超声引导下RISS阻滞在微创McKeown食管癌根治术后的镇痛效果：一项前瞻性随机对照研究

罗富超; 张俊华; 程鹏; 吴旌; 钟斌; 吕兵; 黄国刚; 刘洋; 张泽学; 韦晓红

doi:10.12290/xhyxzz.2023-0358

超声引导下RISS阻滞在微创McKeown食管癌根治术后的镇痛效果：一项前瞻性随机对照研究

Clinical Application of Ultrasound-guided RISS Plane Block for Postoperative Analgesia After Minimally Invasive McKeown Esophagectomy: A Prospective Randomized Controlled Study

摘要

摘要:
目的探讨超声引导下菱形肌-肋间肌-低位前锯肌平面(rhomboid intercostal and subserratus plane, RISS)阻滞对微创McKeown食管癌根治术(minimally invasive McKeown esophagectomy, MIE-McKeown)患者术后镇痛的安全性和有效性，以期为微创食管癌手术患者术后镇痛方案选择提供新思路。
方法前瞻性收集2022年3月—2023年6月于重庆大学附属涪陵医院胸心外科行MIE-McKeown术患者的临床资料，采用随机数字表法将入组患者分为A、B、C 3组：A组采用持续RISS阻滞+患者自控静脉镇痛(patient-controlled intravenous analgesia, PCIA)策略，B组采用单次RISS阻滞+PCIA策略，C组采用单纯PCIA策略。记录并比较各组主要及次要结局指标：(1)镇痛效果术后2 h、6 h、12 h、24 h、48 h的静息和咳嗽视觉模拟量表(visual analogue scale, VAS)疼痛评分；(2)术后镇痛药物使用情况术后24 h内舒芬太尼用量、镇痛泵有效按压次数和补救性镇痛追加次数；(3)术后镇痛期间不良反应发生情况(头晕、嗜睡、恶心呕吐、低血压、尿潴留等)；(4)术中血流动力学指标不同时间点平均动脉压(mean arterial pressure, MAP)和心率；(5)镇痛满意度。其中(1)(2)(3)为主要结局指标，(4)(5)为次要结局指标。
结果共96例符合纳入和排除标准的患者入选本研究，A、B、C每组各32例。A组患者术后2 h、6 h、12 h、24 h、48 h静息和咳嗽VAS评分均低于C组，且术后2 h、24 h的静息VAS评分及术后12 h、24 h的咳嗽VAS评分均低于B组；B组患者术后2 h、6 h、12 h的静息VAS评分及2 h、6 h、12 h、24 h、48 h的咳嗽VAS评分均低于C组，差异均具有统计学意义(P均＜0.05)。术后24 h内舒芬太尼用量、镇痛泵有效按压次数及补救性镇痛的追加次数在A、B、C 3组之间逐渐增加，差异具有统计学意义(P均＜0.001)。C组头晕、恶心呕吐发生率均高于A、B组(P均＜0.05)。3组患者在麻醉诱导前(T₀)、切皮即刻(T₁)、切皮后5 min(T₂)、拔管后5 min(T₃)的MAP和心率差异均无统计学意义(P均＞0.05)。A、B、C 3组镇痛满意度依次降低(P＜0.05)。
结论超声引导下RISS阻滞可为MIE-McKeown术患者提供良好的术后镇痛，作为多模式镇痛的积极探索，持续RISS镇痛效果更佳，值得临床进一步推广使用。

Abstract:
Objective To explore the clinical effect, safety and effectiveness of ultrasound-guided rhomboid intercostal and subserratus plane (RISS) block for postoperative analgesia after minimally invasive McKeown esophagectomy (MIE-McKeown), and provide new ideas for the selection of postoperative analgesia programs for minimally invasive esophageal cancer surgery patients.
Methods A prospective randomized controlled study design was used to collect data. Patients undergoing MIE-McKeown in the Department of cardiothoracic surgery of Fuling Hospital of Chongqing University from March 2022 to June 2023 were prospectively collected as research objects. They were divided into three groups by random number table method: Group A: continuous RISS plane block+patient controlled intravenous analgesia (PCIA), Group B: single RISS plane block+PCIA, and Group C: control group, simple PCIA. The outcome indicators of each group were recorded and compared: ①Analgesic effect visual analogue scale (VAS) pain score for rest and cough at 2, 6, 12, 24, and 48 hours after surgery, ②Postoperative use of analgesics the amount of sufentanil used within 24 hours after surgery, the number of effective presses of the analgesia pump and the number of additional rescue analgesia, ③Adverse reactions during postoperative analgesia dizziness, lethargy, postoperative nausea and vomiting(PONV), hypotension, respiratory depression, urinary retention, etc., ④Intraoperative hemodynamic indicators mean arterial pressure (MAP) and heart rate (HR) at different time points, ⑤Analgesia satisfaction. ①②③ were the primary outcome indicators, and ④⑤were the secondary outcome indicators.
Results A total of 96 patients who met the inclusion and exclusion criteria were enrolled, with 32 cases in each group. Group A patients had lower resting and cough VAS scores at 2, 6, 12, 24, and 48 hours after surgery compared to Group C. Group A had lower resting VAS scores at 2, 24 hours after surgery and lower cough VAS scores at 12, 24 hours after surgery compared to Group B. Group B patients had significantly lower resting VAS scores at 2, 6, 12 hours after surgery and lower cough VAS scores at 2, 6, 12, 24, and 48 hours after surgery compared to Group C (all P < 0.05). The dosage of sufentanil, the number of effective compressions of the analgesic pump, and the additional number of remedial analgesia gradually increased between groups A, B, and C within 24 hours after surgery, with statistical differences (all P < 0.01). The incidence of dizziness and PONV in Group C was higher than that in Groups A and B, respectively (both P < 0.05). There were no statistically significant differences in MAP and HR among the three groups of patients before anesthesia induction (T₀), immediately after skin incision (T₁), 5 minutes after skin incision (T₂), and 5 minutes after extubation (T₃) (all P > 0.05). The satisfaction with pain relief in Group A, Group B, and Group C decreased sequentially(P < 0.05).
Conclusions Ultrasound guided RISS block can provide good postoperative analgesia for MIE-McKeown surgery. As an active exploration of multimodal analgesia, continuous RISS has better analgesic effects. It is safe, effective, and worthy of further clinical promotion and use.

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