非阿片类镇痛药应用在全身麻醉喉罩置入的乳腺癌保乳手术中的可行性

doi:10.3969/j.issn.1674-8115.2021.05.013

摘要/Abstract

摘要：

目的·研究全身麻醉喉罩置入的乳腺癌保乳手术中不使用阿片类药物的可行性。方法·选择行乳腺癌保乳手术的40名女性患者，将患者按照随机数字表分为试验组和对照组，每组20例。试验组在麻醉诱导前经超声引导下行胸神经阻滞和前锯肌平面阻滞，术中复合使用右美托咪定及非甾体抗炎药（nonsteroidal anti-inflammatory drug，NSAID），不使用阿片类药物；对照组不行神经阻滞，予以阿片类药物；其余使用的药物2组均相同。观察患者术前（T0）、开始诱导（T1）、诱导后5 min（T2）、诱导后10 min（T3）、手术划皮（T4）、划皮后5 min（T5）的血流动力学（收缩压、舒张压、平均动脉压、心率）变化。比较2组血管活性药物的使用情况、患者手术时长、术后自主呼吸恢复时长、喉罩拔除时间、恶心呕吐、谵妄情况、复苏室患者静息时和活动时视觉模拟评分（visual analogue score，VAS）、术后6 h的VAS分值（静息与活动时）、术后24 h的VAS分值（静息与活动时）、术后镇痛药使用情况、术后出院时间。结果·2组患者在T3、T5时间点的收缩压、舒张压和平均动脉压的差异有统计学意义（均P<0.05）。T3、T4、T5时间点的心率差异有统计学意义（均P<0.05）。试验组1例患者使用血管活性药物，对照组有6例患者使用血管活性药物。2组患者自主呼吸恢复时长、喉罩拔除时间的差异均无统计学意义。试验组无患者发生术后恶心、呕吐，对照组有2例患者发生恶心，另有2例患者发生恶心、呕吐。试验组术后6 h静息VAS分值高于对照组，差异有统计学意义（P<0.05）。试验组有4例患者术后口服镇痛药，对照组无患者术后使用镇痛药。结论·经超声下行胸神经阻滞、前锯肌平面阻滞，复合右美托咪定及NSAID药物使全身麻醉喉罩置入的乳腺癌保乳手术可以不使用阿片类药物，但术后镇痛效果有待改善。

关键词: 乳腺癌保乳手术, 胸神经阻滞, 前锯肌平面阻滞, 非阿片类镇痛药

Abstract:

Objective·To study the feasibility of not using opioids in breast-conserving surgery under general anesthesia with laryngeal mask airway.

Methods·Forty female patients who underwent breast-conserving surgery for breast cancer were selected and randomly divided into an experimental group and a control group by random number table method, twenty cases in each. The experimental group underwent ultrasound-guided pectoral nerve block and serratus anterior plane block (SAPB) before induction, combined with dexmedetomidine and nonsteroidal anti-inflammatroy drug (NSAID) during the operation, and did not use opioids. The control group was given opioids without nerve block. The rest of the drugs were the same in both groups. The hemodynamic changes (systolic blood pressure, diastolic blood pressure and mean arterial pressure) of the patients at six time points were observed: before induction (T0), start induction (T1), 5 min after induction (T2), 10 min after induction (T3), incision (T4), and 5 min after incision (T5). The use of vasoactive agent, operation time, the recovery time of spontaneous breathing, laryngeal mask removal time, postoperative nausea, postoperative vomiting, postoperative delirium and visual analogue score (VAS) of patients in resuscitation room at rest and during activity, postoperative VAS at 6 h (at rest and during activity), and postoperative VAS at 24 h (at rest and during activity) between the two groups were compared.

Results·The differences in systolic blood pressure, diastolic blood pressure and mean arterial pressure between the two groups at time points T3 and T5 were statistically significant (all P<0.05). The differences in heart rate at time points T3, T4 and T5 were statistically significant (all P<0.05). One patient in the experimental group used vasoactive agent and six patients in the control group used vasoactive agent. No statistical difference was found between the recovery time of spontaneous breathing and laryngeal mask removal time in the two groups. No patients in the experimental group experienced postoperative nausea and vomiting. In the control group, two patients had nausea, and another two patients had nausea and vomiting. The resting VAS at 6 h after surgery in the experimental group was higher than that in the control group, and the result had statistical significance (P<0.05). Four patients in the experimental group took oral analgesic after surgery, and no patients in the control group used oral analgesic after surgery.

Conclusion·Pectoral nerve block, and SAPB combined with dexmedetomidine and NSAID under ultrasound make it possible not to use opioids during breast-conserving surgery under general anesthesia with laryngeal mask airway. The postoperative analgesic effect needs to be improved.

