Zhang Fuzhou,Zheng Tiehua,Ren Yi,et al.Application of multimode analgesia based predominantly upon single thoracic epidural block during pediatric Nuss procedure[J].Journal of Clinical Pediatric Surgery,2023,22(08):751-756.[doi:10.3760/cma.j.cn101785-202206020-010]
以单次胸段硬膜外阻滞为主的多模式镇痛在儿童Nuss手术中的应用
- Title:
- Application of multimode analgesia based predominantly upon single thoracic epidural block during pediatric Nuss procedure
- Keywords:
- Funnel Chest; Orthopedic Procedures; Anesthesia; Epidural; Analgesia; Child
- 摘要:
- 目的 探讨以单次胸段硬膜外阻滞为主的多模式镇痛用于儿童漏斗胸Nuss手术镇痛的效果。方法 本研究为前瞻性研究，以2020年12月至2021年9月在首都医科大学附属北京儿童医院行Nuss手术的42例患儿作为研究对象，采用随机数字表法分为两组，即单次胸段硬膜外阻滞复合全身麻醉组（T组）和全身麻醉组（G组），每组各21例。T组患儿于全身麻醉诱导气管插管后取侧卧位行单次胸段硬膜外阻滞，G组患儿气管插管后使用全凭静脉麻醉维持。术毕两组均使用电子泵静脉镇痛（自控+持续给药模式）。记录所有患儿手术时间、麻醉时间、术中丙泊酚用量、舒芬太尼用量、瑞芬太尼用量及血流动力学变化；记录术后1 h、6 h、12 h、24 h及48 h静息疼痛评分及术后0~1 h、1~6 h、6~12 h、12~24 h、24~48 h各时间段静脉自控镇痛（patient controlled intravenous analgesia，PCIA）次数；记录两组术后恶心、呕吐、便秘、疼痛等并发症以及T组硬膜外阻滞相关并发症情况。结果 术中瑞芬太尼用量：T组[（0.14±0.13）μg·kg-1 ·min-1]少于G组[（0.30±0.14）μg·kg-1 ·min-1]，差异有统计学意义（P<0.05）；术后1 h、6 h、12 h静息疼痛评分：T组[（0.57±0.51）分、（2.95±1.99）分、（2.71±1.66）分]小于G组[（5.20±2.44）分、（4.55±2.12）分、（4.43±1.78）分]，差异均有统计学意义（P<0.05）；两组术后24 h和48 h疼痛评分差异无统计学意义（P>0.05）；术后各时间段PCIA按压次数：T组[（0.67±0.48）次、（3.52±2.46）次、（1.91±1.09）次、（3.32±1.65）次、（7.83±5.15）次]均少于G组[（2.00±1.41）次、（6.80±3.65）次、（6.22±3.78）次、（11.74±7.16）次、（16.90±12.42）次]，差异有统计学意义（P<0.05）；术后需要补救镇痛的患儿例数T组（5例）少于G组（14例）（P<0.05）；恶心患儿例数T组（9例）多于G组（3例），差异有统计学意义（P<0.05）；两组呕吐和便秘例数差异无统计学意义（P>0.05）。T组均硬膜外穿刺成功，无一例穿刺相关并发症。结论 以单次胸段硬膜外阻滞为主的多模式镇痛用于儿童Nuss手术可以减少静脉阿片类药物的使用，术后早期镇痛效果优于单纯静脉镇痛泵，可提高患儿舒适度。
- Abstract:
- Objective To evaluate the efficacy of multimode analgesia based predominantly upon single thoracic epidural block during pediatric Nuss procedure.Methods From December 2020 to September 2021, 42 children underwent Nuss procedure.Random number table method was employed for assigning them into two groups of single thoracic epidural block plus general anesthesia (T) and general anesthesia (G).Group T underwent thoracic epidural block in a lateral position after tracheal intubation induced by general anesthesia.Group G was maintained by intravenous anesthesia after endotracheal intubation.After operation, both groups underwent electronic pump intravenous analgesia (self-control + continuous administration mode).Operative duration, anesthetic time, intraoperative propofol dose, sufentanil dose, remifentanil dose and hemodynamic changes were recorded.The resting pain scores at 1/6/12/24/48h and the timepoints of PCIA at 0-1 h, 1-6 h, 6-12 h, 12-24 h and 24-48 h post-operation were recorded.Postoperative nausea, vomiting, constipation, pain and other complications were recorded.Complications related to epidural puncture were recorded.Results Intraoperative dose of remifentanil in group T was less than that in group G(P<0.05);The resting pain scores of group T were lower than those of group G at 1/6/12 h post-operation (P<0.05).No significant inter-group difference existed in pain scores at 24/48 h post-operation (P>0.05).The frequency of patient controlled intravenous analgesia (PCIA) at each timepoint in group T was less than that in group G(P<0.05).The number of children with postoperative remedial analgesia was less than G(P<0.05) while the number of children with nausea was more than G(P<0.05).No statistical difference existed in the bout of vomiting or constipation (P>0.05).Epidural puncture was successful in T group without puncture related complications.Conclusion In children undergoing Nuss surgery, multi-mode analgesia based predominantly upon single thoracic epidural block may reduce the application of intravenous opioids.Its early postoperative analgesic effect is better than that of intravenous analgesia pump alone, thus improving the comfort level of children.
