超声引导下臂丛上干和颈浅丛神经阻滞联合全身麻醉在肩关节镜手术中的应用
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摘要
目的评价超声引导下臂丛上干和颈浅丛神经阻滞联合全身麻醉应用于肩关节镜手术的优势。方法择期行肩关节镜下肩袖修补手术的患者50例,美国麻醉医师协会(ASA)分级为Ⅰ或Ⅱ级,年龄45～75岁,被随机分入全身麻醉组(采用单纯全身麻醉)和联合组(采用超声引导下臂丛上干和颈浅丛神经阻滞联合全身麻醉),每组25例。在术前(T_0)、手术开始5min(T_1)、手术开始30min(T_2)、手术结束时(T_3)和拔除喉罩30min后(T_4)各时间点,观察并记录患者的平均动脉压(MAP)和心率。记录T_1和T_2时间点的脑电双频指数(BIS)值。记录手术时间、拔管时间(停用七氟烷至拔除喉罩时间)、阿片类镇痛药物(舒芬太尼)用量、七氟烷用量。记录在麻醉后监测治疗室(PACU)中、术后6h、术后12h各时间点的疼痛VAS评分和肱二头肌肌力分级。结果两组间T_1和T_2时间点的BIS值的差异均无统计学意义(P值均>0.05)。两组间T_0时间点的MAP和心率的差异均无统计学意义(P值均>0.05);联合组T_1至T_4时间点的MAP均显著低于全身麻醉组同时间点(P值均<0.01),心率均显著慢于全身麻醉组同时间点(P值分别<0.01、0.05)。与全身麻醉组比较,联合组的拔管时间显著缩短(P<0.01),舒芬太尼和七氟烷用量显著减少(P值均<0.01),在PACU中的肌力分级显著降低(P<0.01),在PACU中、术后6h和术后12h的疼痛VAS评分均显著降低(P值均<0.01);两组间术后6h和术后12h的肌力分级的差异均无统计学意义(P值均>0.05)。结论超声引导下臂丛上干和颈浅丛神经阻滞联合全身麻醉用于肩关节镜手术,能够提供平稳的麻醉状态,减少术中阿片类镇痛药物和七氟烷的用量,有利于术后镇痛。
Objective To investigate the value and advantage of ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block in combination with general anesthesia in arthroscopic shoulder surgery.Methods Fifty patients scheduled for arthroscopic shoulder surgery,American Society of Anesthesiologist(ASA)physical statusⅠorⅡ,aged from 45to 75years old,were divided into two groups(n=25).Group A only underwent general anesthesia.Group B was given ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block before general anesthesia.Mean arterial pressure(MAP)and heart rate were recorded before surgery(T_0),5min after the beginning of the surgery(T_1),30min after the beginning of the surgery(T_2),at the end of the surgery(T_3),and 30min after removing laryngeal mask(T_4).Bispectral index(BIS)was recorded at T_(1 )and T_2.The operation time,extubation time(from stopping using sevoflurane to removing the laryngeal mask),dosage of opioids(sufentanyl),dosage of sevoflurane,visual analogue scale(VAS)scores and muscle strength at post-anesthesia care unit(PACU),6hand 12hafter the surgery were also recorded.Results There were no significant differences in the BIS between two groups at T_1or T_2(both P>0.05).Neither was the MAP or heart rate at T_0(both P>0.05).MAP and heart rate in group B were significantly lower than those in group A from T_1to T_4(P<0.01or 0.05).Compared with group A,patients in group B had significantly shorter extubation time(P<0.01),smaller dosages of sufentanyl and sevoflurane(both P<0.01),lower muscle strength at PACU(P<0.01),and lower VAS scores at PACU,6hand 12hafter the surgery(all P<0.01).But there were no significant differences in the muscle strength at 6hor 12hafter the surgery between groups(both P>0.05).Conclusion Ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block combined with general anesthesia can offer better anesthesia status,reduce dosage of opioid and sevoflurane and help postoperative analgesia.(Shanghai Med J,2018,41:681-685)
Objective To investigate the value and advantage of ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block in combination with general anesthesia in arthroscopic shoulder surgery.Methods Fifty patients scheduled for arthroscopic shoulder surgery,American Society of Anesthesiologist(ASA)physical statusⅠorⅡ,aged from 45to 75years old,were divided into two groups(n=25).Group A only underwent general anesthesia.Group B was given ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block before general anesthesia.Mean arterial pressure(MAP)and heart rate were recorded before surgery(T_0),5min after the beginning of the surgery(T_1),30min after the beginning of the surgery(T_2),at the end of the surgery(T_3),and 30min after removing laryngeal mask(T_4).Bispectral index(BIS)was recorded at T_(1 )and T_2.The operation time,extubation time(from stopping using sevoflurane to removing the laryngeal mask),dosage of opioids(sufentanyl),dosage of sevoflurane,visual analogue scale(VAS)scores and muscle strength at post-anesthesia care unit(PACU),6hand 12hafter the surgery were also recorded.Results There were no significant differences in the BIS between two groups at T_1or T_2(both P>0.05).Neither was the MAP or heart rate at T_0(both P>0.05).MAP and heart rate in group B were significantly lower than those in group A from T_1to T_4(P<0.01or 0.05).Compared with group A,patients in group B had significantly shorter extubation time(P<0.01),smaller dosages of sufentanyl and sevoflurane(both P<0.01),lower muscle strength at PACU(P<0.01),and lower VAS scores at PACU,6hand 12hafter the surgery(all P<0.01).But there were no significant differences in the muscle strength at 6hor 12hafter the surgery between groups(both P>0.05).Conclusion Ultrasound-guided superior trunk of brachial plexus block and superficial cervical plexus block combined with general anesthesia can offer better anesthesia status,reduce dosage of opioid and sevoflurane and help postoperative analgesia.(Shanghai Med J,2018,41:681-685)
引文
[1]KLINE J P.Ultrasound-guided placement of combined superficial cervical plexus and selective C5 nerve root catheters:a novel approach to treating distal clavicle surgical pain[J].AANA J,2013,81(1):19-22.
