尿毒症患者腹膜透析置管中TAP联合 腹直肌后鞘阻滞的局麻药 药代动力学与安全性

Pharmacokinetics and Safety of Local Anesthetics in TAP Combined with Posterior Rectus Sheath Block for Peritoneal Dialysis Catheter Placement in Patients with Uremia

摘要: 在尿毒症/终末期肾病(end-stage kidney disease, ESKD)患者接受腹膜透析(peritoneal dialysis, PD)置管时，超声引导腹横肌平面(transversus abdominis plane, TAP)阻滞已被用于麻醉替代或围术期镇痛的重要组成部分；联合腹直肌后鞘/腹直肌鞘(rectus sheath block, RSB)阻滞后，可进一步覆盖中线切口及导管隧道相关疼痛。需要注意的是，腹壁筋膜平面阻滞往往涉及较大体积局麻药注射，其系统吸收并不低。ESKD患者又常伴蛋白结合状态改变、酸碱与容量波动及心血管合并症，上述因素均可能影响游离药比例及毒性阈值，使相同给药剂量对应的局麻药系统毒性(local anesthetic systemic toxicity, LAST)风险上升。本文将术式限定于PD置管，整合TAP ± RSB在该场景下的局麻药药代动力学与临床安全性证据，并从“剂量–系统暴露–毒性信号”这一线索出发，提出个体化给药和监测思路，同时为后续PK-PD研究提供方法学参考。检索范围涵盖PubMed、Embase、CNKI等数据库，纳入PD置管相关随机对照试验、队列研究、病例系列及技术报告，并补充TAP/RSB血药浓度、药代学研究以及LAST和抗栓管理指南。现有研究提示，TAP在开放或腹腔镜PD置管中可取得较高麻醉成功率，并有助于减轻血流动力学波动；但出口位和隧道操作疼痛仍是常见薄弱环节，联合RSB或局部浸润后，关键步骤镇痛可进一步改善。已有血药浓度资料表明，TAP/RSB后峰浓度可偏高，且个体差异明显；在ESKD患者PD置管中，肋下TAP后罗哌卡因总浓度峰值可接近文献所述潜在毒性范围，但显性LAST事件并不多见，提示风险判断不能仅依赖最大推荐剂量，还需结合游离浓度、酸中毒及心衰等上游因素综合分析。总体而言，PD置管中TAP ± RSB的临床应用价值较为明确，而其可推广性的关键在于以药代学为基础实施暴露管理，包括采用最低有效毫克数、分次注射、必要时联合肾上腺素、避免双侧高剂量叠加，并在高危患者中建立规范的监测与脂质乳剂救治流程。

Abstract: In patients with uremia/end-stage kidney disease (ESKD) undergoing peritoneal dialysis (PD) catheter placement, ultrasound-guided transversus abdominis plane (TAP) block has been used as an important component of anesthetic substitution or perioperative analgesia. When combined with posterior rectus sheath/rectus sheath block (RSB), coverage may be further extended to midline incision pain and catheter tunnel-related pain. It should be noted that abdominal wall fascial plane blocks often involve injection of relatively large volumes of local anesthetics, and systemic absorption is not negligible. Patients with ESKD frequently present with altered protein binding, fluctuations in acid-base and volume status, and cardiovascular comorbidities, all of which may influence the free fraction of the drug and the toxicity threshold, thereby increasing the risk of local anesthetic systemic toxicity (LAST) at the same administered dose. Focusing specifically on PD catheter placement, this review integrates the available evidence on the pharmacokinetics and clinical safety of TAP ± RSB in this setting. Following the pathway of dose-systemic exposure-toxicity signals, it further discusses individualized administration and monitoring strategies and provides methodological reference for future PK-PD studies. The literature search covered PubMed, Embase, CNKI and other databases, and included randomized controlled trials, cohort studies, case series, and technical reports related to PD catheter placement, together with studies on plasma concentrations and pharmacokinetics of TAP/RSB, as well as guidelines on LAST and antithrombotic management. Available evidence suggests that TAP can achieve a relatively high anesthetic success rate in open or laparoscopic PD catheter placement and may help reduce hemodynamic fluctuations. However, pain during exit-site and tunnel manipulation remains a common weak point; analgesia during key procedural steps may be improved after combining RSB or local infiltration. Existing plasma concentration data indicate that peak concentrations after TAP/RSB may be relatively high, with substantial interindividual variability. In ESKD patients undergoing PD catheter placement, peak total ropivacaine concentrations after subcostal TAP may approach the potentially toxic range reported in the literature, although overt LAST events appear to be uncommon. This suggests that risk assessment should not rely solely on the maximum recommended dose, but should also take into account upstream factors such as free drug concentration, acidosis, and heart failure. Overall, TAP ± RSB has clear clinical value in PD catheter placement, and the key to its broader application lies in exposure management based on pharmacokinetic principles, including the use of the lowest effective milligram dose, fractionated injection, addition of epinephrine when necessary, avoidance of bilateral high-dose stacking, and establishment of standardized monitoring and lipid emulsion rescue protocols in high-risk patients.