超声引导下腰方肌阻滞应用于剖宫产术后的镇痛效果
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The Analgesic Effect of Ultrasound-Guided Quadratus Lumborum Block After Cesarean Delivery: A Randomized Clinical Trial
背景与目的：传统定位和超声引导下腹横肌平面阻滞能降低剖宫产术后阿片类药物的用量。后路腰方肌阻滞 (QL)可为胸腰筋膜及椎旁间隙提供更好的局麻药扩散。本研究的目的是评价剖宫产后QL阻滞的效果。
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方法：我们设计了这项随机、双盲、对照试验。40例剖宫产产妇术后接受双侧超声引导下分别用罗哌卡因2mg/ml或生理盐水行QL阻滞。所有患者均采用布比卡因联合舒芬太尼进行腰麻，并采用PCA泵内配有扑热息痛、布洛芬和酚哌丙酮的术后镇痛方案。记录不同剂量下的酚哌丙酮用量和给药时间。主要结局指标为术后24小时内酚哌丙酮用量。探索性分析比较了作为次要结局指标的反复测量的疼痛评分、恶心、疲劳以及直到病人能够站立和行走5米前的总时间差异及有效镇痛评分与时间的相互关系。
结果：40例患者均完成试验，每组20例。与对照组相比，2 4小时内累计酚哌丙酮用量降低（P=.04；均值比=0.60；95%置信区间，0.37-0.97）。与安慰剂组比较，治疗组在休息时(p<.01)和咳嗽(p<.01)时，镇痛效果明显优于安慰剂组(P<0.01)。
结论：罗哌卡因QL阻滞作为无椎管内吗啡用药多模式镇痛方案的一部分，可减少术后酚哌丙酮用量和疼痛强度。
Krohg A, Ullensvang K, Rosseland LA, Langesæter E, Sauter AR The Analgesic Effect of Ultrasound-Guided Quadratus Lumborum Block After Cesarean Delivery: A Randomized Clinical Trial Anesth Analg. Feb,2018;126(2):559-565. doi: 10.1213/ANE.0000000000002648.
BACKGROUND: Landmark and ultrasound-guided transversus abdominis plane blocks have demonstrated an opioid-sparing effect postoperatively after cesarean delivery. The more posterior quadratus lumborum (QL) might provide superior local anesthetic spread to the thoracolumbar fascia and paravertebral space. The aim of our study was to evaluate the efficacy of the QL block after cesarean delivery.
METHODS: A randomized, double-blind, controlled trial was performed. Forty parturients undergoing cesarean delivery received bilateral ultrasound-guided QL blocks with either 2 mg/mL ropivacaine or saline postoperatively. All patients received spinal anesthesia with bupivacaine and sufentanil and a postoperative analgesic regimen of paracetamol, ibuprofen, and ketobemidone administered by a patient-controlled analgesic pump. The ketobemidone consumption and time of each dose administered were recorded. The primary outcome was ketobemidone consumption during the first 24 hours postoperatively. Secondary and exploratory analyses compared repeated measures of pain scores, nausea, and fatigue, and total differences in time until patients were able to stand and able to walk 5 m, and the interaction between the effective analgesic score and time.
RESULTS: All 40 patients completed the trial, 20 in each group. The cumulative ketobemidone consumption in 24 hours was reduced in the active group compared with the control group (P = .04; ratio of means = 0.60; 95% confidence interval, 0.37–0.97). The effective analgesic scores were significantly better in the treatment group compared with the placebo group both at rest (P < .01) and during coughing (P < .01).
CONCLUSIONS: QL block with ropivacaine reduces the postoperative ketobemidone consumption and pain intensity as a part of a multimodal analgesic regimen that excludes neuraxial morphine.
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