足踝手术中超声引导腘窝坐骨神经阻滞最佳给药部位的临床研究
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摘要
目的探讨超声引导腘窝坐骨神经鞘膜下和鞘膜外阻滞在足踝手术中的最佳给药部位。方法选择同济大学附属同济医院2016年5月—2017年4月择期行单侧足踝手术患者40例,通过简单随机化分成两组:神经鞘膜下注药组(X组,n=20)和神经鞘膜外注药组(W组,n=20)。在超声引导下,使用新型连续外周神经阻滞针对两组患者分别实施腘窝坐骨神经鞘膜下和鞘膜外阻滞并留置导管,局部麻醉药物持续滴定的同时采用神经传导监测技术观察远端腓肠肌的复合性肌肉动作电位(compound muscle action potentials,CMAP)波幅变化,记录两组患者波幅下降为0~0.5 m V时的时间、局部麻醉药用量,手术结束后观察两组患者连续神经阻滞的镇痛效果、患者满意度及神经损伤等并发症。结果 X组与W组比较,完全阻滞所需局部麻醉药量[(10.9±1.7)mL vs(16.1±1.2)mL]和完全阻滞耗时[(19.9±3.5)min vs(30.3±2.5)min]差异有统计学意义(P<0.05);X组术后6、24、48 h镇痛局部麻醉药用量较少(P<0.05);而W组术后6、24、48 h自控镇痛次数明显增加(P<0.05);术后6 h,W组静止疼痛评分高于X组(P<0.05),术后24、48 h静止疼痛评分差异无统计学意义;在术后6、24、48 h,两组间活动疼痛评分相比较,W组均高于X组,且差异有统计学意义(P<0.05);X组患者满意度评分较高(P<0.05);两组均无神经损伤临床表现。结论足踝手术应用连续腘窝坐骨神经阻滞麻醉,神经鞘膜下注药麻醉起效更快,用药量更少,术后镇痛效果更好,满意度更高,患者无神经损伤等临床症状。
Objective To compare the subparaneural with extraparaneural injection of local anesthetics in ultrasound-guided popliteal sciatic nerve block for foot and ankle surgery. Methods Forty patients undergoing unilateral foot or ankle surgery from May 2016 to April 2017 were recruited. Subjects were randomized to subparaneural injection group( group X,n = 20) and extraparaneural injection group( group W,n = 20). All participates received an ultrasound-guided continuous popliteal sciatic nerve block using a novel cannula-over-needle nerve block suite. A pipe was placed subparaneural or extraparaneural for postoperative analgesia. The time for the distal gastrocnemius muscle's CMAP amplitude down to 0-0. 5 mv in motor nerve conduction study and the dosage of drug delivery were recorded during the surgery. The postoperative analgesia effect,patient satisfaction and nerve injury were observed after the operation. Results Preoperative local anesthetics dosage [( 10. 9 ± 1. 7) mL vs( 16. 1± 1. 2) mL]and time of motor nerve block[( 19. 9 ± 3. 5) min vs( 30. 3 ± 2. 5) min] were significantly less in group X than those in group W( P < 0. 05). The local anesthetic dosage at 6 th,24 th and 48 th hour of postoperative analgesia were significantly less in group X( P < 0. 05). At the 6 th,24 th and 48 th hour after surgery,times of patient controlled analgesia were significantly higher in group W( P <0. 05). Pain scores of stationary was significantly higher in group W at the 6 th hour after surgery( P <0. 05),while there was no significant difference in scores of 24 th and 48 th hour. Pain scores of activity was significantly higher in group W at the 6 th,24 th and 48 th hour after surgery( P < 0. 05). group X showed significantly higher patient satisfaction scores( P < 0. 05). There was no significant symptom of nerve injury in both groups. Conclusion For patients receiving continuous popliteal sciatic nerve block in foot and ankle surgery,the subparaneural injection of local anesthetics can get a faster nerve block onset,a less local anesthetics dosage,better postoperative analgesia effect,higher patient satisfaction scores,compare to the extraparaneural injection.
