中国科技论文统计源期刊　中文核心期刊  
美国《化学文摘》《国际药学文摘》
《乌利希期刊指南》
WHO《西太平洋地区医学索引》来源期刊  
日本科学技术振兴机构数据库（JST）
第七届湖北十大名刊提名奖  
医药导报
医药导报, 2018, 37(8): 973-976
doi: 10.3870/j.issn.1004-0781.2018.08.011
超声引导下髂腹股沟及髂腹下神经阻滞联合腹直肌鞘阻滞在腹腔镜小儿疝高位结扎术中的应用
Application of Ultrasound-guided Ilioinguinal/Iliohypogastrie Nerve Block Combined with Rectus Sheath Block in High Ligation of Pediatric Hernia by Using Laparoscope
吴云, 金啸, 叶松
宁波市妇女儿童医院麻醉科,宁波 315012
WU Yun,, JIN Xiao, YE Song,
Department of Anesthesiology, Ningbo Women and Childrens Hospital, Ningbo 315012, China
通信作者 叶松(1975-),男,四川宜宾人,教授,学士,主要研究方向:小儿麻醉与产科麻醉。 E-mail:1537616302@qq.com。

作者简介 吴云(1985-),女,江西景德镇人,主治医师,硕士,主要研究方向:小儿麻醉与产科麻醉。E-mail:47955181@qq.com。
中图分类号: R971.2;R614.2     文献标识码: B     文章编号: 1004-0781(2018)08-0973-04
摘要:

目的 评价超声引导下髂腹股沟/髂腹下神经阻滞联合腹直肌鞘阻滞在腹腔镜腹股沟疝囊高位结扎术中的应用效果。方法 选取2016年1—12月间在宁波市妇女儿童医院行腹腔镜下腹股沟疝囊高位结扎术的手术患儿50例,美国麻醉医师协会(ASA)I级、年龄4~8岁,按随机数余数分组法分为超声组(U组)和骶管神经阻滞组(C组),每组25例,均采用丙泊酚、芬太尼诱导七氟烷维持、喉罩,机控呼吸的麻醉方法。U组两侧4个位点分别行超声引导下神经阻滞并注入0.15%罗哌卡因混合液0.1 mL·kg-1,C组行骶管神经阻滞并注人相同局麻药0.75 mL·kg-1。采用北美疼痛行为评估量表(CHEOPS)按评分对患儿在术后恢复室(PACU)的不同时间点及回到病房后的每个时间点做术后疼痛评估,统计应用曲马多镇痛病例数,出院前对患儿家长行满意度调查。结果 U组患儿在PACU、回病房后4及8 h的疼痛评分与C组比较,差异无统计学意义(P>0.05),且回病房后需要曲马多镇痛:U组7例;C组6例,差异无统计学意义(P>0.05)。U组患儿家长满意度评分3(2,3)与C组3(3,3),差异无统计学意义(P>0.05)。两组患儿术中及术后均无其他不良反应发生。结论 对于儿童腹腔镜疝囊高位结扎术,超声引导下的髂腹股沟/髂腹下神经阻滞联合腹直肌鞘阻滞能提供和骶管神经阻滞相当的镇痛效果。
关键词: 髂腹股沟/髂腹下神经阻滞 ; 腹直肌鞘阻滞 ; 小儿疝高位结扎术

Abstract:

Objective To assess application effect of ultrasound guided-guided ilioinguinal/iliohypogastric (IiN/IHN) nerve blocks combined with rectus sheath block (RSB) with local anesthetic (LA) in high ligation of pediatric hernia by using laparoscope. Methods Fifty children aged 4-8 years scheduled for surgery were included in the study. After induction of general anesthesia and prior to surgical incision, patients were prospectively randomized into one of two groups: Group U received US-guided IiN/IHN and RSB with 0.1 mL·kg-1 of 0.15% ropivacaine; Group C received a caudal block with 0.75 mL·kg-1 of 0.15% ropivacaine. CHEOPS was used for pain assessment of the patients at PACU and public ward. Number of cases using tramadol was recorded. Parental satisfaction was surveyed before discharge. Results The average pain scores during hospital stay were not significantly different between group U and group C (P>0.05). In recovery room, no patients required pain rescue medication in group C and group U. Seven patients in the group U and six patients in group C required pain rescue medication at stay unit (P>0.05). No other adverse reaction occurred in the two groups during and after the surgery. Conclusion US-guided IiN/IHN nerve block and rectus sheath block is an ideal postoperative analgesic for hernia repair surgery in children, and is as effective as caudal block.
Key words: Ilioinguinal/iliohypogastric nerve block ; Rectus sheath block ; High ligation of pediatric hernia