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[6]张伟滨,王蕾,徐贤,等.肩撞击综合征的手术治疗[J].上海医学,2004,27(2):105-107.
[7]李莹,姜春岩,王满宜.肩关节的功能解剖与手术入路[J].中华创伤骨科杂志,2005,7(9):865-868.
[8]江琦,翟中云,杨进辉,等.神经刺激器引导臂丛两点阻滞在肩关节镜手术的应用[J].临床麻醉学杂志,2015,31(1):85-86.
[9]GONANO C,KETTNER S C,ERNSTBRUNNER M,et al.Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery[J].Br J Anaesth,2009,103(3):428-433.
[10]韩彬,贾东林,于琳琳,等.臂丛神经阻滞复合全身麻醉在肩关节镜手术中的应用.中国微创外科杂志,2011,11(12):1108-1110.
[11]LEE H Y,KIM S H,SO K Y,et al.Effects of interscalene brachial plexus block to intra-operative hemodynamics and postoperative pain for arthroscopic shoulder surgery[J].Korean J Anesthesiol,2012,62(1):30-34.
[12]LAURILA P A,LPPNEN A,KANGA-SAARELA T,et al.Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery[J].Acta Anaesthesiol Scand,2002,46(8):1031-1036.
[13]魏越,郭向阳,杨璐,等.连续肌间沟臂丛神经阻滞对关节镜肩袖修复术患者围手术期管理的影响[J].中华医学杂志,2012,92(33):2327-2330.
[14]李露,李秋军,周海滨,等.全身麻醉复合臂丛神经阻滞提高肩关节镜术的麻醉质量[J].国际麻醉学与复苏杂志,2013,34(3):230-233,252.
[15]AUNAC S,CARLIER M,SINGELYN F,et al.The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia[J].Anesth Analg,2002,95(3):746-750.
[16]CHUNG F,MEZEI G.Factors contributing to a prolonged stay after ambulatory surgery[J].Anesth Analg,1999,89(6):1352-1359.
[17]徐贯杰.如何看待预先镇痛和预防性镇痛[J].实用疼痛学杂志,2009,5(1):5-8.
[2]傅志海,吴雅松,王小虎,等.超声引导锁骨手术患者C5和颈浅丛联合阻滞的效果[J].中华麻醉学杂志,2013,33(11):1380-1382.
[3]韦民,张钟元,MINOLA R.肩关节镜辅助下小切口肩峰成形及肩袖修补[J].上海医学,2003,26(2):112-114.
[4]赵艳,郭向阳.微创外科与麻醉的变迁[J].中国微创外科杂志,2011,11(1):32-34,41.
[5]SINGELYN F J,LHOTEL L,FABRE B.Pain relief after arthroscopic shoulder surgery:a comparison of intraarticular analgesia,suprascapular nerve block,and interscalene brachial plexus block[J].Anesth Analg,2004,99(2):589-592.
[6]张伟滨,王蕾,徐贤,等.肩撞击综合征的手术治疗[J].上海医学,2004,27(2):105-107.
[7]李莹,姜春岩,王满宜.肩关节的功能解剖与手术入路[J].中华创伤骨科杂志,2005,7(9):865-868.
[8]江琦,翟中云,杨进辉,等.神经刺激器引导臂丛两点阻滞在肩关节镜手术的应用[J].临床麻醉学杂志,2015,31(1):85-86.
[9]GONANO C,KETTNER S C,ERNSTBRUNNER M,et al.Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery[J].Br J Anaesth,2009,103(3):428-433.
[10]韩彬,贾东林,于琳琳,等.臂丛神经阻滞复合全身麻醉在肩关节镜手术中的应用.中国微创外科杂志,2011,11(12):1108-1110.
[11]LEE H Y,KIM S H,SO K Y,et al.Effects of interscalene brachial plexus block to intra-operative hemodynamics and postoperative pain for arthroscopic shoulder surgery[J].Korean J Anesthesiol,2012,62(1):30-34.
[12]LAURILA P A,LPPNEN A,KANGA-SAARELA T,et al.Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery[J].Acta Anaesthesiol Scand,2002,46(8):1031-1036.
[13]魏越,郭向阳,杨璐,等.连续肌间沟臂丛神经阻滞对关节镜肩袖修复术患者围手术期管理的影响[J].中华医学杂志,2012,92(33):2327-2330.
[14]李露,李秋军,周海滨,等.全身麻醉复合臂丛神经阻滞提高肩关节镜术的麻醉质量[J].国际麻醉学与复苏杂志,2013,34(3):230-233,252.
[15]AUNAC S,CARLIER M,SINGELYN F,et al.The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia[J].Anesth Analg,2002,95(3):746-750.
[16]CHUNG F,MEZEI G.Factors contributing to a prolonged stay after ambulatory surgery[J].Anesth Analg,1999,89(6):1352-1359.
[17]徐贯杰.如何看待预先镇痛和预防性镇痛[J].实用疼痛学杂志,2009,5(1):5-8.