Abstract:

Objective To evaluate the effect of preoperative B-ultrasound-leaded transversus abdominisplane block（TAPB）or erector spinae plane block（ESPB）combining with patient controlled intravenous analgesia （PCIA）on postoperative analgesia in patients undergoing orthotopic liver transplantation. Methods Forty-five patients with modified piggy-back orthotopic livertransplantation were selected. The aged was 18 ～ 64 years old. The body mass index was 18 ～ 24 kg/m2，and the ASA grade was Ⅲ～Ⅴ . They were divided into 3 groups（n ＝ 15）：preoperative TAPB group，preoperative ESPB group and regular PCIA group（C group）. In the TAPB group，after the induction of general anesthesia，ultrasound-guided two-step TAPB was performed under the bilateral costal approach. Each point was injected with a mixture drug 15 ml（0.33% ropivacaine 30 ml + dexamethasone 5 mg）. In the ESPB group，after the induction of general anesthesia，ultrasound-guided bilateral TAPB was performed in T7. Each point was injected with a mixture drug 30 ml（0.33% ropivacaine 30 ml + dexamethasone 5 mg）. Group C was a conventional general anesthesia group，no nerve block was performed. Sufentanil 2 μg/kg PCIA was used in every groups，and the visual analog scale score（VAS）was maintained ≤ 3 within 48 h after operation. Sufentanil 5 μg was intravenously injected as rescue analgesic. The intraoperative consumption of remifentanil and the requirement for sufentanil as rescue analgesic were recorded. The extubation time after operation and development of nausea，vomiting，itching and respiratory depression were recorded within 48 h after surgery. Results Compared with group C，the consumption of remifentanil and the requirement of sufentanil as rescue analgesic within 48 h after operation were both decreased in TAPB and ESPB groups. Also the time of extubation was shortened，and the adverse reactions were decrecing within two days after operation（P ＜ 0.05）. Compared with group TAPB，the consumption of remifentanil and the requirement of sufentanil as rescue analgesic within 48 h after operation were decreased in ESPB group. But there were no significant difference of the time of extubation and the adverse reactions between the two groups within 48 h after operation（P ＞ 0.05）. Conclusion Preoperative ultrasound-guided TAPB or ESPB combining with PCIA can both provide better efficacy of postoperative analgesia with fewer adverse reactions in patients undergoing orthotopic liver transplantation. Compared with TAPB，the consumption of postoperative intravenous analgesic is decelerated in ESPB. 

Key words:

Transversus abdominis plane block , Erector spinae plane block , Liver transplantation, Pain

摘要：

目的 比较术前超声引导下腹横肌平面阻滞（transversus abdominis plane block，TAPB）或竖脊肌平面阻滞（erector spinae plane block，ESPB）联合病人自控静脉镇痛（patient controlled intravenous analgesia，PCIA）对原位肝移植患者术后镇痛的应用效果。方法 选取 45 例行改良背驮式原位肝移植术患者，年龄为 18 ～64 岁，体重身高指数（body mass index，BMI）为 18 ～ 24 kg/m2，ASA 分级为Ⅲ～Ⅴ级，分为3 组（n ＝ 15）：术前 TAPB 组、术前 ESPB 组和常规 PCIA 镇痛组（C 组）。TAPB 组在全麻诱导后经 B 超引 导下行双侧肋缘下入路两点腹横肌平面阻滞，每点注入混合药液（0.33％罗哌卡因 30 ml + 地塞米松 5 mg）15 ml。ESPB 组在全麻诱导后经 B 超引导下行双侧 T7 水平竖脊肌平面阻滞，每侧注入混合药液（0.33％罗哌卡因 30 ml + 地塞米松 5 mg）30 ml。C 组为常规 PCIA 镇痛组，术前不行神经阻滞。三组术后均使用舒芬太尼 2 μg/kg PCIA 镇痛泵，若术后 48 h 内疼痛评分 VAS ≤ 3 分，予静脉单次追加舒芬太尼 5 μg 行补救镇痛。记录术中瑞芬太尼用量和拔除气管导管时间。观察术后 48 h 内舒芬太尼补救镇痛用量、恶心呕吐、皮肤瘙痒和呼吸抑制的发生情况。结果 与 C 组比较，TAPB 组和 ESPB 组术中瑞芬太尼及术后补救镇痛舒芬太尼用量均减少，拔除气管导管时间缩短，术后不良反应发生率降低（P ＜ 0.05）。ESPB 组和 TAPB 组比较，术中瑞芬太尼用量、术后 48 h 内舒芬太尼补救镇痛用量减少（P ＜ 0.05），拔除气管导管时间、术后不良反应发生率均无统计学差异（P ＞ 0.05）。结论 术前超声引导 TAPB 或 ESPB 联合 PCIA 静脉镇痛对原位肝移植手术患者均能提供良好的镇痛效果，不良反应少，与 TAPB 相比，ESPB 静脉镇痛药物的用量少。

关键词:

腹横肌平面阻滞 , 竖脊肌平面阻滞 , 肝移植 , 疼痛