对于小儿腹腔镜疝气手术,应用骶管神经阻滞镇痛作用时间较短,运动神经较容易阻滞,且并发症较多;髂腹股沟/髂腹下神经阻滞联合在腹股沟区手术的应用越来越普及,同时兼顾了麻醉和术后镇痛的需求,而超声引导下进行神经阻滞较传统定位法可在直视的情况下看清穿刺针的路径及局麻药注射后药液的扩散和分布情况,从而提高阻滞效果、避免潜在并发症的发生,但是无法满足对于腹腔镜手术肚脐部位的镇痛,而腹直肌鞘阻滞能有效满足肚脐部位的镇痛[1,2,3,4,5,6,7]。为寻求更适合小儿腹腔镜疝高位结扎术的麻醉的方法,减少术中及术后的不良反应,笔者应用超声引导下髂腹股沟及髂腹下神经阻滞(ilioinguinal/iliohypogastric,IiN/IHN)联合腹直肌鞘阻滞(rectus sheath block,RSB)对比骶管神经阻滞在小儿腹腔镜疝高位结扎手术患儿的麻醉,对其效果及安全性进行分析。

1 资料与方法
1.1 临床资料

经医院伦理委员会通过,选取2016年1—12月间在宁波市妇女儿童医院行腹腔镜疝囊高位结扎手术患儿50例,美国麻醉医师协会(American Society of Anesthesiologists,ASA)I级、年龄4~8岁,患儿家长均签署麻醉知情同意书。手术种类为腹股沟斜疝疝囊高位结扎术,按随机数余数分组法将患儿分为超声髂腹股沟/髂腹下神经阻滞组联合腹直肌鞘阻滞(U组)和骶管神经阻滞组(C组),每组25例。两组患儿无心血管、呼吸系统及肝肾疾病,排除局部麻醉药过敏史、出凝血异常、神经系统疾病患儿。患儿家属均签署知情同意书,通过医学伦理委员会审查。

1.2 治疗方法

麻醉过程:患儿术前禁食6 h禁饮2 h,未予任何术前用药。入手术室后予以心电图、氧饱和度监护,全身麻醉诱导时面罩吸入8%七氟烷(上海恒瑞医药有限公司,批准文号:国药准字H20070172),保留患儿自主呼吸,待患儿意识消失,对疼痛无体动反应后,建立静脉通道,停止吸入七氟烷,以纯氧排除残余的麻醉气体,面罩吸氧3~5 min(氧流量6 L·min-1),依次静脉注射丙泊酚乳状注射液(广东嘉博制药有限公司,批准文号:国药准字H20133360)1.5~2.0 mg·kg-1、盐酸芬太尼注射液(宜昌人福药业有限责任公司,批准文号:国药准字H20030197)2 μg·kg-1,待患儿下颌松弛、睫毛反射消失时置入喉罩,行间隙正压通气,VT8 mL·kg-1,呼吸15 次·min-1,吸呼比1:2,呼吸末正压通气0.49 kPa,维持PETCO2 4.7~6.0 kPa。麻醉维持:调整七氟醚浓度维持在1.3mac。术毕清理患儿口腔分泌物,待患儿自主呼吸功能恢复,潮气量>8 mL·kg-1后拔除喉罩,面罩吸氧至患儿完全清醒送术后恢复室(postanesthesia care unit,PACU)观察。神经阻滞:U组使用台式彩色多普勒超声诊断仪(美国索诺声公司,型号m-turbo:),6~13 MHz线型超声探头(型号:SLAx),通过超声成像下辨别靶向神经和周围解剖结构。操作过程由两位擅长超声引导下神经阻滞的麻醉医师完成,患儿成功插入喉罩对位检查良好后,平卧,消毒铺巾,麻醉医生实施神经阻滞,于小儿患侧髂前上棘内侧用超声探头定位腹外斜肌、腹内斜肌、腹横肌,探头放置在髂前上棘内侧、脐与髂前上棘连线方向上,采用平面内法通过皮下组织、腹外斜肌、腹内斜肌向腹内斜肌与腹横机之间的髂腹下及髂腹股沟神经进针,待探针至于两肌肉筋膜间,回抽无血后注入0.15%盐酸罗哌卡因注射液(AstraZeneca AB,批准文号:国药准字H20140764)混合液0.1 mL·kg-1。双侧均进行阻滞;然后将探头横向放置在脐外侧水平,由内向外采用平面内技术进针,经过皮下组织,穿过腹直肌鞘前层,穿过肌肉直到针尖到达腹直肌鞘后层,回抽无血和气体,注射0.15%罗哌卡因混合液0.1 mL·kg-1,双侧均进行阻滞。对照C组对骶管进行穿刺,选择骶2-3或骶3-4垂直进针,有落空感或针尖触及骶管腹侧面,回抽无血液或脑脊液,将相同浓度的局麻药0.75 mL·kg-1注入骶管。