参考文献/References:
[1] Giebler RM, Scherer RU, Peters J.Incidence of neurologic complications related to thoracic epidural catheterization[J].Anesthesiology, 1997, 86(1):55-63.DOI:10.1097/00000542-199701000-00009.
[2] 许增华, 张建敏, 郑超, 等.超声引导双侧竖脊肌平面阻滞用于全麻Nuss术患儿的效果[J].中华麻醉学杂志, 2020, 40(2):186-189.DOI:10.3760/cma.j.issn.0254-1416.2020.02.015. Xu ZH, Zhang JM, Zheng C, et al.Efficacy of ultrasound-guided bilateral erector spinae plane block for children undergoing Nuss procedure under general anesthesia[J].Chin J Anesthesiol, 2020, 40(2):186-189.DOI:10.3760/cma.j.issn.0254-1416.2020.02.015.
[3] 薛金虎, 李治松, 王中玉, 等.双侧胸椎旁神经阻滞联合全身麻醉对漏斗胸患者Nuss术后早期恢复的影响[J].中华麻醉学杂志, 2018, 38(11):1322-1324.DOI:10.3760/cma.j.issn.0254-1416.2018.11.011. Xue JH, Li ZS, Wang ZY, et al.Effect of bilateral thoracic paravertebral block plus general anesthesia on early recovery after Nuss procedure in patients with pectus excavatum[J].Chin J Anesthesiol, 2018, 38(11):1322-1324.DOI:10.3760/cma.j.issn.0254-1416.2018.11.011.
[4] Choudhry DK, Brenn BR, Sacks K, et al.Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure:a comparison with thoracic epidural[J].Paediatr Anaesth, 2016, 26(6):582-589.DOI:10.1111/pan.12904.
[5] 滑蕾, 高铮铮, 王小雪, 等.加速术后康复(ERAS)策略在儿童漏斗胸手术中的临床应用[J].基础医学与临床, 2018, 38(8):1131-1134.DOI:10.3969/j.issn.1001-6325.2018.08.015. Hua L, Gao ZZ, Wang XX, et al.Clinical application of enhanced recovery after surgery (ERAS) protocol in children undergoing Nuss repair of pectus excavatum[J].Basic Clin Med, 2018, 38(8):1131-1134.DOI:10.3969/j.issn.1001-6325.2018.08.015.
[6] 詹振刚.硬膜外腔注射吗啡用于小儿术后镇痛[J].中华麻醉学杂志, 1983, 3(4):245.DOI:10.3760/cma.j.issn.0254-1416.1983.04.129. Zhan ZG.Epidural space injection of morphine for postoperative analgesia in children[J].Chin J Anesthesiol, 1983, 3(4):245.DOI:10.3760/cma.j.issn.0254-1416.1983.04.129.
[7] Brown TCK.History of pediatric regional anesthesia[J].Paediatr Anaesth, 2012, 22(1):3-9.DOI:10.1111/j.1460-9592.2011.03636.x.
[8] 张建敏, 吕红, 刘忠玉, 等.高位硬膜外麻醉和全麻对婴幼儿动脉导管未闭手术控制性降压的影响[J].首都医科大学学报, 2006, 27(4):547-549.DOI:10.3969/j.issn.1006-7795.2006.04.037. Zhang JM, Lyu H, Liu ZY, et al.Clinical effect of high epidural anesthesia on controlled reduction of blood pressure in infants during operation of patent ductus arteriosus ligation[J].J Capit Med Univ, 2006, 27(4):547-549.DOI:10.3969/j.issn.1006-7795.2006.04.037.
[9] 潘守东, 马旭波, 吴新民.罗哌卡因在儿科麻醉中的研究进展——与布比卡因的比较[J].国外医学.麻醉学与复苏分册, 2004, 25(4):220-223.DOI:10.3760/cma.j.issn.1673-4378.2004.04.009. Pan SD, Ma XB, Wu XM.Research advances of ropivacaine during pediatric anesthesia as compared with bupivacaine[J].Foreign Med Sci Anesth Resus, 2004, 25(4):220-223.DOI:10.3760/cma.j.issn.1673-4378.2004.04.009.
[10] St Peter SD, Weesner KA, Weissend EE, et al.Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair:a prospective, randomized trial[J].J Pediatr Surg, 2012, 47(1):148-153.DOI:10.1016/j.jpedsurg.2011.10.040.
[11] Rawal N.Epidural and spinal agents for postoperative analgesia[J].Surg Clin North Am, 1999, 79(2):313-344.DOI:10.1016/s0039-6109(05)70385-6.
[12] 刘晶晶, 肖婷, 蒋丽丹, 等.布洛芬注射液在小儿骨科麻醉恢复室镇痛中的应用[J].临床小儿外科杂志, 2021, 20(3):268-272, 296.DOI:10.12260/lcxewkzz.2021.03.013. Liu JJ, Xiao T, Jiang LD, et al.Application of analgesia of intravenous ibuprofen for orthopedic children in PACU[J].J Clin Ped Sur, 2021, 20(3):268-272, 296.DOI:10.12260/lcxewkzz.2021.03.013.
[13] Grosen K, Pfeiffer-Jensen M, Pilegaard HK.Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity:a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum[J].Eur J Cardiothorac Surg, 2010, 37(4):833-839.DOI:10.1016/j.ejcts.2009.09.035.
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备注/Memo
收稿日期:2022-06-08。
基金项目:吴阶平医学基金会临床科研专项资助基金（320.6750.19089-102）
通讯作者:张建敏,Email:zjm428@sina.com