Clinical effect of percutaneous nephrolithotomy and perioperative pain management under local anesthesia
ZHANGJin1, XIE Jianjun1,2, WANG Weiguo1, LU Jianlin1, CAI Chunjie1, HU Qin1, DENG Junpeng2
1Department of Urology, Suzhou Science & Technology Town Hospital Affiliated to Nanjing Medical University, Suzhou 215153, China; 2Department of Urology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University
摘要目的：观察局麻(local anesthesia, LIA)经皮肾镜取石术的临床疗效,探讨局麻下经皮肾镜取石术术中疼痛管理策略。方法：2018年10月–2020年10月,60例肾结石及输尿管上段结石患者入组此项研究,按麻醉方式分为LIA组（n=30）、GA（general anesthesia）组（n=30）。比较两组患者的基线资料及围术期资料（性别、年龄、BMI、ASA分级、结石情况、结石直径、手术时间、住院时间、住院费用、术后2 h及4 h VAS评分、血流动力学指标等）。观察LIA组患者术中不同时间点的视觉模拟疼痛评分(VAS)和血流动力学指标。结果：两组患者均I期完成取石术,无肾盂肾盏撕裂穿孔,无结肠损伤、胸膜损伤等严重并发症,全麻组2例行介入血管栓塞术,无死亡病例。LIA组平均手术时间少于GA组[（100.0±6.7）min vs. (120.0±8.6)min,P<0.05],LIA组平均住院时间短于GA组[（6.8±0.5)d vs. (10.6±1.2)d,P<0.05],LIA组平均住院费用少于GA组[（18 263±981)元vs. （22 673±1 477）元,P<0.05],两组患者术后2 h和术后4 h的VAS评分比较显示,LIA组均高于GA组[（6.1±2.0分 vs. 5.0±1.0分）,（4.6±1.0分vs. 4.4±1.4分）,P<0.05],但均在可忍受范围。LIA组术中不同时间点VAS评估显示,术中撬动工作鞘时疼痛评分最高,扩张通道时次之,截石位留置输尿管导管时最低[（7.6±1.5) vs. (6.2±1.3) vs. (4.5±1.2),P<0.05]。对于LIA组VAS>7分患者启动术前防止疼痛预案,采取暂停手术,予以丙泊酚25~50 mg·kg-1·min-1静脉泵入等措施,疼痛均明显缓解,采用修订版面部表情疼痛量表(FPS-R)重新评分,待FPS-R<4分后继续完成手术。结论：局麻和全麻经皮肾镜取石术均可获得较好的麻醉效果和治疗效果,但局麻提供了更低的成本、更快的恢复和更短的住院时间。局麻经皮肾镜取石术术中撬动工作鞘时患者疼痛最明显,术前充分准备预防疼痛预案并及时启动预案可同样取得良好效果。
Abstract：Objective： To observe the clinical effect of percutaneousnephrolithotomy （PCNL） under local anesthesia （LIA）, and to explore the pain management strategy in local anesthesia. Methods： From October 2018 to October 2020, 60 patients with kidney stones and upper ureteral stones were enrolled in this study.The 60 patients were divided into LIA group （observation group, n=30） and general anesthesia （GA） group （control group, n=30）. General clinical data and perioperative clinical data （gender, age, body mass index, ASA grade, stone status, stone diameter, surgical time, hospital stay, hospitalization costs, 2-h and 4-h postoperative VAS scores, hemodynamic indicators, etc.） were compared. The intraoperative visual simulation score （VAS） and hemodynamic indicators at different time points in the LIA group were observed. Results： Thestage I lithotomy was successfully done in all groups. There was no perforation of pyelonephrine tear, and no serious complications such as colon injury and pleural injury occurred. Two patients underwent vascular interventional embolization in the GA group and there were no deaths. The mean surgical time in the LIA group was shorter than in the GA group （100.0 ± 6.7） vs. （120.0 ± 8.6） min, P < 0.05. The mean hospital stay in the LIA group was shorter than that in the GA group （6.8 ± 0.5） vs. （10.6 ± 1.2） d, P < 0.05. The average hospitalization cost in the LIA group was less than that in the GA group （RMB 18 263 ± 981） vs. （RMB 22 673 ± 1 477）, P < 0.05. VAS scores in LIA group at 2 h （6.1 ± 2.0） vs. （5.0 ± 1.0） and 4 h （4.6 ± 1.0） vs. （4.4 ± 1.4） were higher than those in GA group （P < 0.05）. VAS assessment at different time points in the LIA group showed the highest pain score when moving the working sheath, second when expanding the channel and the lowest when indwelling ureteral catheters （7.6 ± 1.5） vs. （6.2 ± 1.3） vs. （4.5 ± 1.2）,P<0.05. In LIA group with VAS>7 points, the preoperative pain prevention plan was carried out, the operation was suspended, propofol （25-50 mg·kg-1·min-1） was pumped intravenously, and the pain was significantly relieved. The revised facial expression pain scale （FPS-R） was rescored, and the operation was continued after FPS-R <4 points. Conclusion： The PCNL under local and general anesthesia can achieve better anesthesia and treatment effects, but local anesthesia provides lower cost, faster recovery, and shorter hospital stay.In PCNL under local anesthesia, the most obvious pain occurs when swinging the sheath.Fully preparing the pain prevention plan before the operation and timely triggering the plan can achieve preferable effect.
张锦, 谢建军, 王卫国, 卢建林, 蔡淳杰, 胡秦, 邓君鹏. 局麻下经皮肾镜取石术临床疗效观察及围术期疼痛管理研究[J]. 微创泌尿外科杂志, 2021, 10(6): 370-375.
ZHANGJin, XIE Jianjun, WANG Weiguo, LU Jianlin, CAI Chunjie, HU Qin, DENG Junpeng. Clinical effect of percutaneous nephrolithotomy and perioperative pain management under local anesthesia. JOURNAL OF MINIMALLY INVASIVE UROLOGY, 2021, 10(6): 370-375.
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