1.3 观察指标

比较两组手术持续时间,术后送PACU,由同一护士按北美疼痛行为评估量表(Children’s Hospital of Eastern Ontario Pain Scale,CHEOPS)评分[5]做术后疼痛评估,30 min内每10 min一次,随后转出PACU 8 h内每4 h测1次予以记录。术后镇痛持续时间及首次应用镇痛药时间等。

1.4 疗效判断标准

疼痛评分法:CHEOPS疼痛评分包含6项疼痛行为类型:哭闹、面部表情、言语、腿部运动、躯体活动、伤口可触摸程度。每个类别的分值为0~2或者是1~3,分值4~13分,总分低于6分认为无疼痛,总分大于6分则给予曲马多2 mg·kg-1缓慢静推,记录每组给予曲马多的例数。对家长行满意度调查。若哭闹较剧烈,家长安慰无效即为不满意;若偶有哭闹,家长安慰有效即为一般;若无哭闹,家长无需安慰即为满意,3种满意度分别按1,2,3分记录。

1.5 统计学方法

效能检验计算出50例病例可以提供80%的效力在0.05的显著性下检验出U组较C组需要镇痛比例下降50%。采用SPSS20.0版统计软件进行统计学分析,计数资料以例数表示,组间比较采用卡方检验;对于计量资料,成正态分布的资料以均数±标准差( x ¯ ±s)表示,用t检验进行分析,成偏态分布的资料以中位数(最小值~最大值)表示,用Mann-Whitney秩和检验进行分析。以P<0.05为差异有统计学意义。

2 结果
2.1 临床观察指标结果

超声引导下髂腹下及髂腹股沟神经阻滞联合腹直肌鞘阻滞及骶管阻滞均在5 min内完成,成功率为100.0%。两组患儿年龄、体质量、性别、手术时间比较差异无统计学意义。见表1。PACU内因CHEOPS高于6分需要接受曲马多按2 mg·kg-1缓慢静脉推注的患者例数,两组均为0。见表2。

表1 两组患儿临床资料比较
Tab.1 Comparison of baseline data between two groups of pediatric patients x¯±s,n=25
组别 性别 年龄/
岁		 体质量/
kg		 手术时间/
h
男/例 女/例
U组 22 3 4.66±1.74 15.9±3.72 10±1.22
C组 21 4 4.48±1.57 16.2±3.31 11±1.13

表1 两组患儿临床资料比较

Tab.1 Comparison of baseline data between two groups of pediatric patients x¯±s,n=25

