| PartⅠAnalgesic efficacy of ultrasound-guided subcostal transverse abdominal plane blockObjective: To evaluate the analgesic efficacy on defined areas of the abdomen and back after ultrasound-guided subcostal transversus abdominis plane(TAP)block using 0.25% levobupivacaine 0.5 ml/kg.Methods: Twenty patients undergoing elective laparoscopic cholecystectomy,between 20 and 60 years of age with operative time <1h,received subcostal TAP block using 0.25% levobupivacaine 0.5ml/kg on the left side.Surgery started after one hour of observation.Sensory assessment was undertaken using pinprick and 75% ethyl alcohol at 10 min,20 min,30 min,1 hour,3 hours,and 12 hours after TAP block at 19 testing zones which were divided by anatomic landmark lines on abdomen and back.Efficacy of zone was defined as loss of cold temperature sensation or loss of pinprick pain sensation in more than 50% patients in that testing zone.Duration was determined by analgesia and loss of temperature sensation beginning within 30 minutes of TAP block placement lasting until time points of 1,3,12 h.All of the testing zones were divided as Group I effective at 20 minutes in less than 50% patients(0-50%),Group II >50-70% patients,Group III >70-90% patients,and Group IV >90-100% patients.Results Twenty patients meeting the study requirements were included.At each time points,the efficacy between four groups were significant different.Subcostal TAP had good efficacy and stable duration in zone 1,2,3,5,6.Conclusion Subcostal TAP block with 0.25% levobupivacaine0.5ml/kg dose provided effective analgesia in the anterior abdominal wall between medioventral line to anterior axillary line except the lateral upper abdominal region.Part Ⅱ Analgesic effects of different regions in abdomen and backside by the ultrasound-guided mid-axillary transverse abdominis plane blockObjective to find analgesic effects of different regions in abdomen and backside by the ultrasound-guided mid-axillary transverse abdominis plane block with 0.25% levobupivacaine 0.5ml/kg.Methods twenty ASA I orⅡpatients aged 18~64 yrs,unisex,BMI 20-27 kg/m2 and operated less one hour who scheduled for elective laparoscopic cholecystectomy were received ultrasound-guided mid-axillary transverse abdominis plane block with 0.25% levobupivacaine 0.5ml/kg,where block located in the left body.Patients should be observed for 1h and did operation after the block with the left body.Analgesic effects were measured by cold stimulation(75% alcohol)and needle point in different regions in the left abdomen and backside(surface markers divided the left body into 19 regions)after block,10 min,20min,30 min,1h,3h and 12 h.Analgesic effects were availability if 50% patients made reduced by cold stimulation or needle point pain in regions.If analgesic effects were availability in any two points of 10 min,20min and 30 min and any two points of 1h,3h and 12 h,analgesic effects are considered as stability.Groups were divided by the positive rate in 20 min point in different regions into 4 groups : group(<50)% positive rate,group(50-<70)% positive rate,group(70-<90)% positive rate,group(90-100)% positive rate.Results Twenty one patients were enrolled in the study.One patients were withdrawn due to operative time exceeding one hour.Thus twenty cases were analyzed.At twenty minutes point effective rates of group(50-70%)are 1,4zones,effective rates of group(70-<90%)are 7,9,10 zones,effective rates of group(90-100%)are 2,3,5,6zones and effective rates of group(<50%)are others.Effective rates of group(90-100)% were always higher than 50%,even 4 time points were in excess of 90% showed that block effects were stable in 2,3,5,6 regions and excellent;effective rates of group(70-<90)% were higher than 50% except 1h and 12 h time points;in group(50-<70)%,the effective rates were higher than 50% at 10 min and 20 min.Conclusion Mid-axillary transverse abdominis plane block analgesic effects are excellent and stability in 2,3,5,6 regions and have some significance in 7,9,10 regions.Part Ⅲ The investigation between imaging range and effects of subcostal transverse abdominal plane blockObjective to investigate the relation between imaging range and effects on abdomen and back by subcostal transverse abdominal plane block with levobupivacaine.Methods Ten volunteers with American Society of Anesthesiologists(ASA)grade I,age between 18 and 60 years,were recruited for this study.These volunteers received subcostal TAP block using 0.25% levobupivacaine mixed with 370 iopromide injection with 0.5ml/kg on one side(group A)and 0.15ml/kg on the other side(group B).Sensory assessment was undertaken using pinprick and 75% ethyl alcohol at 20 min,1 hour and 3 hours after TAP block at 19 testing zones which were divided by anatomic landmark lines on abdomen and back.Movable type C arm X-ray system was used to photo pictures at the time points of 10 min,20min,30 min,1h,2h and 3h after TAP block.After 3h,assessment would begin on the other side.Results The imaging range at the point of 20 min in group A shows that on the inner local anaesthetic diffused between midclavicular line and vertebral body with five volunteers,and could not diffuse across midclavicular line with five volunteers;on the outer(lateral)local anaesthetic diffused between vertebral body midpoint and vertebral plate midpoint with four volunteers,between vertebral anterior edge and vertebral body midpoint with four volunteers,and could not diffuse across vertebral anterior edge with two volunteers;on the head end local anaesthetic diffused on upper one third of the second lumbar vertebra with seven volunteers,on middle one third of the second lumbar vertebra with one volunteer,and on below one third of the second lumbar vertebra with two volunteers;on the trailing end local anaesthetic diffused on middle one third of the third lumbar vertebra with one volunteer,on upper one third of the fourth lumbar vertebra with four volunteers,on middle one third of the second lumbar vertebra with two volunteers,on below one third of the fourth lumbar vertebra with two volunteers,and on upper one third of the fifth lumbar vertebra with one volunteer.In group B shows that on the inner local anaesthetic diffused between midclavicular line and vertebral body with four volunteers,and could not diffuse across midclavicular line with six volunteers;on the outer(lateral)local anaesthetic diffused between vertebral anterior edge and vertebral body midpoint with two volunteers,and could not diffuse across vertebral anterior edge with eight volunteers;on the head end local anaesthetic diffused on below one third of the first lumbar vertebra with one volunteer,on upper one third of the second lumbar vertebra with one volunteer,on middle one third of the second lumbar vertebra with five volunteers,on below one third of the second lumbar vertebra with two volunteers,and on upper one third of the third lumbar vertebra with one volunteers;on the trailing end local anaesthetic diffused on upper one third of the third lumbar vertebra with one volunteer,on below one third of the third lumbar vertebra with one volunteer,on upper one third of the fourth lumbar vertebra with six volunteers,on middle one third of the fourth lumbar vertebra with two volunteers.The positive numbers of Seven and eleven zones at the 20 min time point between two groups were significantly different(P<0.05).Conclusion local anaesthetic limited in anterior and lateral abdominal wall of subcostal TAP can block not only anterior and lateral abdominal wall but also the small of the back.On the mechanism,paravertebral block can be excluded and the effect of blocking through the nerves can’t interpret all of the appearances,so some other mechanisms may be exist. |
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