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1、腹横肌平面阻滞在腹部手术术后镇痛中的应用研究,麻醉学论文麻醉学毕业论文优选范文10篇之：腹横肌平面阻滞在腹部手术术后镇痛中的应用研究 内容摘要： 正 疼痛是手术应激反响的重要表现，是术后预后不良的预测指标之一。腹部手术的疼痛主要产生于前腹壁，可通过采用多形式镇痛如曲马多、非甾体类抗炎药复合静脉应用阿片类药物得以缓解。阿片类药物常以病人自控镇痛patient controlled analgesia,PCA方式静脉给药，但因众多副作用如恶心呕吐、过度镇静、皮肤瘙痒、尿潴留 疼痛是手术应激反响的重要表现，是术后预后不良的预测指标之一。腹部手术的疼痛主要产生于前腹壁，可通过采用多形式镇痛如曲马多、非
2、甾体类抗炎药复合静脉应用阿片类药物得以缓解。阿片类药物常以病人自控镇痛patient controlled analgesia,PCA方式静脉给药，但因众多副作用如恶心呕吐、过度镇静、皮肤瘙痒、尿潴留、抑制呼吸和胃肠道功能，使其临床应用遭到一定的限制。因而，减少阿片类镇痛药的应用已成为术后快速康复的重要措施之一1.区域阻滞椎管内或外周神经阻滞是术后镇痛常用的替代方式方法或辅助措施。而硬膜外阻滞镇痛可引起血管扩张、低血压、内脏灌注缺乏、运动阻滞致活动受限，甚至有文献报道硬膜外镇痛有时是恶化预后的原因2. 近年研究表示清楚，腹横肌平面transversus abdominis Plane,TAP阻
3、滞能够成功阻滞腹部外周疼痛信号的传导，有效缓解疼痛。选择TAP阻滞作为腹腔镜手术多形式镇痛的重要组成部分，能够明显减轻患者术后疼痛，减少阿片类药物的使用，促进术后康复。现就腹横肌平面阻滞在腹部手术患者术后镇痛中的应用阐述如下。 1 腹横肌平面阻滞的解剖学 腹部正前方肌肉主要由腹直肌及其腱鞘构成，腹壁前外侧的肌肉由外及里依次为腹外斜肌、腹内斜肌、腹横肌，肌肉之间为筋膜层；腹内斜肌与腹横肌之间的平面称为腹横肌平面。 腹前部的皮肤、肌肉及壁层腹膜由T7L1脊神经的前支支配，这些神经离开椎间孔后发出分支穿过侧腹壁肌肉，沿腹横肌平面走行，然后继续往前进入腹直肌层，再发出前分支支配腹中线附近肌肉和皮肤；T
4、6T9神经过腋前线的内侧进入TAP,T9L1起源的神经则在内腋前线外侧走行进入TAP3.通过对尸体的解剖发现，肋间、肋下、髂腹下神经在通过侧腹壁向前内侧移动中在腰三角区域有一段共同的通路4,而且不同节段的神经在TAP存在广泛的分支和交通，尤其是T9L1分支组成的TAP神经丛，其与旋髂深动脉伴行。因而，在TAP平面注射局麻药，能够阻滞相对应神经疼痛信号的传导。 2 腹横肌平面阻滞操作方式方法 2.1 体表定位的 盲穿法 标准盲穿法最早由Rafi5于2001年描绘叙述，之后由Mc Donnell等6进一步改良。此法主要根据腹部的解剖构造而将穿刺针置于TAP.首先确定Petit三角Trangle o
5、f petit，Petit三角是以髂嵴为下界，腹外斜肌的边缘为前界，背阔肌边缘为后界所围成的一类似三角形的区域。其定位方式方法：先确定髂嵴，再确定腹外斜肌边边缘，然后由前向后直到触及背阔肌边缘。在髂嵴上方，腋后线上方Petit三角区域垂直于皮肤穿刺进针，当感觉到两次落空感或阻力消失表示穿刺针到达TAP区域。有关TAP阻滞对改善腹腔镜手术镇痛效果的随机对照临床研究的荟萃分析31,以为TAP阻滞可减轻术后早期和晚期的静息疼痛，减少阿片类药物的用量，手术切皮前施行TAP阻滞效果更佳。 但也有文献32报道，TAP阻滞应用于腹腔镜子宫切除术并不能改善术后恢复质量以及降低VAS疼痛评分和减少镇痛药的用量。
6、 总而言之，大多数学者以为，腹腔镜手术采用TAP阻滞进行术后镇痛可获得良好的镇痛效果，减少术后阿片类药物的用量，促进患者术后康复。 5.3 连续TAP阻滞用于腹部手术术后镇痛 由于单次TAP在4 h开场减退，24 h阻滞效果完全消失6.因而，能否通过导管输注局麻药而延续TAP阻滞时间和效果，这是近年研究的热门。Heil等33具体描绘叙述了超声辅助下置入导管行连续肋缘下TAP阻滞，其方式方法是通过导管分别以每侧4 ml/h速度持续输注0.2%罗哌卡因至术后72 h,每4 h对患者进行疼痛评分。结果表示清楚持续TAP阻滞能提供完善的镇痛效果。此后多位学者尝试不同方式方法施行连续TAP阻滞用于腹部手
7、术术后镇痛，均获得不同程度的镇痛效果34,35.但有关通过导管行持续TAP阻滞应用于临床的文献仍然很少。因而，通过导管输注局麻药的安全浓度、剂量以及输注速度有待更多的临床研究予以确定。尽管如此，现有的研究已表示清楚持续TAP阻滞在一定情况下能够替代持续硬膜外镇痛。 6 TAP阻滞的并发症 业已证明，TAP阻滞由经过培训的操作者施行是相当安全的。迄今为止，文献只报道了少见的严重并发症。一般并发症包括36:针创伤、腹腔内注射、神经缺血、局麻药意外注入血管、局麻药毒性反响、感染、股神经麻木、阻滞效果不好。据文献报道37,38,体表定位盲穿法和超声引导下TAP阻滞可误穿肝脏，可能的原因是：穿刺位置过高
8、，没能确认针尖位置，没能识别清楚落空感而导致腹腔内穿刺。即便在超声引导下，但若在TAP内过度移动穿刺针也会增加神经和血管损伤的风险。 7 小结 腹横肌平面阻滞用于腹部手术尤其是腹腔镜手术术后镇痛，具有确切的镇痛效果，可减少术后阿片类药物用量，有利于肠道功能的恢复，促进患者术后康复之优点。但此技术需要在超声引导下进行方可保证其阻滞效果，因而当前尚没有能广泛开展。连续TAP阻滞已获得一定成功，有助于延长镇痛时间，但双侧持续TAP阻滞因局麻药用量较大，仍有发生局麻药中毒之风险。至于双侧持续TAP阻滞的局麻醉药安全浓度、剂量及注射速度仍有待更多的临床研究予以确定。TAP阻滞操作不当，仍可发生与穿刺相关
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