表2 两组患儿镇痛评分比较
Tab.2 Comparison of analgesic effect between two groups of pediatric patients 分,n=25
项目 术前
评分		 PACU内
首次评分 10 min 20 min 30 min 加曲马多例数
U组 0 2 2 2 2 0
C组 0 2 2 2 2 0
项目 PACU外
4 h 8 h 加曲马多例数 家长满意度
U组 5 4 7 3
C组 5 4 6 3

表2 两组患儿镇痛评分比较

Tab.2 Comparison of analgesic effect between two groups of pediatric patients 分,n=25

2.2 不良反应

术后未发生不良反应,无严重并发症发生。

3 讨论

骶管神经阻滞通常能提供4~6 h的镇痛效果,并发症有诸如穿刺进入骨髓腔,穿破硬脊膜及局麻药中毒。存在中枢神经系统疾病,脊髓病变或者神经阻滞部位的感染或凝血功能紊乱情况都是骶管神经阻滞的

禁忌证,所以需要找到一个镇痛效果相当的麻醉方式。髂腹下神经及髂腹神经阻滞联合腹直肌鞘阻滞能使用较少的局麻药提供类似的镇痛效果,尤其是在超声定位指导下的应用。尽管使用很普遍,但是在一些医院其成功率只有70%~80%[8,9,10,11]。其相关并发症有结肠小肠穿孔、盆腔血肿、股神经麻痹股四头肌瘫痪。本研究中超声引导下使用更少剂量的局麻药达到好的髂腹下神经和髂腹股沟神经阻滞、腹直肌鞘阻滞效果,失败率为0,且无并发症。国内的腹腔镜技术需要在肚脐打孔,所以仅仅进行腹股沟区的麻醉镇痛是不够的,还要进行脐部的镇痛,所以本研究中复合了腹直肌鞘阻滞,国外的腹腔镜疝气手术方式有所不同,大都不会在脐部打孔,所以仅仅进行腹股沟区的阻滞即可。WEINTRAUD等[3]研究发现传统标记定位方法行髂腹下神经和髂腹股沟神经阻滞局麻药注射至正确的解剖位置比例只有14%,所有整体的髂腹下神经和髂腹股沟神经阻滞成功率只有61%。BHATTARAI等[12]的前瞻性随机对照研究比较了超声引导下和传统定位标记法进行髂腹下神经和髂腹股沟神经阻滞的有效性,显示超声引导下神经阻滞成功率显著高于传统法,切皮引起的血流动力学波动比例下降,且术后复苏室使用镇痛的人数显著下降。进一步的研究发现使用超声引导下神经阻滞局麻药的用量减少至0.075 mL·kg-1(传统法是0.3~0.5 mL·kg-1)。本文髂腹下神经和髂腹股沟神经阻滞所采用的局麻药剂量接近这个剂量。

BHATTARAI等[12]研究表明对于疝修补术,相比于骶管神经阻滞,髂腹下/髂腹股沟神经阻滞能提供更长的镇痛时间和术后更少的镇痛药。本研究结果显示两种镇痛方法对于术后第一阶段的疼痛评分下降无区别。ABDELLATIF等[13]研究显示超声引导髂腹下神经或者髂腹股神经阻滞组有16例行腹股沟疝修补术的患儿,这些患儿术后首次需要镇痛的时间明显比这组睾丸下降固定术的患儿晚。区别可能是因为睾丸手术皮肤镇痛平面需要到达L1-2,即需要阻滞生殖股神经,而髂腹股沟神经阻滞仅仅阻滞到L1平面。但此研究的缺陷在于纳入的手术类型有腹股沟斜疝手术和睾丸下降固定术,对于术后镇痛评分比较会有所影响;另外使用的超声是索诺声S-180,相比较于最新的超声机器分辨率还不是最好的。本研究组中手术种类只有腹腔镜下疝囊高位结扎术,无睾丸手术,更具有可比性。类似的是在复苏室术后镇痛的剂量两组间差异无统计学意义;不良反应发生情况差异无统计学意义,术后3 h内无患儿发生腿部肌力减退。同样父母亲对两组麻醉镇痛技术的满意度差异无统计学意义。

