超声引导下TAPB与RSB用于小儿急诊腹腔镜阑尾切除术后的镇痛效果比较OA

Objective:To compare the analgesic effects of ultrasound-guided transversus abdominis plane block(TAPB)and rectus abdominis sheath block(RSB)for pediatric emergency laparoscopic appendectomy in children.Methods:A total of 92 children aged 2 to 9 years with American Society of Anesthesiologists(ASA)physical status Ⅰ or Ⅱ who underwent emergency laparoscopic appendectomy in our hospital from April 2023 to April 2024 were enrolled.The exclusion criteria included appendiceal suppuration,periappendiceal abscess,major organ diseases,systemic immune diseases,hematological diseases,infectious diseases,mental disorders and malignant tumors.The children were randomly divided into the TAPB group and the RSB group,with 46 cases in each group.Both groups were examined with a Mindray M7 color ultrasound system in B-mode,with a probe frequency of 5～10 MHz,a gain of 60～80 dB,and a resolution of 0.1～0.5 mm.For the TAPB group,the child was placed in the supine position,and the abdominal area near the costal margin was exposed.The ultrasound probe was placed between the costal margin and the iliac crestnear the anterior axillary line to identify the external oblique muscle,internal oblique muscle,transversus abdominis muscle and rectus abdominis muscle,and to find the optimal puncture position laterally.After accurate positioning,the probe was fixed,and a puncture needle was inserted using the in-plane technique.No blood was aspirated before injecting 1～2 mL of normal saline.After visualizing the abdominal wall muscle groups,0.2 mL/kg of 0.25％ropivacaine was injected with no blood aspiration again.The position of the needle tip was adjusted under ultrasound guidance to ensure sufficient diffusion of the drug solution.For the RSB group,the in-plane technique was adopted for puncture at 2 cm lateral to the umbilical level.The needle passed through the subcutaneous tissue and the anterior layer of the rectus abdominis sheath,with the tip reaching the posterior layer of the rectus abdominis sheath,and 0.2 mL/kg of 0.25％ropivacaine was injected with no blood aspiration.Hemodynamic indexes(mean arterial pressure,heart rate),postoperative pain degree(FLACC score),comfort level(BCS score),stress response indexes(cortisol,norepinephrine),rescue analgesia rate and adverse reactions(nausea,vomiting,dizziness,agitation)were observed and compared between the two groups.Results:There were significant differences in mean arterial pressure and heart rate between the two groups at the time of block completion,admission to the post-anesthesia care unit(PACU)and discharge from the PACU(P＜0.05).The FLACC scores of the TAPB group at 2 h,6 h,12 h and 24 h after surgery were 2.51±0.57,2.93±0.66,3.35±0.71 and 2.17±0.48,respectively,which were significantly lower than those of the RSB group(2.75±0.53,3.20±0.69,3.77±0.84,2.45±0.50,all P＜0.05).The BCS scores of the TAPB group at the above time points were 3.37±0.37,3.20±0.40,3.11±0.43 and 3.49±0.22,respectively,which were significantly higher than those of the RSB group(3.26±0.32,3.06±0.37,2.94±0.35,3.32±0.30,all P＜0.05).The serum levels of cortisol and norepinephrine in both groups were significantly increased at 1 day after surgery compared with the preoperative levels(P＜0.05),and the levels in the TAPB group were significantly lower than those in the RSB group(P＜0.05).The rescue analgesia rate of TAPB group was significantly lower than that of RSB group(P＜0.05),while there was no significant difference in the incidence of adverse reactions between the two groups(P＞0.05).Conclusion:Ultrasound-guided TAPB exerts a better analgesic effect than ultrasound-guided RSB in pediatric patients undergoing emergency laparoscopic appendectomy.It can effectively alleviate postoperative pain and stress response,improve the comfort level,reduce the rescue analgesia rate,and has a similar safety profile to RSB,which is worthy of clinical promotion and application.The superior effect of TAPB is due to its high precision in nerve block:it can clearly display the distribution of abdominal muscles and nerves,and accurately locate and block the subcostal,iliohypogastric and ilioinguinal nerves under ultrasound guidance,thus achieving precise and effective analgesia.Compared with RSB,TAPB is easier to perform,with more uniform drug diffusion and more definite analgesic effect.