超声引导下弓状韧带上腰方肌阻滞联合盐酸羟考酮超前镇痛对宫颈癌患者围手术期应激反应的影响

Effect of ultrasound-guided superior arcuate ligament quadratus lumborum block combined with oxycodone hydrochloride preemptive analgesia on perioperative stress response in cervical cancer patients

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摘要目的观察超声引导下弓状韧带上腰方肌阻滞联合盐酸羟考酮超前镇痛对宫颈癌患者围手术期应激反应的影响,探讨其镇痛、镇静效果。方法2020年10月—2023年10月郑州大学第一附属医院行腹腔镜子宫切除术的宫颈癌患者212例,随机分为对照组和观察组各106例。2组麻醉诱导前均行超声引导下弓状韧带上腰方肌阻滞,观察组于阻滞前静脉注射盐酸羟考酮0.1 mg/kg超前镇痛。2组麻醉诱导均依次静脉注射舒芬太尼0.3μg/kg、咪达唑仑0.02 mg/kg、依托咪酯0.2 mg/kg、顺式阿曲库铵0.2 mg/kg;术中静脉泵注瑞芬太尼0.1~0.3μg/(kg·min)、丙泊酚3~6 mg/(kg·h)维持麻醉,间断静脉注射顺式阿曲库铵0.03 mg/kg维持肌松;术后均采用帕洛诺司琼0.25 mg+氢吗啡酮0.15 mg/kg+质量分数0.9%氯化钠溶液静脉自控镇痛。比较2组入手术室(T_(0))、插管(T_(1))、完成手术(T_(2))、术后12 h(T_(3))时去甲肾上腺素、肾上腺素、皮质醇含量,麻醉苏醒后6、12、24 h时静息时活动状态下视觉模拟评分(VAS),麻醉苏醒后即刻及苏醒后6、12、24 h时Ramsay镇静评分,术后48 h镇痛泵按压次数、氢吗啡酮使用量、补救镇痛率、15项恢复质量(QoR-15)评分、麻醉药物不良反应及神经阻滞相关并发症发生率以及首次下床活动时间、肠鸣音恢复时间、住院时间。结果(1)观察组T_(0)时去甲肾上腺素[(242.60±22.60)μg/L]、肾上腺素[(16.25±4.66)μg/L]及皮质醇[(102.58±16.22)nmol/L]含量与对照组[(240.85±23.02)μg/L、(16.50±4.48)μg/L、(101.60±15.47)nmol/L]比较差异均无统计学意义(t=0.559、0.398、0.450,P均>0.05),T_(1)、T_(2)、T_(3)时去甲肾上腺素[(268.60±32.50)、(255.72±28.33)、(246.36±30.02)μg/L]、肾上腺素[(23.74±5.34)、(20.88±4.89)、(18.26±4.56)μg/L]及皮质醇[(120.73±21.64)、(112.64±18.27)、(106.56±15.89)nmol/L]含量均低于对照组[去甲肾上腺素:(325.58±30.22)、(307.42±31.40)、(296.33±28.94)μg/L;肾上腺素:(29.02±5.46)、(25.18±5.02)、(21.96±4.28)μg/L;皮质醇:(148.39±20.02)、(138.54±18.34)、(128.05±16.52)nmol/L](t=12.338~13.219,P均<0.05;t=6.091~7.118,P均<0.05;t=9.653~10.301,P均<0.05)。2组T_(1)、T_(2)、T_(3)时去甲肾上腺素、肾上腺素及皮质醇含量均高于T_(0)时(P<0.05),均依次降低(P<0.05)。(2)观察组苏醒后6、12、24 h时静息[(3.88±0.41)、(3.12±0.34)、(2.37±0.28)分]、活动[(4.21±0.56)、(3.81±0.47)、(3.20±0.32)分]状态下VAS均低于对照组[静息:(4.90±0.43)、(4.13±0.30)、(3.41±0.30)分,活动:(5.38±0.54)、(4.96±0.50)、(4.42±0.36)分](t=17.675~26.093,P均<0.05;t=15.484~26.078,P均<0.05),苏醒后即刻Ramsay镇静评分[(3.26±0.56)分]与对照组[(3.30±0.54)分]比较差异无统计学意义(t=0.529,P=0.597),苏醒后6、12、24 h时Ramsay镇静评分[(2.87±0.48)、(2.42±0.42)、(2.14±0.38)分]均低于对照组[(3.52±0.45)、(2.88±0.38)、(2.66±0.40)分](t=8.362~10.171,P均<0.05)。2组苏醒后6、12、24 h时静息、活动状态下VAS依次降低(P<0.05),苏醒后即刻及苏醒后6、12、24 h时Ramsay镇静评分依次降低(P<0.05)。(3)观察组术后48 h镇痛泵按压次数[(11.60±3.87)次]、氢吗啡酮使用量[(2.64±0.30)mg]均少于对照组[(13.55±4.02)次、(3.88±0.33)mg](t=3.598,P<0.001;t=28.626,P<0.001),补救镇痛率(3.77%)低于对照组(11.32%)(χ^(2)=4.327,P=0.038),QoR-15评分[(116.52±10.30)分]高于对照组[(96.60±11.02)分](t=13.596,P<0.001),首次下床活动时间[(16.24±3.20)h]、肠鸣音恢复时间[(20.30±3.52)h]及住院时间[(8.64±1.22)d]均短于对照组[(20.12±3.52)h、(23.64±3.64)h、(10.02±2.30)d](t=5.457~8.397,P均<0.05)。(4)观察组术后48 h麻醉药物不良反应发生率(7.55%)、神经阻滞相关并发症发生率(4.72%)与对照组(6.60%、2.83%)比较差异均无统计学意义(χ^(2)=0.072,P=0.789;χ^(2)=0.130,P=0.719)。结论行腹腔镜子宫切除术的宫颈癌患者采用超声引导下弓状韧带上腰方肌阻滞联合盐酸羟考酮超前镇痛可减轻围手术期应激反应,提高镇痛及镇静效果,促进术后恢复,不增加麻醉药物不良反应和神经阻滞相关并发症。 