婴幼儿腹横肌平面阻滞的相关临床研究
发布时间：2018-08-14 11:22
【摘要】：腹横肌平面阻滞(Transversus abdominis plane block,TAPB)是一种针对腹部的区域阻滞镇痛技术,其通过对腹壁的腹横肌平面腔隙的神经阻滞,可提供前腹壁皮肤、肌肉和腹膜壁层的有效镇痛。目前,随着超声影像技术在临床麻醉上的应用,采用超声引导下行小儿TAPB也逐渐增多,成为小儿多模式镇痛的重要组成部分之一。本研究从超声影像学变化、药物有效剂量、穿刺入路等方面对婴幼儿TAPB进行探讨。第一部分婴幼儿不同容量1%利多卡因TAP阻滞后术中镇痛效果的比较及药物扩散的超声影像变化目的:比较婴幼儿不同容量1%利多卡因行腹横肌平面阻滞后的术中镇痛效果及药物扩散超声影像变化。方法:选择符合入选标准拟行择期单侧腹股沟斜疝或鞘膜积液手术婴幼儿60例,男40例,女20例。按随机数子法将所有患儿分为L_(0.3)、L_(0.5)和C三组,每组各20例。全部患儿均采用七氟烷吸入诱导后,超声引导下用侧入腋中线法行TAP穿刺成功后,L_(0.3)组患儿注入1%利多卡因0.3ml/kg,L_(0.5)组患儿注入1%利多卡因0.5ml/kg,C组患儿注入生理盐水0.3ml/kg或0.5ml/kg。完成患儿TAP穿刺及注药后,在咪达唑仑维持镇静下,用针刺法测试利多卡因起效时间及阻滞范围。测试完成后,患儿吸入七氟烷麻醉诱导后置入喉罩,以3%七氟烷吸入维持麻醉,术中根据患儿心率及血压变化,调整瑞芬太尼连续或间断输注的用量,术后测试TAP阻滞作用消失时间。通过超声影像在腋中线处测量注药后、阻滞起效时及术毕时局麻药液在TAP内向头尾端、前后侧扩散距离、TAP内腹内斜肌与腹横肌之间(I-T)最大间距以及药液距最下肋缘、髂脊之间的距离,观察TAP阻滞作用消失后药液的残留情况。记录L_(0.3)、L_(0.5)两组患儿TAP阻滞起效时间、阻滞范围、作用时间及不同时间点超声影像的变化。结果:(1)L_(0.3)、L_(0.5)两组患儿TAPB起效时间及持续作用时间相同(P0.05),L_(0.5)组患儿的TAP阻滞平面可达T10水平,而L_(0.3)组患儿的TAP阻滞平面低于L_(0.5)组(P0.01)。L_(0.3)、L_(0.5)两组患儿术中瑞芬太尼的用量均较C组减少(P0.01),而L_(0.3)、L_(0.5)两组间术中瑞芬太尼的用量并无差异(P0.05)。(2)婴幼儿不同容量1%利多卡因TAP阻滞后药物扩散的超声影像学变化:给予患儿TAP内注药后,超声影像显示为梭形或勺状TAP药液腔隙。注药后至药物起效时药液向前后双向扩散距离、头尾端扩散距离加大,药液距肋下缘距离减小,但至术毕时,药液上述扩散距离较起效时均无明显变化。在不同时间点,L_(0.5)组与L_(0.3)相比,药液距肋下缘距离更近,向其它方向扩散距离更大。药液向后侧扩散均较向前扩散为多,但两组患儿药液向前或向后单向扩散距离却无明显差异。注药后I-T间距随着时间逐渐下降,L_(0.3)组较L_(0.5)组患儿I-T间距更为窄小。在TAP阻滞作用消失时,超声影像显示两组均有部分患儿TAP腔内仍有小量残液存在,腹内斜肌后鞘膜及腹横肌筋膜被药液浸润后,可见明显的增厚和膨胀。结论:(1)0.3ml/kg和0.5ml/kg的1%利多卡因均能为腹股沟斜疝及鞘膜积液手术的婴幼儿提供可靠的TAP阻滞效果,并可减少术中阿片类药物的使用。(2)婴幼儿TAP内注药后,随时间变化,超声影像显示药物扩散特点不同:注药后至药物起效时药液向前后双向扩散、头尾端扩散明显;而至术毕时药物扩散稳定于药物起效时水平,无明显变化。药物容量对其在TAP内的扩散影响明显,容量加大后药液向各方向扩散距离增加,距肋下缘缩短,有利于提高下腹部支配神经的阻滞范围。