综上所述,对于儿童单侧腹股沟区手术超声引导下的髂腹下/髂腹股沟神经阻滞联合腹直肌鞘阻滞能提供和骶管神经阻滞相当的镇痛效果。

The authors have declared that no competing interests exist.
参考文献
[1] NARASIMHAN J,LISA S,AMOD S,et al.Unilateral groin surgery in children:will the addition of an ultrasound-guided ilioinguinal nerve block enhance the duration of analgesia of a single-shot caudal block?[J].Pediatric Anesth,2009,19(2):892-898.
DOI:10.1111/pan.2009.19.issue-9      URL    
[本文引用:1]
[2] WILLSCHKE H,MARSHIER P,BOSENBERG A,et al.Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children[J].Br J Anesth,2005,95(3):226-230.
Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.
DOI:10.1093/bja/aei157      PMID:15923270      URL    
[本文引用:1]
[3] WEINTRAUD M,MARHOFER P,BOSENBERG A,et al.Ilioinguinal/iliohypogastric blocks in children:where do we administer the local anesthetic without direct visualization?[J].Anesth Analg,2008,106(5):89-93.
DOI:10.1213/01.ane.0000287679.48530.5f      URL    
[本文引用:2]
[4] NEAL J M.Assessment of lower extremity nerve block:reprise of the Four P's Acronym[J].Reg Anesth Pain Med,2002,27(3):618-620.
Abstract BACKGROUND AND OBJECTIVES: Successful performance of lower-extremity regional anesthesia includes sensory and/or motor block assessment of up to 4 major peripheral nerves. This brief report describes a methodology for the rapid evaluation of lower-extremity anesthesia before surgical incision. METHODS: Illustrations highlight the techniques for evaluation of sciatic, obturator, lateral femoral cutaneous, and femoral nerve anesthesia. This methodology is based on a Four P's acronym: push, pull, pinch, punt. CONCLUSIONS: Accurate assessment of lower-extremity regional anesthesia can be achieved rapidly using The Four Ps evaluation tool.
DOI:10.1053/rapm.2002.37411      PMID:12430115      URL    
[本文引用:1]
[5] YILDIZ T S,KORKMAZ F,SOLAK M.Clonidine addition prolongs the duration of caudal analgesia[J].Acta Anaesthesiol Scand,2006,50(4):501-504.
Abstract Background:68 In this study, using a dose-ranging design, we examined the effects of clonidine with 0.125% bupivacaine on the duration of post-operative analgesia in caudal anaesthesia in children. Methods:68 We conducted a controlled, prospective study of clonidine in caudal anaesthesia in 60 children, aged 1–10years, undergoing elective inguinal hernia repair. Induction and maintenance of anaesthesia were performed by inhalation of sevoflurane and nitrous oxide. The children were randomized in a double-blind fashion to four groups, and were given a caudal anaesthetic with either 0.125% plain isobaric bupivacaine (1ml/kg) or bupivacaine plus 1, 1.5 or 208g/kg of clonidine. The blood pressure and heart rate were recorded peri-operatively. Analgesia was evaluated by the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) or a visual analogue scale (VAS). Paracetamol was given when the mCHEOPS score was greater than five or when the VAS score was greater than 30mm. The monitoring of scores for pain, haemodynamic changes and post-operative nausea and vomiting was performed by nurses blind to the study allocation. Results:68 The duration of analgesia was found to be significantly longer in the group given bupivacaine plus 208g/kg of clonidine (median, 650min; range, 300–900min). Peri-operative hypotension and bradycardia, post-operative respiratory depression and motor block were not recorded in any patient. Conclusions:68 The addition of clonidine to 0.125% bupivacaine prolongs the duration of post-operative analgesia without any respiratory or haemodynamic side-effects.
DOI:10.1111/j.1399-6576.2005.00941.x      PMID:16548864      URL    
[本文引用:2]
[6] LIM S L,NGSB A,TAN G M.Ilioinguinal and iliohypogas-tric nerve block revisited:single shot versus double shot technique for hernia repair in children[J].Paediatr Anaesth,2002,12(4):255-260.
