自控锁骨下臂丛神经阻滞用于患者肘关节松解术后镇痛的效果

Efficacy of patient-controlled infraclavicular brachial plexus block for analgesia after elbow arthroly-

目的 评价自控锁骨下臂丛神经阻滞用于患者肘关节松解术后镇痛的效果.方法 选择拟行肘关节松解术患者80例,年龄18 ～ 64岁,性别不限,ASA分级Ⅰ-Ⅲ级,体重指数18～ 25kg/m2,采用随机数字表法分为2组（n=40）：腋路臂丛神经阻滞组（A组）和锁骨下臂丛神经阻滞组（Ⅰ组）.2组分别于术前在超声引导下将导管留置在臂丛神经周围.术后苏醒后待患者疼痛时,经导管注射0.2％罗哌卡因20 ml,15 min后采用0.2％罗哌卡因（400 ml）行自控臂丛神经阻滞,背景输注速率5 ml/h,PCA剂量5 ml,锁定时间30 min.术后24 h时进行功能锻炼,1次/d,连续3d.记录置管时间、阻滞成功情况、置管时中重度疼痛[疼痛数字评分法（NRS）评分＞4分]和高度置管阻力（置管阻力评分法评分＞1分）的发生情况、置管过程中神经异感和血管损伤的发生情况.记录术后24、48和72 h功能锻炼时的NRS评分.记录术后72 h时肘关节活动范围,计算活动范围改善程度,记录活动范围改善满意（活动范围改善≥80％）和活动范围完全改善（活动范围改善达100％）的发生情况.记录术后72 h内导管有关不良反应（渗液、堵塞、脱出等）和局麻药有关不良反应（恶心呕吐、全身毒性反应）的发生情况.结果 2组置管时阻滞成功率均为100％.与A组比较,Ⅰ组置管时间缩短,置管时中重度疼痛和高度置管阻力的发生率降低,置管过程中神经异感及血管损伤的发生率降低,术后24 h功能锻炼时的NRS评分降低,肘关节活动范围完全改善率升高（P＜0.05）,肘关节活动范围改善程度和改善满意率差异无统计学意义（P＞0.05）.结论 自控锁骨下臂丛神经阻滞可安全、有效地用于患者肘关节松解术后镇痛,其效果优于自控腋路臂丛神经阻滞.

Objective To evaluate the efficacy of patient-controlled infraclavicular brachial plexus block for analgesia after elbow arthrolysis.Methods Eighty patients with elbow stiffness of both sexes, aged 18-64 yr, of American Society of Anesthesiologists physical status Ⅰ-Ⅲ, scheduled for elective elbow arthrolysis, were equally and randomly assigned to receive either the infraclavicular （Ⅰ group） or axillary （A group） brachial plexus block.All catheters were placed using ultrasound visualization preoperatively.When patients complained of pain in the recovery room after regaining consciousness, 0.2% ropivacaine was injected via the catheter, 15 min later patient-controlled infraclavicular brachial plexus block was performed with 0.2% ropivacaine （400 ml）, and an electronic pump was set up with a 5 ml bolus dose, a 30 min lockout interval and background infusion at a rate of 5 ml/h.The patients underwent rehabilitation exercise everyday for 3 consecutive days starting from 24 h after operation.The catheter insertion time, successful block, and occurrence of moderate or severe pain （numeric rating scale [NRS] score 〉 4） and greater inserting resistance （inserting resistance score〉 1） during insertion, and the occurrence of paresthesia and vascular damage during insertion were recorded.NRS score was recorded at 24, 48 and 72 h after operation during rehabilitation exercise.The elbow articular range of motion was recorded at 72 h after operation, and the improvement in articular range of motion was calculated.The satisfaction with the improvement in articular range of motion （improvement ≥ 80%） and occurrence of complete improvement in articular range of motion （improvement=100%） were recorded.Catheter-related adverse reactions （such as oozing from the insertion site, obstruction, prolapse） and local anesthetics-related adverse reactions （nausea and vomiting, central nervous system toxicity） were recorded.Results The success rate of blockade was 100% during insertion in both groups.Compared with group A, the catheter insertion time was significantly shortened, the incidence of moderate or severe pain and greater inserting resistance during insertion was decreased, the incidence of paresthesia and vascular damage during insertion was decreased, NRS score at 24 h after operation durig rehabilitation exercise was decreased, the incidence of complete improvement was increased （P〈0.05）, and no significant change was found in the improvement in articular range of motion and satisfaction with the improvement in group I （P〉0.05）.Conclusion Patient-controlled infraclavicular brachial plexus block can be safely and effectively used for analgesia after elbow arthrolysis, and it provides better efficacy than patient-controlled axillary brachial plexus block.