锁骨下臂丛神经周围置管两种入路技术的比较研究

Ultrasound-guided continuous infraclavicular nerve block for analgesia after elbow release surgery a comparison of medial and lateral approach

目的比较内、外侧两种入路技术行超声引导锁骨下臂丛神经周围置管的操作易行性及有效性。方法选取肘关节松解手术患者40例,年龄18-65岁,ASA分级Ⅰ-Ⅲ级,随机分成外侧入路（LIT组,n=20）和内侧入路组（MIT组,n=20）,在术前置管：LIT组于喙突下定位,MIT组于较其偏内处胸大肌与三角肌间沟顶点定位,经导管注入初始量局麻药1%利多卡因40ml,全麻下完成手术,术毕连接电子镇痛泵,持续输注镇痛用量局麻药0.2%盐酸罗哌卡因,总量250ml,背景量5ml/h,单次剂量5ml,锁定时间20分钟。比较两组置管操作时间,初次置管成功率,异感、血管损伤及穿刺点渗液发生率,术后24、36、48小时静息、运动疼痛评分及运动阻滞发生率,关节活动范围改善度,患者满意度,不良反应发生情况。结果与MIT组比较,LIT组具有较少异感发生率及较低穿刺点渗液率,神经束位置固定且穿刺路径内血管数量少。术后疼痛评分、关节活动改善度及不良反应发生率两组间差异无显著性。结论使用超声引导锁骨下臂丛神经置管用于肘关节松解患者术后镇痛,与内侧入路相比,外侧入路操作更舒适安全且损伤小,更值得推荐。

Objective Although the comparison of the medial and lateral technique for single-injection ultrasound guided infraclavicular block is well established,no controlled study of it is available,and the relative risks and benefits remain unknown. In this randomized study,we compared the lateral（ LIT） and medial（ MIT） puncture sites for continuous infraclavicular block（ CINB）,with respect to catheterization facility and analgesia quality for elbow release sugery. Method Forty patients undergoing elbow release surgery were randomly assigned to receive ultrasound-guided CINB either with the lateral puncture inferior to the coracoids process（ lateral group,n = 20） or the medial one at the apex of tedelto-pectoral groove（ medial group,n = 20）. Catheters were advanced blindly 3 cm beyond needle tip. 1% lidocaine 40 ml was administered and sensory block of all the four nerves within 15 minutes was defined as success. All surgery was conducted under general anesthesia. Postoperatively,subjects were discharged ward with a portable pump（ 250 ml reservoir） infusing 0. 2% ropivacaine（ basal rate of 5ml / h; 5ml bolus dose; 20 min lockout interval）. Cathetering procedure time,ultrasound anatomy structure character and side effects during needle insertion were recorded. Post-operative VAS was assessed respectively at 24 h,36h and 48 h. Rage of motion（ ROM） percentage of the elbow joint on POD3（ gold standard for surgery effect）,patient satisfaction and were recorded. Result All catheters were successfully placed. More stable position of the nerve cords and less amount of veins within the puncture path ensured its catheterization facility. MIT had more perfect block for cutaneus brachii medialis,while LIT for axillary N. There were no significant differences in pain scores,improvement of ROM percentage,incidence of catheter occlusion or dislocation and patient satisfaction between the two groups. Conclusion In CINB under ultrasound guidance,LIT had more clear and stable anatomy structures,facilitating the catheterization operation and lower the side effects of catheter insertion while providing a similar quality of analgesia after elbow release surgery as compared with MIT.