6、超声引导下髂腹下神经阻滞

Ultrasound-guidedtransversusabdominisplaneblock:descriptionofanewtechniqueandcomparisonwithconventionalsystemicanalgesiaduringlaparoscopiccholecystectomy†A.A.El-Dawlatly1,A.Turkistani1,S.C.Kettner2,A.-M.Machata2,M.B.Delvi1,A.Thallaj1,S.Kapral2andP.Marhofer2*1DepartmentofAnaesthesiaandIntensiveCareMedicine,KingSaudUniversity,CollegeofMedicine,Riyadh,SaudiArabia.2DepartmentofAnaesthesia,IntensiveCareMedicineandPainTherapy,MedicalUniversityofVienna,WaehringerGuertel18-20,A-1090Vienna,Austria*Correspondingauthor.E-mail:[e-mail]lane(TAP)blockisusuallyperformedbylandmark-basedmethods.Thisprospective,randomized,anddouble-blindedstudywasdesignedtodescribeamethodofultrasound-guidedTAPblockandtoevaluatetheintra-andpostoperativeanalgesicefficacyinpatientsundergoinglaparoscopiccholecystectomyundergeneralanaesthe-siawithorwithoutTAPblock.Methods.Forty-twopatientsundergoinglaparoscopiccholecystectomywererandomizedtoreceivestandardgeneralanaestheticeitherwith(GroupA,n¼21)orwithoutTAPblock(GroupB,n¼21).Ultrasound-guidedbilateralTAPblockwasperformedwithahighfrequentlinearultrasoundprobeandanin-planeneedleguidancetechniquewith15mlbupivacaine5mgml21oneachside.Intraoperativeuseofsufentanilandpostoperativedemandofmorphineusingapatient-controlledanalgesiadevicewererecorded.Results.Ultrasonographicvisualizationoftherelevantanatomy,detectionoftheshaftandtipoftheneedle,andthespreadoflocalanaestheticwerepossibleinallcaseswhereaTAPblockwasperformed.PatientsinGroupAreceivedsignificantlymoreintraoperativesufentanilandpostoperativemorphinecomparedwiththoseinGroupB[mean(SD)8.6(3.5)vs23.0(4.8)mg,P,0.01,and10.5(7.7)vs22.8(4.3)mg,P,0.05].Conclusions.UltrasonographicguidanceenablesexactplacementofthelocalanaestheticforTAPblocks.Inpatientsundergoinglaparoscopiccholecystectomyunderstandardgeneralanaesthetic,ultrasound-guidedTAPblocksubstantiallyreducedtheperioperativeopioidconsumption.BrJAnaesth2009Keywords:anaesthetictechniques,regional;equipment,ultrasoundmachines;surgery,laparoscopyAcceptedforpublication:February26,2009Althoughlaparoscopiccholecystectomyisconsideredtobeaminimallyinvasivesurgicalprocedurewithlowerperioperativepainscorescomparedwithopenprocedures,itisassociatedwithsignificantlevelsofpostoperativepain.12Usually,standardgeneralanaestheticisgiventopatientsundergoinglaparoscopiccholecystectomy.However,theuseofneuraxialanaesthesia3–5orofintra-peritoneallocalanaesthesia6hasbeenshowntoincreasetheefficacyofperioperativepaintherapyandreducetheconsumptionofopioiddrugs.Peripheralregionalanaes-thetictechniquescouldbeconsideredasanattractivealternativetocentralblocksorhigh-doseintraperitonealanaesthesia.Thetransversusabdominisplane(TAP)blockinvolvesthesensorynervesupplyoftheanterior–lateralabdominalwall,wheretheT7–12intercostalnerves,theilioinguinalandiliohypogastricnerves,andthelateralcutaneousbranchesofthedorsalramiofL1–3areblockedwithaninjectionoflocalanaestheticbetweenthe†ThestudywasperformedattheDepartmentofAnaesthesiaandIntensiveCareMedicine,KingSaudUniversity,CollegeofMedicine,Riyadh,SaudiArabia.#TheAuthor[2009].PublishedbyOxfordUniversityPressonbehalfofTheBoardofDirectorsoftheBritishJournalofAnaesthesia.Allrightsreserved.ForPermissions,pleaseemail:[e-mail]thesiaPage1of5doi:10.1093/bja/aep067BJAAdvanceAccesspublishedApril17,2009internalobliqueabdominalmuscle(IOAM)andthetrans-verseabdominalmuscle(TAM).7TAPblocksareper-formedforindicationssuchasCaesareandelivery,8bowelsurgery,9orretropubicprostatectomy.10Despitetheencouraginginitialresults,theTAPblockisnotwelldescribedintheliteratureintermsofblocktechnique,successrates,orlocalanaestheticplasmalevels.Sofar,theblockisperformedbyso-called‘pop’89or‘double-pop’7methodsintheanatomicalareaofthe‘Petit’tri-angle,whichislocatedbetweentheiliaccrest,thelatissi-musdorsi,andexternalobliqueabdominalmuscles(EOAM).Consequently,inadvertentneedlepositionswithsubsequentseverecomplicationsaredescribed.11DirectultrasonographicvisualizationoftheanatomyinvolvedandthespreadoflocalanaestheticcouldserveasanalternativetechniquetoperformaTAPblock.Onlyanec-dotalreportsareavailableabouttheuseofultrasoundforTAPblocks.1213Therefore,wedesignedaprospective,ran-domized,anddouble-blindedstudytodescribethefeasibilityofultrasound-guidedTAPblockandtocomparetheefficacyofultrasound-guidedTAPblocksforlaparoscopiccholecys-tectomyasapartofaconceptforbalancedanaesthesiawiththeconventionalmethodofstandardgeneralanaesthesia.MethodsAfterapprovalbytheEthicsCommitteeoftheKingSaudUniversityinRiyadh(SaudiArabia)andwritteninformedconsent,42patients(ASAIorII),undergoinglaparo-scopiccholecystectomy,wererandomlyassignedtoreceiveeitheracombinationofstandardgeneralanaes-theticwithanultrasound-guidedTAPblock(GroupA)orsolestandardgeneralanaesthetic(GroupB).Theanaesthe-siologistwhoperformedgeneralanaesthesiawasblindedtotheestablishmentofTAPblock.Exclusioncriteriawerebloodcoagulationpathologies,allergiesagainstamino-amidelocalanaesthetics,orin