Objective To observe the influence of ultrasound-guided superior arcuate ligament quadratus lumborum block combined with oxycodone hydrochloride preemptive analgesia on perioperative stress response in patients with cervical cancer,and to explore its analgesic and sedative effects.Methods Totally 212 patients with cervical cancer underwent laparoscopic hysterectomy in the First Affiliated Hospital of Zhengzhou University from October 2020 to October 2023,and were randomly and equally divided into control group and observation group.Both groups were performed ultrasound-guided superior arcuate ligament quadratus lumborum block before anesthesia induction,and observation group received preemptive analgesia with an intravenous injection of 0.1 mg/kg oxycodone hydrochloride before block.In both groups,0.3μg/kg sufentanil,0.02 mg/kg midazolam,0.2 mg/kg etomidate and 0.2 mg/kg cisatracurium were injected intravenously sequentially for anesthesia induction,0.1-0.3μg/(kg·min)remifentanil and 3-6 mg/(kg·h)propofol were pumped intravenously for maintenance anesthesia,0.03 mg/kg cisatracurium was injected intravenously and intermittently to maintain muscle relaxation during surgery,and 0.25 mg palonosetron+0.15 mg/kg hydromorphone+0.9%sodium chloride solution was used intravenously for self-controlled analgesia after surgery.The levels of norepinephrine,epinephrine and cortisol at entry into operating room(T_(0)),intubation(T_(1)),end of surgery(T_(2))and 12 h after surgery(T_(3)),visual analogue scale(VAS)scores of resting state and active state 6,12 and 24 h after awakening,Ramsay sedation scores immediately after awakening and 6,12 and 24 h after awakening,number of analgesic pump compressions,hydromorphone usage,remedial analgesia rate,15-item quality of recovery(QoR-15)score,anesthetics adverse reactions,incidence of complications related to nerve block 48 h after surgery,first out-of-bed activity time,recovery time of bowel sounds,and length of hospital stay were compared between two groups.Results(1)There were no significant differences in the levels of norepinephrine,epinephrine and cortisol at T_(0) between observation group[(242.60±22.60)μg/L,(16.25±4.66)μg/L,(102.58±16.22)nmol/L]and control group[(240.85±23.02)μg/L,(16.50±4.48)μg/L,(101.60±15.47)nmol/L](t=0.559,0.398,0.450;all P values>0.05).The levels of norepinephrine,epinephrine and cortisol at T_(1),T_(2) and T_(3) were lower in observation group[norepinephrine:(268.60±32.50),(255.72±28.33),(246.36±30.02)μg/L;adrenaline:(23.74±5.34),(20.88±4.89),(18.26±4.56)μg/L;cortisol:(120.73±21.64),(112.64±18.27),(106.56±15.89)nmol/L]than those in control group[norepinephrine:(325.58±30.22),(307.42±31.40),(296.33±28.94)μg/L;adrenaline:(29.02±5.46),(25.18±5.02),(21.96±4.28)μg/L;cortisol:(148.39±20.02),(138.54±18.34),(128.05±16.52)nmol/L](t=12.338-13.219,all P values<0.05;t=6.091-7.118,all P values<0.05;t=9.653-10.301,all P values<0.05),which were higher than those at T_(0) in both groups(P<0.05)and were decreased sequentially(P<0.05).