胸壁神经阻滞对乳腺术后患者恢复影响的临床研究

发布时间：2018-05-06 08:40

本文选题：胸壁神经阻滞 + 右美托咪定　；参考：《广州中医药大学》2017年硕士论文

【摘要】：目的:观察乳腺手术患者术后在超声引导下行胸壁神经阻滞(pectoral nerves,Pecs)对患者术后恢复的影响,同时观察术后给予患者胸壁神经阻滞后慢性疼痛的发生情况,对比单纯使用罗哌卡因阻滞和使用右美托咪定(Dexmedetomidine,DEX)加罗哌卡因阻滞的恢复情况,探讨胸壁神经阻滞对此类手术患者术后的慢性疼痛的发生率及其恢复的影响,为临床术后镇痛提供参考依据。方法:将135例择期在全麻下行乳腺区段切除术患者随机分为3组:对照组(C组)、单纯罗哌卡因Pecs组(P组)、右美托咪定加罗哌卡因Pecs组(D组)。干预措施:P组患者在手术结束后行Pecs阻滞(即分别在胸大肌和胸小肌之间筋膜层,胸小肌和前锯肌之间的筋膜层给予局麻药注射),给予0.16%浓度的罗哌卡因30ml;D组患者在手术结束后行Pecs阻滞,给予0.16%浓度的罗哌卡因加1.0 μg/kg右美托咪定30ml;C组患者不予Pecs阻滞,由病房常规按需镇痛(VAS4,予盐酸曲马多缓释片100mg 口服)。术后在手术室时的补救措施为若试验组患者接受Pecs阻滞后或者对照组患者术后未离开手术室时VAS评分大于4分,则给予舒芬太尼5μg静脉注射;记录术中患者生命体征、用药、输液、手术时间、肿物情况等。评估乳腺术后患者术后6h(T1)、术后1d(T2)、术后2d(T3)、术后1周(T4)、术后1月(T5)、术后3月(T6)的视觉模拟评分(visual analogue scale,VAS);术后 6h Ramsay 镇静评分、恶心呕吐(post operative nausea and vomiting,PONV)情况及病房镇痛用药情况;术后1d睡眠干扰DSIS评分;术前1d及术后1d的QoR-40评分。结果:三组患者年龄、身高、体重、体重指数(body mass index,BMI)、ASA分级及肿物情况比较差异无显著性(P0.05)。三组患者阿片类用药及手术时间比较差异无显著性(P0.05)。三组患者术后6h、术后1d、术后2d、术后1周、术后1月的VAS评分各时间点组间比较结果显示差异有统计学意义(P0.05),术后3月的VAS评分组间比较显示差异无统计学意义(P0.05);三组患者慢性疼痛发生率虽然在数值上P组和D组均小于C组,但结果显示差异无统计学意义(P0.05)。本研究三组患者术后1d DSIS睡眠干扰评分组间比较差异有统计学意义(P0.05);结果显示,三组患者术后6 hPONV发生率组间比较差异无统计学意义(P0.05)。三组患者的身体舒适度、情绪状态、自理能力、心理支持、疼痛及QoR-40总分在术后与术前比较差异有统计学意义(P0.05)。结果显示三组患者各术前指标组间比较差异无统计学意义(P0.05),术后除自理能力差异无统计学意义(P0.05),其余术后项组间比较均差异有统计学意义(P0.05),两两比较时,与P组相比,仅有D组的情绪状态组间比较差异有统计学意义(P0.05)。结果显示乳腺术后患者的QoR-40量表的评分总体Pecs组高于对照组,而单纯罗哌卡因组和罗哌卡因联合应用右美托咪定Pecs组相比差异无统计学意义(P0.05)。结论:虽然Pecs阻滞对乳腺术后患者慢性疼痛的发生率在数值上比对照组降低,但三组慢性疼痛发生率组间比较差异无统计学意义,提示Pecs阻滞对乳腺术后患者的急性疼痛有预防作用,但并未明显减少乳腺术后患者的慢性疼痛的发生。胸壁神经阻滞可以促进乳腺术后患者的恢复,但与0.16%浓度的罗哌卡因组相比较,联合应用1.0 μ g/kg右美托咪定组患者的恢复影响无显著优势。
[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.

【学位授予单位】：广州中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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