第二部分左旋布比卡因用于婴幼儿下腹部手术TAP阻滞的有效浓度和有效容量目的:测定0.5ml/kg左旋布比卡因用于婴幼儿超声引导下TAP阻滞对下腹部手术的有效浓度和0.25%左旋布比卡因的有效容量。方法:(1)选择符合入选标准的婴幼儿100例,男75例,女25例,行单侧腹股沟斜疝手术或下腹壁肿物切除手术患儿各50例。将患儿随机分为L_(0.1)、L_(0.125)、L_(0.15)、L_(0.2)及L_(0.25)五个浓度剂量组,每组各20例。全部患儿均采用七氟烷吸入诱导后,超声引导下行TAP穿刺,按分组不同TAP内分别给予浓度为0.1%、0.125%、0.15%、0.20%及0.25%左旋布比卡因0.5ml/kg。给药后,测试阻滞侧T10~L1皮区的针刺体动反应,反应阴性的患儿继续观察切皮时患儿有无体动反应及心率或血压变化,若出现体动反应,或心率或血压较切皮前升高20%持续超过1min,则认为TAP阻滞无效。记录并比较五组患儿一般情况、TAPB有效人数,TAPB有效患儿神经阻滞平面及术TAPB术后镇痛作用时间。用Probit单位回归法测算0.5ml/kg左旋布比卡因用于婴幼儿TAPB的EC50、EC95及95%可信区间。(2)选择符合入选标准的婴幼儿100例,男77例,女23例,行单侧腹股沟斜疝手术或脐下单侧腹壁肿物切除手术患儿各50例。将患儿随机分为L_(0.2)、L_(0.25)、L_(0.3)、L_(0.3)5及L0.4五个容量组,每组各20例,TAPB给予的0.25%左旋布比卡因容量分别为0.2ml/kg、0.25ml/kg、0.30ml/kg、0.35ml/kg及0.4ml/kg,其余方法和评估同上,记录并比较五组患儿一般情况、TAPB有效人数,TAPB有效患儿神经阻滞平面及术TAPB术后镇痛作用时间。用Probit单位回归法测算0.25%左旋布比卡因用于婴幼儿超声引导下TAP阻滞的EV50、EV95及95%可信区间。结果:(1)超声引导下婴幼儿给予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50为0.13%(95%可信区间为0.118%~0.148%),,EC95为0.23%(其95%可信区间为0.20%~0.31%);Probit量效关系方程为:Probit=5.84+6.682X。各剂量组TAP阻滞有效的患儿,其组间术后镇痛作用时间有统计学差异(P0.01),每两组之间比较也均有不同(P均0.05)。TAP阻滞有效的患儿,其术后镇痛作用时间与浓度有显著的正相关(P0.01),并呈线性关系(P0.01),其线性方程为:术后镇痛时间=-3.316+68.03X。(2)超声引导下婴幼儿给予0.25%左旋布比卡因行下腹部TAPB的EV50为0.27ml,其95%可信区间为(0.248~0.284),EC95为0.37ml,其95%可信区间为(0.339~0.435),量效关系方程为:Probit=6.57+11.43X。各容量组TAP阻滞有效的患儿,其组间术后镇痛作用时间无统计学差异(P0.01)结论:(1)超声引导下婴幼儿给予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50为0.13%,EC95为0.23%;各剂量组TAP阻滞有效的患儿,其术后镇痛作用时间与浓度正相关并呈线性关系。(2)超声引导下婴幼儿给予0.25%左旋布比卡因行下腹部手术TAPB的EV50为0.27ml,EV95为0.37ml;各容量组TAP阻滞有效的患儿,其术后镇痛作用时间无差异同。第三部分罗哌卡因用于婴幼儿腋中线法和后路法TAP阻滞效果的比较目的:比较罗哌卡因腋中线法和后路法TAP阻滞对婴幼儿下腹部手术的镇痛效果。