不同水平坐骨神经-股神经联合阻滞与连续硬脊膜外腔阻滞麻醉用于胫腓骨骨折手术麻醉效果的比较

Comparison of anesthetic effects between different levels of sciatic nerve block combined with femoral nerve block and continuous epidural anesthesia in internal fixation for tibiofibula fracture

目的比较不同水平坐骨神经-股神经联合阻滞与连续硬脊膜外腔阻滞麻醉用于胫腓骨骨折手术麻醉的效果。方法选择2012年8月-2015年8月间在中国人民解放军第四一一医院行胫腓骨骨折切开复位内固定手术的患者90例，年龄18-60岁，将患者随机分人3组，分别行超声引导下坐骨结节水平坐骨神经一股神经联合阻滞麻醉（坐骨结节组）、超声引导下胴窝处坐骨神经-股神经联合阻滞麻醉（胭窝组）和连续硬脊膜外腔阻滞麻醉（硬脊膜外腔组），每组30例。监测患者术中心率（HR）、血压、脉搏血氧饱和度的变化，麻醉完成情况和不良反应发生情况，比较各组患者的血流动力学改变度、麻醉满意度、镇痛时间、术后下肢运动恢复度。结果90例患者均未发生操作相关的局部麻醉药中毒、血管内注射、神经损伤等严重并发症，坐骨结节组、胭窝组、硬脊膜外腔组的麻醉成功率分别为93．3％、100．0％、96．7％，坐骨神经-股神经联合阻滞麻醉（坐骨结节组＋胭窝组）的成功率为96．7％，连续硬脊膜外腔阻滞麻醉的成功率为96．7％。坐骨结节组的麻醉满意度显著低于硬脊膜外腔组（P〈O．01），镇痛时间显著短于硬脊膜外腔组（P〈0．01），术后下肢运动恢复度显著高于硬脊膜外腔组（P〈0．01），但两组间血流动力学改变度的差异无统计学意义（P〉0．05）。胭窝组的血流动力学改变度显著小于硬脊膜外腔组（P〈0．01），镇痛时间显著短于硬脊膜外腔组（P〈0．01），术后下肢运动恢复度显著高于硬脊膜外腔组（P〈0．01），两组间麻醉满意度的差异无统计学意义（P〉0．05）。坐骨结节组的麻醉满意度显著低于胭窝组（P〈0．01），两组间血流动力学改变度、镇痛时间和术后下肢运动恢复度的差异均无统计学意义（P值均〉0．05）。结论在超声引导下行坐骨神经一股神经联合阻滞麻醉的镇痛时间短，有利于患者的术后恢复。就阻滞位置而言，较之坐骨结节水平，于胭窝处行坐骨神经一股神经联合阻滞麻醉的麻醉满意度和麻醉成功率更高，对于膝部以下位置的手术更具优势。

Objective To compare anesthetic effects between sciatic nerve block combined with femoral nerve block at different levels and continuous epidural block in patients with tibiofibula fracture. Methods Ninety patients （aged 18-60 years） undergoing open reduction and internal fixation for tibiofibula fracture in No. 411 Hospital of Chinese People＇s Liberation Army from August 2012 to August 2015 were selected for the investigation. The patients were divided into 3 groups at random （n = 30）. Ultrasound-guided sciatic nerve block combined with femoral nerve block at the level of ischial tuberosity, sciatic nerve block combined with femoral nerve block at the level of popliteal fossa, and continuous epidural block were performed in groups A, B and C, respectively. Heart rate （HR）, blood pressure （BP）, and oxygen saturation （SpO2） were monitored. Anesthesia effect and adverse reactions were observed. Hemodynamic changes, anesthesia satisfaction, analgesic maintenance time and postoperative lower extremity sensory recovery were compared between groups. Results No severe complications such as toxicity of local anesthetics, intravascular injection, or nerve injury occurred. The anesthesia success rates of groups A, B and C were 93.3%, 100.0%, and 96.7%, respectively. Compared with those of group C, anesthesia satisfaction was significantly decreased （P 〈 0. 01 ）, analgesic maintenance time was obviously shortened （ P〈0.01 ）, but lower extremity sensory recovery was better in group A （ P〈0.01 ）. There was no significant difference in hemodynamic changes between group A and C （P〉0.05）. Compared with those of group C, smaller hemodynamic changes, shorter analgesic maintenance time and faster limb sensory recovery were achieved in group B （all P〈0.01 ）, but no significant difference was found in the anesthesia satisfaction between the two groups （P〉0.05）. The satisfaction index of anesthesia of group A was significantly lower than that of group B （P〈0.01）, but there were no significant differences in the hemodynamic changes, analgesic maintenance time or lower limb sensory recovery between the two groups （all P〉0.05）. Conclusion Sciatic nerve block combined with femoral nerve block under the guidance of ultrasound can achieve a short analgesic maintenance time, which is helpful for postoperative recovery. Sciatic nerve block combined with femoral nerve block at the level of popliteal fossa can achieve higher satisfaction and success rate of anesthesia as compared with the blocks at the level of ischial tuberosity in the operations below the knee. （Shanghai Med J, 2016, 39; 711- 714）