Objective To compare the subparaneural with extraparaneural injection of local anesthetics in ultrasound-guided popliteal sciatic nerve block for foot and ankle surgery. Methods Forty patients undergoing unilateral foot or ankle surgery from May 2016 to April 2017 were recruited. Subjects were randomized to subparaneural injection group( group X,n = 20) and extraparaneural injection group( group W,n = 20). All participates received an ultrasound-guided continuous popliteal sciatic nerve block using a novel cannula-over-needle nerve block suite. A pipe was placed subparaneural or extraparaneural for postoperative analgesia. The time for the distal gastrocnemius muscle's CMAP amplitude down to 0-0. 5 mv in motor nerve conduction study and the dosage of drug delivery were recorded during the surgery. The postoperative analgesia effect,patient satisfaction and nerve injury were observed after the operation. Results Preoperative local anesthetics dosage [( 10. 9 ± 1. 7) mL vs( 16. 1± 1. 2) mL]and time of motor nerve block[( 19. 9 ± 3. 5) min vs( 30. 3 ± 2. 5) min] were significantly less in group X than those in group W( P < 0. 05). The local anesthetic dosage at 6 th,24 th and 48 th hour of postoperative analgesia were significantly less in group X( P < 0. 05). At the 6 th,24 th and 48 th hour after surgery,times of patient controlled analgesia were significantly higher in group W( P <0. 05). Pain scores of stationary was significantly higher in group W at the 6 th hour after surgery( P <0. 05),while there was no significant difference in scores of 24 th and 48 th hour. Pain scores of activity was significantly higher in group W at the 6 th,24 th and 48 th hour after surgery( P < 0. 05). group X showed significantly higher patient satisfaction scores( P < 0. 05). There was no significant symptom of nerve injury in both groups. Conclusion For patients receiving continuous popliteal sciatic nerve block in foot and ankle surgery,the subparaneural injection of local anesthetics can get a faster nerve block onset,a less local anesthetics dosage,better postoperative analgesia effect,higher patient satisfaction scores,compare to the extraparaneural injection.
引文
[1]CHOQUET O,NOBLE G B,ABBAL B,et al.Subparaneural versus circumferential extraneural injection at the bifurcation level in ultrasound-guided popliteal sciatic nerve blocks:a prospective,randomized,double-blind study[J].Reg Anesth Pain M ed,2014,39(4):306-311.
[2]TIYAPRASERTKUL W,BERNUCCI F,GONZLEZ A P,et al.A randomized comparison betw een singleand triple-injection subparaneural popliteal sciatic nerve block[J].Reg Anesth Pain M ed,2015,40(4):315-320.
[3]PERLAS A,WONG P,ABDALLAH F,et al.Ultrasound-guided popliteal block through a common paraneural sheath versus conventional injection:a prospective,randomized,double-blind study[J].Reg Anesth Pain M ed,2013,38(3):218-225.
[4]HADZIC A,DILBEROVIC F,SHAH S,et al.Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs[J].Reg Anesth Pain M ed,2004,29(5):417-423.
[5]CAPPELLERI G,CEDRATI V L,FEDELE L L,et al.Effects of the intraneural and subparaneural ultrasound-guided popliteal sciatic nerve block:a prospective,randomized,double-blind clinical and electrophysiological comparison[J].Reg Anesth Pain M ed,2016,41(4):430-437.
[6]SELANDER D,DHUNR K G,LUNDBORG G.Peripheral nerve injury due to injection needles used for regional anesthesia.An experimental study of the acute effects of needle point trauma[J].Acta Anaesthesiol Scand,1977,21(3):182-188.
[7]KARMAKAR M K,SHARIAT A N,PANGTHIPAMPAI P,et al.High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa[J].Reg Anesth Pain M ed,2013,38(5):447-451.
[8]卢祖能,曾庆杏.临床运动神经传导检测的一般原则:临床神经电重量系列讲座之一[J].卒中与神经疾病,1998,5(3):231-233.
[9]CHAROUS M T,MADISON S J,SURESH P J,et al.Continuous femoral nerve blocks:varying local anesthetic delivery method(bolus versus basal)to minimize quadriceps motor block w hile maintaining sensory block[J].Anesthesiology,2011,115(4):774-781.
[10]何苗,邹天笑,谢书奇,等.新型神经阻滞针行连续股神经阻滞定位方法的研究[J].同济大学学报(医学版),2016,37(2):57-61.
[11]王权光,陈丽梅,刘乐,等.超声引导下连续股神经阻滞联合单次前路坐骨神经阻滞用于膝关节置换术后镇痛[J].温州医科大学学报,2013,43(12):792-795.
[12]刘丹,闵苏,何开华,等.全膝关节置换术患者术后超声联合神经刺激器引导下连续股神经阻滞的镇痛效果[J].第三军医大学学报,2013,35(22):2477-2481.
[13]YU B,ZHANG X,SUN P,et al.Non-stimulation needle w ith external indw elling cannula for brachial plexus block and pain management in 62 patients undergoing upper-limb surgery[J].Int J M ed Sci,2012,9(9):766-771.
