超声引导下周围神经阻滞后暴发痛的临床特征及影响因素分析
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摘要
目的:观察超声引导下的单次神经阻滞(single-shot peripheral nerve blocks,sPNBs)麻醉术后暴发痛的发生情况及特点,探讨暴发痛可能的影响因素。方法:选择sPNBs麻醉下进行择期骨科手术的患者。患者术前超声引导下行神经阻滞,阻滞完成后的24 h、48 h分别随访患者,采用疼痛数字评分(numeric rating scale,NRS)描述峰值疼痛,记录疼痛出现的时间、性质、缓解措施及手术当晚的睡眠质量。结果:共纳入了31例22～83岁患者。术后峰值疼痛达到中、重度疼痛(NRS≥4)的患者25例(80.6%),其中重度疼痛(NRS≥7)患者15例(48.4%)。主诉中、重度疼痛的患者疼痛均为突然发生,使用舒芬太尼无法缓解,持续约30 min～1 h后逐渐缓解。峰值疼痛发生时间距离阻滞时间的中位数为16.8 h(IQR 12.3～22.9)。年龄≤60岁的患者术后中、重度疼痛的发生率高于年龄>60岁的患者(P<0.05)。峰值疼痛的发生距离阻滞的时间与当时的NRS评分线性负相关(P<0.05)。单纯sPNBs麻醉是暴发痛发生的危险因素。结论:超声引导下sPNBs麻醉的骨科手术后中、重度疼痛的发生率高,60岁以下患者的发生率高于60岁以上人群;暴发痛出现在阻滞后12～24 h,随着发生时间的延后,疼痛程度有所下降;单纯sPNBs麻醉术后比联合麻醉更易发生暴发痛。
Objective: To explore the pain profile following ultrasound guided single shot peripheral nerve blocks(sPNBs) anesthesia and investigate risk factors for rebound pain. Methods: Patients scheduled for orthopedic surgery under ultrasound guided sPNBs anesthesia were selected. The patients were followed up 24 h and 48 h after the block. The numeric rating scale(NRS) score, onset time, characteristics, pain-relief approach of peak pain, and sleep quality on the operation day were recorded. Results: A total of 31 patients aged 22-83 years old were included. There were 25 patients(80.6%) with moderate to severe pain levels(NRS≥4), 15(48.4%) of whom reached severe pain level(NRS≥7). Those who with moderate to severe pain described the pain as suddenly onset, poorly controlled by sulfentanil administration, and resolved after 30 min to 1 h. The median occurrence time of peak pain was 16.8 h(IQR 12.3-22.9). The rebound pain was less pronounced in patients >60 years old(P<0.05). The later the pain occurred, the lower the NRS score was(P<0.05). sPNBs administration alone was the risk factor for rebound pain. Conclusions: The incidence of moderate to severe pain after orthopedic surgery undergoing ultrasound-guided sPNBs anesthesia is high, and the incidence of patients ≤60 years old is higher than that of patients over 60 years old. Rebound pain occurs in 12-24 h after the block, and the degree of pain decreases with the delay of the time. Patients who have PNBs anesthesia alone are more prone to rebound pain than those who have combined anesthesia.
Objective: To explore the pain profile following ultrasound guided single shot peripheral nerve blocks(sPNBs) anesthesia and investigate risk factors for rebound pain. Methods: Patients scheduled for orthopedic surgery under ultrasound guided sPNBs anesthesia were selected. The patients were followed up 24 h and 48 h after the block. The numeric rating scale(NRS) score, onset time, characteristics, pain-relief approach of peak pain, and sleep quality on the operation day were recorded. Results: A total of 31 patients aged 22-83 years old were included. There were 25 patients(80.6%) with moderate to severe pain levels(NRS≥4), 15(48.4%) of whom reached severe pain level(NRS≥7). Those who with moderate to severe pain described the pain as suddenly onset, poorly controlled by sulfentanil administration, and resolved after 30 min to 1 h. The median occurrence time of peak pain was 16.8 h(IQR 12.3-22.9). The rebound pain was less pronounced in patients >60 years old(P<0.05). The later the pain occurred, the lower the NRS score was(P<0.05). sPNBs administration alone was the risk factor for rebound pain. Conclusions: The incidence of moderate to severe pain after orthopedic surgery undergoing ultrasound-guided sPNBs anesthesia is high, and the incidence of patients ≤60 years old is higher than that of patients over 60 years old. Rebound pain occurs in 12-24 h after the block, and the degree of pain decreases with the delay of the time. Patients who have PNBs anesthesia alone are more prone to rebound pain than those who have combined anesthesia.
引文
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[11] HEESEN M,KLIMEK M,IMBERGER G,et al.Co-administration of dexamethasone with peripheral nerve block:intravenous vs perineural application:systematic review,meta-analysis,meta-regression and trial-sequential analysis [J].Br J Anaesth,2018,120(2):212-227.
[ 2 ] BARRINGTON M J,UDA YJCOIA.Did ultrasound fulfill the promise of safety in regional anesthesia?[J].Curr Opin Anesthesiol,2018,31(5):649-655.
[ 3 ] MELNYK V,IBINSON J W,KENTOR M L,et al.Updated retrospective single‐center comparative analysis of peripheral nerve block complications using landmark peripheral nerve stimulation versus ultrasound guidance as a primary means of nerve localization [J].J Ultrasound Med,2018,37(11):2477-2488.
[ 4 ] WILLIAMS B A,BOTTEGAL M T,KENTOR M L,et al.Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction:retrospective analysis of a prospective,randomized clinical trial [J].Reg Anesth Pain Med,2007,32(3):186-192.
[ 5 ] GALOS D K,TAORMINA D P,CRESPO A,et al.Does brachial plexus blockade result in improved pain scores after distal radius fracture fixation?A randomized trial[J].Clin Orthop Relat Res,2016,474(5):1247-1254.
[ 6 ] SORT R,BRORSON S,G?GENUR I,et al.Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery:An exploratory pilot study[J].Acta Anaesthesiol Scand,2019,63(3):396-402.
[ 7 ] HENNINGSEN M,SORT R,M?LLER A,et al.Peripheral nerve block in ankle fracture surgery:a qualitative study of patients’ experiences [J].Anaesthesia,2018,73(1):49-58.
[ 8 ] LAUTENBACHER S,KUNZ M,STRATE P,et al.Age effects on pain thresholds,temporal summation and spatial summation of heat and pressure pain [J].Pain,2005,115(3):410-418.
[ 9 ] KIRKSEY M A,HASKINS S C,CHENG J,et al.Local anesthetic peripheral nerve block adjuvants for prolongation of analgesia:a systematic qualitative review[J].PLoS One,2015,10(9):e0137312.
[10] JANDA A,LYDIC R,WELCH K B,et al.Thermal hyperalgesia after sciatic nerve block in rat is transient and clinically insignificant [J].Reg Anesth Pain Med,2013,38(2):151-154.
[11] HEESEN M,KLIMEK M,IMBERGER G,et al.Co-administration of dexamethasone with peripheral nerve block:intravenous vs perineural application:systematic review,meta-analysis,meta-regression and trial-sequential analysis [J].Br J Anaesth,2018,120(2):212-227.