超声引导连续髂筋膜间隙阻滞与神经刺激仪引导连续股神经阻滞用于全膝关节置换术病人术后镇痛效果的比较

Efficacy of ultrasound-guided continuous fascia iliac compartment block versus neurostimulator-guided con- tinuous femoral nerve block for postoperative analgesia in patients undergoing total knee arthroplasty

目的比较超声引导下连续髂筋膜间隙阻滞与神经刺激仪引导连续股神经阻滞用于全膝关节置换术病人术后镇痛的效果。方法择期拟行单侧全膝关节置换术病人66例，年龄46～78岁，体重45～88kg，性别不限，ASA分级I或Ⅱ级。采用随机数字表法，将病人随机分为2组（n=33）：连续股神经阻滞组（I组）和连续髂筋膜间隙阻滞组（Ⅱ组）。手术开始前30min时，I组在神经刺激器引导下行股神经阻滞，Ⅱ组在超声引导下行髂筋膜间隙阻滞，2组均注入0．5％罗哌卡因20ml并留置导管。术后0．5h时，I组股神经留置导管和Ⅱ组髂筋膜间隙留置导管分别连接镇痛泵行病人自控镇痛（PCA）至术后48h。镇痛药物为0．2％罗哌卡因，背景输注速率5ml／h，PCA量5ml，锁定时间30min，维持VAS评分≤3分。分别于首次注药后10min和术后0．5、4、24h时，评价感觉阻滞范围，计算感觉阻滞有效率。当VAS评分〉4分时，每12h静脉注射或口服曲马多50～100mg进行镇痛补救；当VAS评分〉5分时，肌肉注射哌替啶50mg进行镇痛补救。记录术后4h内、4～12h和12～24h镇痛泵按压次数和术后24h内和24～48h曲马多和哌替啶的用量。记录术后24h内和24～48h病人夜间睡眠质量评分。记录神经阻滞操作过程中血管内穿刺和异感等的发生情况；记录术后局麻药中毒、严重的恶心呕吐（持续1d以上）和神经损伤等不良反应的发生情况。结果与I组比较，Ⅱ组首次注药后10min时股内侧区感觉阻滞有效率降低，术后0．5h时股外侧区感觉阻滞有效率升高（P〈0．05）。2组不同时段镇痛泵按压次数、曲马多和哌替啶的用量、夜间睡眠质量评分比较差异无统计学意义（P〉0．05）。2组神经阻滞操作过程中均未见血管内穿刺和异感的发生；术后均未见局麻药中毒症状、严重的恶心呕吐和神经损伤的发生。结论与神经刺激器定位下连续股神经阻滞相比，超声引导下连续髂筋膜间隙阻滞用于全膝关节置换术病人术后镇痛效果相似，但感觉阻滞范围更广。

Objective To compare the efficacy of ultrasound-guided continuous fascia iliac compartment block （cFICB） and neurostimulator-guided continuous femoral nerve block （cFNB） for postoperative analgesia in patients undergoing total knee arthroplasty. Methods Sixty-six ASA I or Ⅱ patients, aged 46-78 yr, weighing 45-88 kg, scheduled for unilateral total knee arthroplasty, were randomly divided into 2 groups （ n = 33 each） ： cFNB group （group I ） and cFICB group （group Ⅱ ）. At 30 min before surgery, the patients received FNB guided by neurostimulator in group I and FICB guided by ultrasound in group Ⅱ . A bolus of 0.5% ropivacaine 20 mlwas injected and a catheter for continuous nerve block was inserted in both groups. At 0.5 h after surgery, the catheter was connected to a patient-controlled analgesia （PCA） pump. PCA with 0.2% ropivaeaine was used for postoperative analgesia （48 h）. The PCA pump was set up to deliver a 5 sill bolus dose with a 30-min lockout in- terval and background intusion at 5 ml/h. VAS score was maintained ≤ 3. The distribution of sensory block was as- sessed at 10 min after the first administration, and at 0.5, 4 and 24 h after surgery. The effective rate of sensory block was calculated. When VAS score 〉 4, tramadol 50 mg was given intravenously or orally every 12 h as a rescue analgesic. When VAS score 〉 5, pethidine 50 mg was injected intramuscularly as a rescue analgesic. The number of attempts was recorded during 0-4 h, 4-12 h and 12-24 h alder surgery. The consumption of tramadol and pethidine was also recorded during 0-24 h and 24-48 h after surgery. The sleep quality＇ score during the nighttime was also recorded during 0-24 h and 24-48 h after surgery. Vascular puncture and parasthesia during nerve block were recorded. The toxic reaction, severe nausea and vomiting （lasting tor more than 1 day） and nerve damage were recorded after surgery. Results Compared with group Ⅰ , the effective rate of sensory block in the medial aspect of the thigh was significantly decreased at 10 min after the first administration, and the effective rate of sen- sory block in the lateral aspect of the thigh was significantly increased at 0.5 h after surgery in group ≤ （ P 〈 0.05） . There was no significant difference in the number of attempts, e, onsumption of tramadol and pethidine, and sleep quality score during the nighttime during different time periods between the two groups （ P 〉 0.05）. No vas- cular puncture or parasthesia was found during nerve block in the two groups. No toxic reaction, severe nausea and vomiting or nerve damage was found after surgery in the two groups. Conclusion Ultrasound-guided eFICB has the similar analgesic efficacy with neurostimulator-guided cFNB after operation, but it can provide a wider distribution of sensory blockade in patients undergoing total knee arthroplasty.