超前镇痛对髋部与股骨骨折患者麻醉操作所致应激反应的干预研究

An intervention study on the effects of preemptive analgesia on stress response in patients with hip fracture of femur undergoing anesthesia procedure

目的：探讨超前镇痛（PA）对髋部股骨骨折（HFF）患者麻醉操作所致应激反应的干预效果。方法对2012年1月~2013年6月在我院就诊的90例 HFF 患者的临床资料行回顾性分析,采用随机、双盲（拆信封法）、对照（安慰剂）、平行分组法,将其分为3组：观察组60例,采用单次腰丛神经分支阻滞法行 PA,其中 A 组、B 组各30例,分别选择股神经干分支或闭孔神经干阻滞；对照组30例,仅注射生理盐水（安慰剂）,比较3组 PA 前（T0）、PA 后5 min（T1）、摆麻醉侧卧体位时（T2）、椎管内穿刺后改平卧位即刻（T3）、麻醉结束后（T4）的镇痛效果及生命体征、应激指标。结果组内比较,较之 T0,观察组 T1~4的疼痛视觉模拟评分（VAS）、RR 及 T1的 HR 明显降低,B 组 T2~3的血糖（BS）浓度,对照组T2~4的 BS 浓度、E、NE、ACTH、TNF-α水平及 T2~3的 COR、IL-6水平明显升高；较之 T1,观察组 T4的 HR,B 组T2~4的 BS 浓度,对照组 T2~4的 BS 浓度、E、ACTH、TNF-α水平及 T2~3的 COR、NE、IL-6水平明显升高；较之 T0、T1,对照组 T2~3的 VAS 评分、HR、RR、MAP 明显升高,差异均有统计学意义（P 〈0.05）。组间比较：A 组 T1~4的 VAS评分,观察组 T1~3的 HR、RR,T2~3的 MAP 明显低于 B 组和对照组,B 组的 VAS 评分明显低于对照组；观察组 T2~4的BS 浓度,A 组 T2~4的 COR、E、NE、ACTH、IL-6、TNF-α水平,B 组 T2~3的 COR 及 T4的 E 水平,明显低于对照组；A组 T2~4的 BS 浓度明显低于 B 组,差异均有统计学意义（P 〈0.05）。结论对于 HFF 患者,在实施椎管内麻醉前,行腰丛神经分支阻滞 PA 可有效减轻麻醉操作所致的应激反应,尤其是股神经干分支阻滞（10 ml 2%利多卡因＋5 ml 0.75%布比卡因的混合液）效果更明显,值得推广。

Objective To observe the intervention effects of preemptive analgesia （PA）on stress response in patients with hip fracture of femur （HFF）undergoing anesthesia procedure. Methods The clinical materi-als of 90 patients with HFF cared at our hospital from January 2012 to June 2013 were retrospectively reviewed and analyzed.Patients were assigned into three groups by the methods of randomized,double-blind （unsea-ling method）,control （placebo）and parallelly grouping.The PA with single lumbar plexus branch block was used for the observation group （n =60）,patients of the observation group were subdivided into group A （n =30）and group B （n =30）.Group A patients selected the femoral nerve fascicular block,group B selected the obturator nerve block,and the control group （n =30）was injected with saline （placebo）.Compared the anal-gesia effect,the vital signs,and stress indexes obtained before PA （T0 ）,5 min after PA （T1 ）,at adjusting an-esthesia lateral position （T2 ）,spinal puncture flat lying immediately （T3 ）and after the end of anesthesia （T4）. Results Intra - group comparison results：compared with T0 ,the scores of visual analogue scale/score （VAS）,RR at T1 ~4 ,HR at T1 for the observation group were decreased significantly,concentration of blood sugar （BS）at T2 ~3 for group B,concentration of BS,levels of E,NE,ACTH and TNF-αat T2 ~4 ,and levels of COR and IL-6 at T2 ~3 for the control group were increased significantly;compared with T1 ,the HR in T4 for the observation group,concentration of BS in T2 ~4 for group B,concentration of BS,levels of E, ACTH and TNF-αin T2 ~4 ,and levels of COR,NE,IL-6 in T2 ~3 for the control group were increased sig-nificantly.Compared with the T0 and T1 ,the score of VAS,and HR,RR,MAP in T2 ~3 for the control group were increased significantly.There were statistically significant differences （P 〈0.05）.Group-paired com-parison results：the scores of VAS in T1 ~4 for group A,HR,RR in T1 ~3 ,and MAP in T2 ~3 for the observation group were significantly lower than those of group B and control group,and the score of VAS for group B was significantly lower than that of the control group.The concentration of BS in T2 ~4 for the observation group, the levels of COR,E,NE,ACTH,IL-6 and TNF-αin T2 ~4 for group A,the levels of COR in T2 ~3 and E at T4 for group B were significantly lower than those of the control group.The concentrations of BS in T2 ~4 for＆nbsp;group A were significantly lower than those of group B.There were statistically significant differences （P 〈0. 05）. Conclusion The PA with lumbar plexus branch block before intravertebral anesthesia for HFF can re-duce stress reaction caused by anesthesia operation,especially the femoral nerve fascicular block is more effec-tive （mixed liquid with 10 ml 2% lidocaine ＋ 5 ml 0.75% bupivacaine）,which is worthy of clinical recommen-dation.