超声联合神经刺激仪引导下连续肌间沟臂丛神经阻滞对再植术后手指组织灌注的影响

Effect of ultrasound and nerve stimulator guided continuous interscalene brachial plexus nerve block on blood perfusion during amputated finger replantation

目的评估超声联合神经刺激仪引导下行肌间沟臂丛神经连续阻滞的镇痛方法对断指再植术后再植手指组织灌注的影响。方法选择急诊断指再植术后患者60例,排除年龄<6岁、既往有雷诺综合征病史、美国麻醉医师协会分级Ⅱ级以上和伴严重合并伤者。将患者随机分入研究组和对照组,每组30例。研究组患者应用超声联合神经刺激仪引导下行肌间沟臂丛神经置管,术后接电子镇痛泵行持续镇痛,镇痛配方为0.2%罗哌卡因共200mL,维持量5mL/h,术后48h拔除导管;对照组患者术后单纯在神经刺激仪引导下进行以上操作。在术后12、24、36、48h各时间点,记录患者的皮温差(再植手指远端的皮温与对应健侧手指皮温的差值)和组织灌注评分(再植手指的皮肤颜色、肿胀程度和毛细血管充盈时间3项评分的总和);记录患者在断指病房监护室住院天数和总住院天数,以及不良反应发生情况。结果在术后12、24、36和48h各时间点,研究组的皮温差绝对值均显著小于对照组同时间点(P值均<0.05),再植手指的组织灌注评分均显著高于对照组同时间点(P值均<0.05)。两组间在断指病房监护室住院天数和总住院天数的差异均无统计学意义(P值均>0.05)。对照组中有2例患者因血管危象行二次探查手术,研究组无类似不良事件,两组均无再植手指坏死的病例。结论超声联合神经刺激仪引导下肌间沟臂丛神经连续阻滞较常规阻滞能改善阻滞效果,为断指再植术后患者提供了良好的镇痛,同时能升高再植手指皮温,改善组织灌注,防止术后血管危象的发生。

Objective To investigate the influence of ultrasound and nerve stimulator guided continuous interscalene brachial plexus nerve block on blood perfusion during amputated finger replantation. Methods Sixty patients undergoing finger replantation in emergency, aged older than 6 years, no history of Raynaud＇s syndrome, American Society of Anesthesiologists （ASA） physical status T or ][, no combination of serious trauma were enrolled in this study. They were randomized into control group and study group （n = 30）. Under the guidance of ultrasound and nerve stimulator, interscalene brachial plexus block was performed in study group, followed by an infusion of 0.2 ropivacaine （200 mL, 5 mL per hour for up to 2 days）. Control group received the nerve block only guided by versus nerve stimulator. The difference between the skin temperature of the reconstructive site and contralateral non-surgical site was calculated at 12, 24, 36 and 48 hours after surgery. In addition, graft＇s blood perfusion including skin color, capillary refill and turgor was scored. The stay time in amputation ward care unit, the total hospital stay and adverse reactions were recorded. Results At 12, 24, 36 and 48 hours after surgery, the difference between the surface temperature of the reconstructive site and contralateral non-surgical site in study group were significantly smaller than those in control group （all P〈0. 05）, and scores of graft＇s blood perfusion in study group were significantly higher than those in control group （all P 〈0. 05）. There were no significant differences in the stay time in amputation ward care unit or total hospital stay between groups （both P〉0.05）. Vascular spasm occurred in two patients in control group and secondary operation was performed. No necrosis happened. Conclusion Ultrasound and nerve stimulator guided continuous interscalene brachial plexus block can provide more efficient postoperative analgesia. Meanwhile, skin temperature of amputated finger increases and blood perfusion can be improved after replantation by preventing neurologically-mediated vasospasm. （Shanghai Med J, 2016, 39： 719-723）