方法:选择符合入选标准的婴幼儿60例,男44例,女16例,根据TAP阻滞方法的不同,按随机数子法将患儿分为A、B和C三组,每组各20例。全部患儿均采用七氟烷吸入诱导,A组患儿行超声引导下腋中线法TAP阻滞,B组患儿行超声引导下后路法TAP阻滞,注入药物均为0.25%罗哌卡因0.4ml,C组为全麻对照组,仅行外周静脉穿刺,不行TAP阻滞。完成患儿TAP穿刺及注药后,在咪达唑仑维持镇静下,用针刺法测试罗哌卡因起效时间及阻滞范围。测试完成后,患儿吸入七氟烷麻醉诱导后置入喉罩,以3%七氟烷吸入维持麻醉,术中根据患儿心率及血压变化,调整给予瑞芬太尼连续或间断输注的用量。记录所有患儿一般情况、手术时间、麻醉时间、拔除喉罩时间、患儿在PACU停留时间及A、B两组患儿TAP阻滞起效时间、阻滞范围,观察各组患儿手术切皮前后血压和心率变化,计算术中镇痛药物瑞芬太尼的使用总量;在PACU期间对所有患儿进行躁动评分,对躁动程度进行评估;对术后2h、4h、8h、12h、16h、24h时的疼痛情况进行FLACC评分。注意观察TAP阻滞过程有无操作相关并发症及局麻药毒性不良反应。术后24h随访,记录恶心呕吐、头晕头痛、心悸、呼吸抑制、嗜睡等不良反应的发生情况。结果:A、B两组患儿的起效时间分别为:(12±2.10)min及(11.6±2.08)min,两组间起效时间无统计学差异(P0.05);A组所有患儿阻滞范围下端均达L1神经平面,上端均达T10神经平面,B组所有患儿阻滞范围下端均达L1神经平面,上端达T9~T7神经平面。三组患儿间切皮前后平均血压、心率无统计学差异,A、B两组术中瑞芬太尼使用总量少于全麻对照组(P0.01);在PACU停留期间,A、B两组患儿躁动发生率、PAED评分均较对照组降低(P0.05);A、B两组患儿术后2h、4h、8h和12h的FLACC评分均显著降低(P0.05);B组患儿术后16h的FLACC评分较A、C两组患儿均明显降低(P0.05)。结论:采用腋中线法和后路法给予0.25%罗哌卡因0.4ml/kg行TAP阻滞,均能为下腹部手术的婴幼儿提供满意的TAP阻滞效果,其起效时间相同,但后路法TAPB所达平面更高,术后镇痛时间也更长,明显优于腋中线法;两种方法均可明显减少婴幼儿术中瑞芬太尼的用量,降低其麻醉恢复期躁动的发生。小结1.0.3ml/kg和0.5ml/kg的1%利多卡因均能为腹股沟斜疝及鞘膜积液手术的婴幼儿提供可靠的TAP阻滞效果。2.超声影像显示,婴幼儿TAP内注入1%利多卡因后至药物起效时药液扩散明显;而至术毕时药物扩散稳定于药物起效时水平;药物容量对其在TAP内的扩散影响明显。3.超声引导下婴幼儿给予0.5ml/kg左旋布比卡因行下腹部TAPB的EC50为0.13%,EC95为0.23%。4.超声引导下婴幼儿给予0.25%左旋布比卡因行下腹部手术TAPB的EV50为0.27ml,EV95为0.37ml。5.腋中线法和后路法0.25%罗哌卡因0.4ml/kg行婴幼儿TAPB,起效时间相同,但后路法TAPB的阻滞范围更高,术后镇痛时间也更长长,明显优于腋中线法。
[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.
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R726.1
[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.
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R726.1
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