS評(píng)分組間比較顯示差異無統(tǒng)計(jì)學(xué)意義(P0.05);三組患者慢性疼痛發(fā)生率雖然在數(shù)值上P組和D組均小于C組,但結(jié)果顯示差異無統(tǒng)計(jì)學(xué)意義(P0.05)。本研究三組患者術(shù)后1d DSIS睡眠干擾評(píng)分組間比較差異有統(tǒng)計(jì)學(xué)意義(P0.05);結(jié)果顯示,三組患者術(shù)后6 hPONV發(fā)生率組間比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)。三組患者的身體舒適度、情緒狀態(tài)、自理能力、心理支持、疼痛及QoR-40總分在術(shù)后與術(shù)前比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)果顯示三組患者各術(shù)前指標(biāo)組間比較差異無統(tǒng)計(jì)學(xué)意義(P0.05),術(shù)后除自理能力差異無統(tǒng)計(jì)學(xué)意義(P0.05),其余術(shù)后項(xiàng)組間比較均差異有統(tǒng)計(jì)學(xué)意義(P0.05),兩兩比較時(shí),與P組相比,僅有D組的情緒狀態(tài)組間比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)果顯示乳腺術(shù)后患者的QoR-40量表的評(píng)分總體Pecs組高于對(duì)照組,而單純羅哌卡因組和羅哌卡因聯(lián)合應(yīng)用右美托咪定Pecs組相比差異無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:雖然Pecs阻滯對(duì)乳腺術(shù)后患者慢性疼痛的發(fā)生率在數(shù)值上比對(duì)照組降低,但三組慢性疼痛發(fā)生率組間比較差異無統(tǒng)計(jì)學(xué)意義,提示Pecs阻滯對(duì)乳腺術(shù)后患者的急性疼痛有預(yù)防作用,但并未明顯減少乳腺術(shù)后患者的慢性疼痛的發(fā)生。胸壁神經(jīng)阻滯可以促進(jìn)乳腺術(shù)后患者的恢復(fù),但與0.16%濃度的羅哌卡因組相比較,聯(lián)合應(yīng)用1.0 μ g/kg右美托咪定組患者的恢復(fù)影響無顯著優(yōu)勢(shì)。
[Abstract]:Objective: To observe the effect of pectoral nerves (Pecs) on postoperative recovery of patients after breast surgery under ultrasound guidance, and observe the occurrence of chronic pain after chest wall nerve block, and compare the use of ropivacaine obstruction and right metomomidine (Dexmedetomidine, DEX) with droperidol. The recovery of cocaine block and the effect of thoracic wall nerve block on the incidence of chronic pain and its recovery after operation in this kind of operation were discussed. Methods: 135 patients were randomly divided into 3 groups: control group (group C), group Pecs of simple ropivacaine (group P), Right metoamidine plus ropivacaine group Pecs (group D). Intervention: group P patients underwent Pecs block at the end of the operation (i.e. the fasciae between the pectoralis major and the pectoralis minor muscle, the fasciae between the pectoralis minor and the anterior sawing muscles were injected into the local anesthetic), and given the 0.16% concentration of roperacine 30ml; group D patients underwent Pecs block after the operation and given 0.16 The concentration of ropivacaine plus 1 g/kg right metomomidine 30ml; group C with no Pecs block and routine on-demand analgesia (VAS4, Tramadol Hydrochloride Sustained Release Tablets 100mg). The remedial measures in the operation room after the operation were after the Pecs block in the experimental group or the control group had not left the operation room after the operation and the VAS score was greater than 4 points. Sufentanil was given 5 u g intravenous injection; the patient's vital signs, medication, infusion, operation time, and swelling were recorded. The postoperative 6h (T1), postoperative 1D (T2), postoperative 2D (T3), postoperative 2D (T4), postoperative January (T5), postoperative March (T6) postoperative visual analogue score (visual analogue) were evaluated. Nausea and vomiting (post operative nausea and vomiting, PONV) and drug use in ward; 1D sleep disturbance DSIS score after operation; preoperative 1D and QoR-40 score of postoperative 1D. Results: there was no significant difference in age, height, weight, body mass index, mass index, and swelling in the three groups. Three groups of patients. There was no significant difference (P0.05) between the three groups of patients with 6h, postoperative 1D, postoperative 2D, 1 weeks after operation, and the results of VAS scores in January after operation showed significant difference (P0.05), and there was no significant difference between the group of VAS scores in March after the operation (P0.05); the three group of patients with chronic pain occurred. Although the rate of birth rate was less than group C in group P and group D, the results showed no significant difference (P0.05). The difference of 1D DSIS sleep disturbance scores between the three groups in this study was statistically significant (P0.05). The results showed that there was no statistical difference between the three groups after the 6 hPONV incidence (P0.05). The three group of patients had no statistically significant difference (P0.05). The differences of physical comfort, emotional state, self-care ability, psychological support, pain and QoR-40 total score were statistically significant (P0.05) after operation (P0.05). The results showed that there was no significant difference between the three groups before operation (P0.05), and there was no significant difference in self-care ability after operation (P0.05). The difference was statistically significant (P0.05). When compared with the P group, there was a significant difference in the emotional state between the group D and the group P (P0.05). The results showed that the overall QoR-40 scale of the patients after breast surgery was higher than that of the control group, while the difference in the combination of ropivacaine and ropivacaine in the right metoimidin Pecs group was significantly different. No statistical significance (P0.05). Conclusion: Although the incidence of chronic pain in postoperative patients with Pecs block is lower than that of the control group, there is no statistical difference between the three groups of chronic pain, suggesting that Pecs block has a preventive effect on the acute pain of the patients after breast surgery, but it does not significantly reduce the postoperative patients. The chest wall nerve block can promote the recovery of patients after breast surgery, but compared with the 0.16% concentration ropivacaine group, there is no significant effect on the recovery of the combined use of the 1 g/kg dexmedetomidin group.

【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R614

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