[14]余斌,孙佩莉,张晓庆,等.特制神经阻滞导管针在臂丛阻滞及镇痛中的应用[J].同济大学学报(医学版),2012,33(2):72-75.
[15]余斌,孙佩莉,杨博,等.改良肌间沟法连续臂丛神经阻滞及术后镇痛的临床研究[J].同济大学学报(医学版),2008,29(6):63-66.
[16]YU B,HU X,ZOU T,et al.Effects of postoperative continuous femoral nerve block analgesia w ith braun continuous peripheral nerve block catheter set versus novel needle-over-cannula after total knee arthroplasty[J].Med Sci Monit,2015,21:1843-1849.
[17]MCCLELLAN K J,FAULDS D.Ropivacaine:an update of its use in regional anaesthesia[J].Drugs,2000,60(5):1065-1093.
[2]TIYAPRASERTKUL W,BERNUCCI F,GONZLEZ A P,et al.A randomized comparison betw een singleand triple-injection subparaneural popliteal sciatic nerve block[J].Reg Anesth Pain M ed,2015,40(4):315-320.
[3]PERLAS A,WONG P,ABDALLAH F,et al.Ultrasound-guided popliteal block through a common paraneural sheath versus conventional injection:a prospective,randomized,double-blind study[J].Reg Anesth Pain M ed,2013,38(3):218-225.
[4]HADZIC A,DILBEROVIC F,SHAH S,et al.Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs[J].Reg Anesth Pain M ed,2004,29(5):417-423.
[5]CAPPELLERI G,CEDRATI V L,FEDELE L L,et al.Effects of the intraneural and subparaneural ultrasound-guided popliteal sciatic nerve block:a prospective,randomized,double-blind clinical and electrophysiological comparison[J].Reg Anesth Pain M ed,2016,41(4):430-437.
[6]SELANDER D,DHUNR K G,LUNDBORG G.Peripheral nerve injury due to injection needles used for regional anesthesia.An experimental study of the acute effects of needle point trauma[J].Acta Anaesthesiol Scand,1977,21(3):182-188.
[7]KARMAKAR M K,SHARIAT A N,PANGTHIPAMPAI P,et al.High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa[J].Reg Anesth Pain M ed,2013,38(5):447-451.
[8]卢祖能,曾庆杏.临床运动神经传导检测的一般原则:临床神经电重量系列讲座之一[J].卒中与神经疾病,1998,5(3):231-233.
[9]CHAROUS M T,MADISON S J,SURESH P J,et al.Continuous femoral nerve blocks:varying local anesthetic delivery method(bolus versus basal)to minimize quadriceps motor block w hile maintaining sensory block[J].Anesthesiology,2011,115(4):774-781.
[10]何苗,邹天笑,谢书奇,等.新型神经阻滞针行连续股神经阻滞定位方法的研究[J].同济大学学报(医学版),2016,37(2):57-61.
[11]王权光,陈丽梅,刘乐,等.超声引导下连续股神经阻滞联合单次前路坐骨神经阻滞用于膝关节置换术后镇痛[J].温州医科大学学报,2013,43(12):792-795.
[12]刘丹,闵苏,何开华,等.全膝关节置换术患者术后超声联合神经刺激器引导下连续股神经阻滞的镇痛效果[J].第三军医大学学报,2013,35(22):2477-2481.
[13]YU B,ZHANG X,SUN P,et al.Non-stimulation needle w ith external indw elling cannula for brachial plexus block and pain management in 62 patients undergoing upper-limb surgery[J].Int J M ed Sci,2012,9(9):766-771.
[14]余斌,孙佩莉,张晓庆,等.特制神经阻滞导管针在臂丛阻滞及镇痛中的应用[J].同济大学学报(医学版),2012,33(2):72-75.
[15]余斌,孙佩莉,杨博,等.改良肌间沟法连续臂丛神经阻滞及术后镇痛的临床研究[J].同济大学学报(医学版),2008,29(6):63-66.
[16]YU B,HU X,ZOU T,et al.Effects of postoperative continuous femoral nerve block analgesia w ith braun continuous peripheral nerve block catheter set versus novel needle-over-cannula after total knee arthroplasty[J].Med Sci Monit,2015,21:1843-1849.
[17]MCCLELLAN K J,FAULDS D.Ropivacaine:an update of its use in regional anaesthesia[J].Drugs,2000,60(5):1065-1093.