Key words: breast-conserving surgery, pectoral nerve block, serratus anterior plane block (SAPB), non-opioid analgesic

中图分类号:

R614.4

张海燕, 储晓英. 非阿片类镇痛药应用在全身麻醉喉罩置入的乳腺癌保乳手术中的可行性[J]. 上海交通大学学报(医学版), 2021, 41(5): 637-641.

Hoiyin CHEUNG, Xiao-ying CHU. Feasibility of non-opioid analgesic in breast-conserving surgery under general anesthesia with laryngeal mask airway[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(5): 637-641.

图/表 4

参考文献 21

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Item	Experimental group (n=20)				Control group (n=20)
Item	SBP/mmHg	DBP/mmHg	MAP/mmHg	HR/min^-1	SBP/mmHg	DBP/mmHg	MAP/mmHg	HR/min^-1
T0	125.6±11.4	77.5±10.9	90.3±10.6	81.7±8.3	120.9±15.8	79.0±12.8	91.6±14.7	80.5±12.2
T1	117.3±15.3	66.7±9.0	85.0±10.2	77.9±8.8	114.5±13.3	65.4±14.1	83.0±15.7	76.3±10.6
T2	100.6±11.5	64.5±12.6	78.3±11.2	66.5±9.1	103±15.6	62.6±11.9	77.5±13.4	67±10.5
T3	103.7±15.6	63.3±10.5	75.6±12.0	62.7±16.4	79.5±10.6^①	47.3±14.7^②	57.5±10.2^③	57.4±11.2^④
T4	93.0±16.5	56.7±8.1	68.7±11.1	64.3±12.4	96.0±13.1	54.0±16.9	67.5±9.5	59.1±9.9^⑤
T5	99.3±16.5	61.0±11.3	71.3±10.0	63.0±10.7	89.5±16.0^⑥	48.1±11.2^⑦	61.5±13.3^⑧	56.3±9.8^⑨

Item	Experimental group (n=20)				Control group (n=20)
Item	SBP/mmHg	DBP/mmHg	MAP/mmHg	HR/min^-1	SBP/mmHg	DBP/mmHg	MAP/mmHg	HR/min^-1
T0	125.6±11.4	77.5±10.9	90.3±10.6	81.7±8.3	120.9±15.8	79.0±12.8	91.6±14.7	80.5±12.2
T1	117.3±15.3	66.7±9.0	85.0±10.2	77.9±8.8	114.5±13.3	65.4±14.1	83.0±15.7	76.3±10.6
T2	100.6±11.5	64.5±12.6	78.3±11.2	66.5±9.1	103±15.6	62.6±11.9	77.5±13.4	67±10.5
T3	103.7±15.6	63.3±10.5	75.6±12.0	62.7±16.4	79.5±10.6^①	47.3±14.7^②	57.5±10.2^③	57.4±11.2^④
T4	93.0±16.5	56.7±8.1	68.7±11.1	64.3±12.4	96.0±13.1	54.0±16.9	67.5±9.5	59.1±9.9^⑤
T5	99.3±16.5	61.0±11.3	71.3±10.0	63.0±10.7	89.5±16.0^⑥	48.1±11.2^⑦	61.5±13.3^⑧	56.3±9.8^⑨

Item	Experimental group (n=20)	Control group (n=20)	Z value	P value
Operation time/min	94.6 (92.3, 97.0)	95 (93.6, 99.0)	1.79	0.85
Spontaneous breathing recovery time/min	13 (11.0, 15.0)	12.5 (10.0, 15.0)	0.88	0.31
Laryngeal mask removal time/min	3.0 (2.0, 4.0)	3.3 (2.2, 4.0)	0.44	0.69

Item	Experimental group (n=20)	Control group (n=20)	Z value	P value
Operation time/min	94.6 (92.3, 97.0)	95 (93.6, 99.0)	1.79	0.85
Spontaneous breathing recovery time/min	13 (11.0, 15.0)	12.5 (10.0, 15.0)	0.88	0.31
Laryngeal mask removal time/min	3.0 (2.0, 4.0)	3.3 (2.2, 4.0)	0.44	0.69

Item	Experimental group (n=20)	Control group (n=20)	Z value	P value
Resuscitation room
Resting VAS	0.5 (0, 1.0)	0.7 (0, 1.2)	0.86	0.50
Motion VAS	0.6 (0, 1.0)	1.4 (0, 2.0)	0.77	0.12
Six hours after operation
Resting VAS	3.0 (2.0, 4.0)	2.1 (1.0, 3.0)	1.21	0.01
Motion VAS	3.2 (2.0, 4.0)	2.6 (2.0, 3.0)	1.09	0.17
Twenty-four hours after operation
Resting VAS	0.6 (0, 1.0)	0.9 (0, 2.0)	0.41	0.58
Motion VAS	0.6 (0, 1.2)	1.1 (0, 2.0)	0.42	0.50