双侧腹横肌平面阻滞在腹腔镜肝切除术中的安全性和有效性：前瞻性随机对照盲法临床研究
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双侧腹横肌平面阻滞在腹腔镜肝切除术中的安全性和有效性：前瞻性随机对照盲法临床研究
翻译：吴学艳 编辑：冯玉蓉 审校：曹莹
目的：由于存在围术期肝功能障碍的风险，肝切除患者的术后疼痛管理仍是一个挑战。经腹横肌平面(TAP)阻滞是一种很有前景的区域镇痛技术。然而，关于肝切除术患者局部麻醉药的剂量和方案的正确指南尚未明确。本研究旨在评价超声引导下大剂量罗哌卡因BD-TAP阻滞在腹腔镜肝切除术中的安全性和有效性。
方法：本项前瞻性、盲法、随机、对照研究纳入50例拟行择期腹腔镜肝切除术的患者。全麻联合BD-TAP阻滞(3 mg/kg罗哌卡因稀释至60mL)的患者分为BD-TAP阻滞组(n=25)；只接受全身麻醉的患者为对照组(n=25)。主要观察结果是术后48小时内舒芬太尼用量和血浆罗哌卡因浓度，次要观察结果是疼痛的严重程度(休息时和咳嗽时)、恶心和/或呕吐，以及康复质量。
结果：与对照组比较，BD-TAP阻断组术后2小时、24小时、48小时舒芬太尼用量明显减少，术后2小时VAS评分明显降低。BD-TAP阻滞组患者术后2h(=0.019)、24h(=0.001)、48h(=0.001)舒芬太尼用量明显减少，术后2h(=0.004)咳嗽时视觉模拟评分 (VAS) 也显著降低；术后恶心和/或呕吐、排气、拔除导尿管、下床活动、肝功能以及术后住院时间均无统计学差异。罗哌卡因平均总峰值浓度为1067.85 ng/mL，出现在给药后1h，罗哌卡因平均游离浓度为52.32 ng/mL。注射罗哌卡因45min后，最高个体峰值血药浓度为2360.90 ng/mL，游离罗哌卡因浓度为139.29 ng/mL。
结论：超声引导下BD-TAP阻滞用于腹腔镜肝切除术后的镇痛效果显著。同时本研究还证实，在腹腔镜肝切除术中，超声引导下用3 mg/kg罗哌卡因行BD-TAP阻滞时的血浆罗哌卡因浓度几乎不会导致有关神经毒性。
原始文献来源：Zhang J, Liu T, Zhou H, et al.The Safety and Efficacy of Ultrasound-Guided Bilateral Dual Transversus Abdominis Plane (BD-TAP) Block in ERAS Program of Laparoscopic Hepatectomy: A Prospective, Randomized, Controlled, Blinded, Clinical Study.[J].Drug Des Devel Ther 2020;14 ,10.2147/DDDT.S255385.
The Safety and Efficacy of Ultrasound-Guided Bilateral Dual Transversus Abdominis Plane (BD-TAP) Block in ERAS Program of Laparoscopic Hepatectomy: A Prospective, Randomized, Controlled, Blinded, Clinical Study
Purpose: Postoperative pain management for patients undergoing hepatic resection is still a challenge due to the risk of perioperative liver dysfunction. The transversus abdominis plane (TAP) block is a promising regional analgesic technique. However, the correct guidelines regarding the dose and regimen of local anesthetics in patients undergoing hepatic resection have yet to be established completely. This study aimed to evaluate the safety and efficacy of ultrasound-guided BD-TAP block with a large dose of ropivacaine in laparoscopic hepatectomy.
Patients and Methods: This prospective, blinded, randomized, controlled study was conducted with 50 patients who were scheduled for selective laparoscopic hepatectomy. Patients who received a BD-TAP block (3 mg/kg of ropivacaine diluted to 60 mL) with general anesthesia were categorized into the BD-TAP block group (n = 25), and those who received general anesthesia were categorized into the control group (n = 25). The primary outcomes were consumption of sufentanil within 48 hourspost-operation and plasma ropivacaine concentration. The secondary outcomes were the severity of pain (at rest and upon coughing), nausea and/or vomiting, and quality of recovery.
Results:Compared with the control group, the patients in BD-TAP block group had a significant reduction of postoperative sufentanil consumption at 2 hours ( = 0.019), 24 hours ( = 0.001), and 48 hours ( = 0.001), and the visual analog scale (VAS) scores on coughing were significantly lower at postoperative 2 hours ( = 0.004). There were no statistically significant differences in postoperative nausea and/or vomiting, flatus, catheter removal, off-bed activity, liver function, or postoperative hospital stay. The mean peak total ropivacaine concentration was 1,067.85 ng/mL, which occurred 1 hour after administering the block, and mean free ropivacaine concentration was 52.32 ng/mL. The highest individual peak plasma concentration was 2,360.90 ng/mL at 45 min postinjection, and the free ropivacaine concentration was 139.29 ng/mL.
Conclusion:Ultrasound-guided BD-TAP block provides effective postoperative analgesia after laparoscopic hepatectomy. This study also confirms that ultrasound-guided BD-TAP blocks with 3 mg/kg ropivacaine during laparoscopic hepatectomy almost never results in the plasma ropivacaine concentrations associated with neurotoxicity.
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