[目的]将超声引导下腹壁神经阻滞（包括腹横肌平面阻滞和腹直肌鞘阻滞）联合瑞芬太尼应用于合并心血管疾病行腹膜透析置管术患者,通过观察镇痛效果及不良反应,探讨其有效性及安全性。[方法]选择60例ASAⅢⅣ级合并心血管疾病拟行择期腹膜透析置管术的患者,随机分为生理盐水组（R0组,术中泵注同等容积的生理盐水）和瑞芬太尼组（R1组,术中血浆靶控输注瑞芬太尼2 ng/ml）。R0组、R1组患者行腹壁神经阻滞前即开始分别泵注生理盐水、瑞芬太尼,两组患者均待手术结束时停止输注。达到预设靶浓度后行超声引导下术侧腹横肌平面阻滞（注射0.3%罗哌卡因20ml）和腹直肌鞘阻滞（0.3%罗哌卡因8ml）。记录观察两组术前（To）、腹壁神经阻滞穿刺时（T1）、切开皮肤时（T2）、钝性分离肌肉时（T3）、提起及切开腹膜时（T4）、置入腹膜透析导管时（Ts）、打皮下隧道时（T6）、缝皮时（T7）的生命体征、警觉/镇静（OAA/s）评分、疼痛评分（采用数字评分法vAs评分）。记录观察需要补救例数、转全麻例数及患者满意度。同时观察围术期不良反应及并发症的发生率（包括腹壁神经阻滞穿刺并发症、瑞芬太尼副作用、术中及术后24h心血管不良事件）。[结果]两组患者均顺利完成手术,未出现需要转全身麻醉患者。R,组术中平均动脉压、心率、呼吸频率、OAA/s评分均较术前呈明显下降趋势,且与R0组相比具有统计学意义（p<0.05）,但两组患者血氧饱和度比较无显著差异（p>0.05）。R1组患者T3-7时段vAs评分较R0组明显减低（p<0.05）,但两组患者术后24h vAs评分比较,差异无统计学意义（p>0.05）。R1组患者满意度明显增加（73%vs.47%）,需要补救人数明显减少（5人vs.11人）（p<0.05）。两组患者不良反应及并发症发生率无显著差异（p>0.05）。[结论]腹壁神经阻滞可为腹膜透析置管术患者提供确切有效的镇痛。瑞芬太尼通过其镇静镇痛作用,可显著减轻此类患者术中疼痛、增加患者满意度,且不增加不良反应及并发症发生率。故腹壁神经阻滞联合瑞芬太尼应用于合并心血管疾病行腹膜透析置管术患者是安全且有效的。 

Objective: To observe the analgesic effect and adverse reactions of ultrasound-guided abdominal wall nerve block (including transversus abdominal plane block and rectus sheath block) combined with remifentanil for cardiovascular patients receiving peritoneal dialysis catheter implantation , and explore its efficacy and safety.
Methods: A total of 60 cardiovascular patients (ASA physical status III 〜IV) ,scheduled for elective peritoneal dialysis catheter implantation ,were randomly divided into normal saline group (group R_0)and remifentanil group (group R_1). Before abdominal wall nerve block , Group R_1 were infused with a target controned infusion (TCI) of remifentanil at 2ng∕ml while the group R_0 were infused with the same volume of normal saline. Remifentani or normal saline stopped at the end of the operation.
The patients were both treated with unilateral transversus abdominal plane block (0.3% ropivacaine 20ml) and rectus sheath block (0.3% ropivacaine 8ml) under ultrasound-guidance. Mean arterial pressure(MAP), respiratory rate(RR) , heart rate (HR), SpO2, alertness/ sedateon(OAA∕S) scale and pain scores (VAS) were recorded at the different time during the operation: pre-block(T_0), during nerve wock(T_1) , skin incision(T_2) , muscle separation (T_3) , lifting and incising peritoneum(T4) , catheteriZatiOn(T5) , forming subcutaneOus tunnel (Тб) , skin cIosure(T7). The number of patients alterating to general anesthesia and requiring remediation, the satisfaction to the effect anesthesia by the patients needed to be recorded. The occurrence of adverse events related to abdominal wall nerve block and remifentanil were also recorded. Incidence of adverse cardiac events were recorded intraoperative and 24 hours postoperative.
Resuits: All patients successfuny completed the operation, and no patient needed to be transferred for general anesthesia. MAE HR, RR in the R_1 Group were significantly lower than in the R_0 Group ( p <0.05) ,while there was no significant difference in SpO2 between the two groups (p>0.05) . The VAS scores at the time points of T_3-7 were significantly Iower than in the R_1 Gfoup compared to the R_0 Group. There were no significant changes in the VAS scores at 24 hours after surgery (p>0.05 ) . The R_1 Group showed a higher satisfaction of the patients (73%vs.47% ) and needed less remediation ( 5 patients vs. 11patients ) ( p<0.05 ) . There were no relevant differences in adverse reactions and complications (p>0.05).
Conclusion: Abdominal wall nerve block can provide effective analgesia for patients undergoing peritoneal dialysis catheter implantation . sedative and analgesic effects of. remifentanil can significantly relieve pain during operation, improve the patient experience and not increase the incidence of adverse reactions and complications.
Abdominal wall nerve block combined with remifentanil is safe and effective for cardiovascuIar patients in peritoneal dialysis catheter implantation.