(2)The VAS scores 6,12 and 24 h after awakening in observation group at resting state(3.88±0.41,3.12±0.34,2.37±0.28)and active state(4.21±0.56,3.81±0.47,3.20±0.32)were lower than those in control group(resting state:4.90±0.43,4.13±0.30,3.41±0.30;active state:5.38±0.54,4.96±0.50,4.42±0.36)(t=17.675-26.093,all P values<0.05;t=15.484-26.078,all P values<0.05).There was no significant difference in Ramsay sedation score immediately after awakening between observation group(3.26±0.56)and control group(3.30±0.54)(t=0.529,P=0.597).The Ramsay sedation scores 6,12 and 24 h after awakening in observation group(2.87±0.48,2.42±0.42,2.14±0.38)were lower than those in control group(3.52±0.45,2.88±0.38,2.66±0.40)(t=8.362-10.171,all P values<0.05).The VAS scores 6,12 and 24 h after awakening at resting state and active state decreased sequentially(P<0.05),and the Ramsay sedation score immediately after awakening and 6,12 and 24 h after awakening decreased sequentially in both groups(P<0.05).(3)The number of analgesic pump compressions and hydromorphone usage 48 h after surgery were lower in observation group[(11.60±3.87)times,(2.64±0.30)mg]than those in control group[(13.55±4.02)times,(3.88±0.33)mg](t=3.598,P<0.001;t=28.626,P<0.001),the remedial analgesia rate was lower in observation group(3.77%)than that in control group(11.32%)(χ^(2)=4.327,P=0.038),the QoR-15 score was higher in observation group(116.52±10.30)than that in control group(96.60±11.02)(t=13.596,P<0.001),and the first out-of-bed activity time,recovery time of bowel sounds,and length of hospital stay were shorter in observation group[(16.24±3.20)h,(20.30±3.52)h,(8.64±1.22)d]than those in control group[(20.12±3.52)h,(23.64±3.64)h,(10.02±2.30)d](t=5.457-8.397,all P values<0.05).(4)There were no significant differences in the incidence of anesthetics adverse reactions and complications related to nerve block 48 h after surgery between observation group(7.55%,4.72%)and control group(6.60%,2.83%)(χ^(2)=0.072,P=0.789;χ^(2)=0.130,P=0.719).Conclusion Ultrasound-guided superior arcuate ligament quadratus lumborum block combined with oxycodone hydrochloride preemptive analgesia can alleviate perioperative stress response,improve analgesic and sedative effects,promote postsurgical recovery,and do not increase the anesthetics adverse reactions and complications related to nerve block in cervical cancer patients undergoing laparoscopic hysterectomy.

作者侯军凯邢飞薛长江杨建军卫新 HOU Junkai;XING Fei;XUE Changjiang;YANG Jianjun;WEI Xin(Department of Anesthesiology,Perioperative and Pain Medicine,the First Affiliated Hospital of ZhengzhouUniversity,Zhengzhou,Henan 450052,China)

机构地区郑州大学第一附属医院麻醉与围术期及疼痛医学部

出处《中华实用诊断与治疗杂志》 2024年第11期1168-1174,共7页 Journal of Chinese Practical Diagnosis and Therapy

基金河南省医学科技攻关计划项目(2018020119)。

关键词宫颈癌腹腔镜子宫切除术腰方肌阻滞弓状韧带盐酸羟考酮超前镇痛应激反应 cervical cancer laparoscopic hysterectomy quadratus lumborum block arcuate ligament oxycodone hydrochloride preemptive analgesia stress response