DOI:10.1046/j.1460-9592.2002.00832.x      URL    
[本文引用:1]
[7] AMORY C,MARISCAL A,GUYOT E.Is ilioinguinal/ilio-hypogastric nerve block always totally safe in children?[J].Paediatr Anesth,2003,13(2):164-166.
Summary We report a case of accidental puncture of the small bowel during an ilioinguinal/iliohypogastric nerve block procedure for hernia repair. The diagnosis was made a few days later during a laparoscopic exploration owing to the progressive onset of clinical and radiological intestinal obstruction. A large, obstructing subserosal haematoma was found without any apparent perforation of the mucosa, and the damaged loop was resected. Such a complication has already been reported once in the literature after use of a long bevel needle for the puncture. This case is the first reported using an atraumatic short bevel needle. We discuss the technical aspects of the procedure and underline the fact that regional anaesthesia in children is never totally risk free.
DOI:10.1046/j.1460-9592.2003.01005.x      PMID:12562490      URL    
[本文引用:1]
[8] VAISMAN J.Pelvic hematoma after an ilioinguinal nerve block for orchialgia[J].Anesth Analg,2011,92(4):1048-1049.
ABSTRACT lioinguinal nerve block may be performed for ei- ther diagnosis of nerve entrapment in patients with chronic pelvic pain (1) or as part of regional anesthesia/analgesia when surgery of the inguinal area is contemplated. In many patients complaining of chronic orchialgia, the source of pain may be elusive, despite extensive diagnostic work-up (2). In this case, a local anesthetic block of the ilioinguinal nerve was helpful in the diagnosis of referred testicular pain. Reported herein is a case of a small, retroperitoneal pelvic hematoma after the performance of this block.
DOI:10.1097/00000539-200104000-00045      PMID:11273948      URL    
[本文引用:1]
[9] GHANI K R,MCMILLAN R.Transient femoral nerve palsy following ilioinguinal nerve blockade for day case inguinal hernia repair[J].J R Coll Surg Edinb,2002,47(1):626-629.
[本文引用:1]
[10] EREZ I,SHENKMAN Z.Quadriceps paresis in pediatric groin surgery[J].Pediatr Surg Int,2012,18(2):157-158.
A total of 2,624 groin operations were performed in 2,202 infants and children aged 6 months 14 years during the last 4.5 years. Preventive analgesia was used in all operations, and included ilioinguinal and iliohypogastric nerve block combined with inguinal canal infiltration. In 6 patients transient postoperative quadriceps muscle paresis (QMP) was noted. They required bed rest and monitoring for a few hours, and complete spontaneous recovery was noted in all cases. The aim of this study was to examine the incidence of transient QMP following regional nerve block and to discuss models of possible prevention.
DOI:10.1007/s003830100652      PMID:11956784      URL    
[本文引用:1]
[11] WILLSCHKE H,BOSENBERG A,MARHOFER P.Ultra-sonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia:what is the optimal volume?[J] .Anesth Analg,2016,102(6):1680-1684.
[本文引用:1]
[12] BHATTARAI B K,RAHMAN T R,SAH B P.Analgesia after inguinal herniotomy in children:combination of simplified (single puncture) ilioinguinal and iliohypogastric nerve blocks and wound infiltration vs. caudal block with 0.25% bupivacaine[J].Kathmandu Univ Med J (KUMJ),2015,11(2):208-211.
[本文引用:2]
[13] ABDELLATIF A A.Ultrasound-guided ilioinguinal/iliohy-pogastric nerve blocks versus caudal block for postoperative analgesia in children undergoing unilateral groin surgery[J].Saudi J Anaesth,2012,91(6):1047-1049.
[本文引用:1]
资源
摘要
PDF下载数    
RichHTML 浏览数    
摘要点击数    
分享
导出
EndNote | Ris | Bibtex
相关文章:
关键词（key words）
髂腹股沟/髂腹下神经阻滞
腹直肌鞘阻滞
小儿疝高位结扎术
Ilioinguinal/iliohypogast...
Rectus sheath block
High ligation of pediatri...
作者
吴云
金啸
叶松
WU Yun
JIN Xiao
YE Song