超声引导下臂丛神经阻滞与全身麻醉在肘关节手术中的应用比较

Comparison between ultrasound-guided brachial plexus block and general anesthesia for surgery of elbow joint

目的对比在肘关节手术中超声引导下臂丛神经阻滞技术及全身麻醉技术的优劣。方法选取2014年10月至2017年4月涿鹿县中医院行肘关节周围骨折切开复位内固定术的患者共60例,随机分为臂丛神经阻滞组(BB组,n=30)及全身麻醉组(GA组,n=30)。BB组在超声引导下行腋路神经阻滞,GA组采用气管插管全身麻醉。对比两组患者麻醉前(T0)、手术前(T1)、手术开始1 h后(T2)及手术结束时(T3)的平均动脉压及心率;对比两组患者术中的血糖升高水平;对比两组患者术后的视觉模拟评分(visual analogue score,VAS)、对麻醉及镇痛的满意度。结果 BB组患者各时间点的平均动脉压及心率的比较差异无统计学意义,GA组患者的平均动脉压及心率存在时间效应,各时间点的比较差异有统计学意义(F=9.568,P<0.001;F=7.746,P=0.001)。两组患者术中的血糖水平均高于术前,BB组血糖的升高低于GA组[(0.6±0.4)mmol/L vs(0.9±0.6)mmol/L,t=-2.243,P=0.030]。BB组患者术后随访时的VAS评分低于GA组[1(1,1)vs 2(1,2.25),Z=2.066,P<0.001]。BB组患者对麻醉及镇痛处理的满意度高于GA组[4(3,5)vs 3(2.75,4),Z=1.549,P=0.016]。结论相较于全身麻醉,超声引导臂丛神经阻滞技术可以提供更好的血流动力学稳定性,更为有效的抑制手术引起的应激反应,改善患者术后疼痛评分,提高患者术后满意度。

Background Brachial plexus block is commonly used for surgery and analgesia of the upper extremity.Due to the simplicity of operation and the safety of approaches to brachial plexus block,the axillary brachial plexus block,which provides effective anesthesia distal to the elbow,is the most widely performed approach.Being decisional for traditional method,the anatomical structures however,express variations sometimes.A meta-analysis demonstrated that the failure rate of axillary brachial plexus block using anatomical-based traditional approach or nerve stimulation was nearly 20%.Consequently,further general anesthesia is required for the completion of surgery.The development of precise nerve localization modalities using ultrasound shortens the performance time,reduces the incidence of vascular puncture,and improves block success,which makes it possible for axillary brachial plexus block to take the place of general anesthesia for the surgery of elbow joint completely.Currently,there is still few evidence of the superiority of ultrasound guidance axillary brachial plexus block compared to general anesthesia in anesthesia and analgesia for the surgery of elbow joint.The goal of this study was to determine whether ultrasound guidance axillary brachial plexus block is more effective than general anesthesia in the suppression of hemodynamic and stress response to the elbow joint surgery.Methord(1)General data.Sixty patients who received open reduction and internal fixation surgeries for fractures around elbow joints in zhuolu county hospital of traditional Chinese medicine from October 2014 to April 2017 were enrolled in this study.Inclusion criteria:①age ranges from 18-80 years old;②class I-II based on American Society of Anesthesiologists(ASA)scale without severe systematic diseases;③closed fractures of elbow joint without neurovascular injuries.Exclusive criteria:①pathologic fractures;②multiple fractures or injuries of other parts required to be treated at the same time;③patients who do not undergo axillary brachial plexus block or general anesthesia and endotracheal intubation;④patient rejection.Exclusion criteria:serious adverse effects occurred;the operation could not be conducted under brachial plexus block and should be transferred to general anesthesia.All patients were randomly assigned into 2 groups:the brachial plexus block group(group BB,n=30)and the general anesthesia group(group GA,n=30).(2)Anesthetic management.All patients underwent routine preoperative preparation.The blood pressure,heart rate and blood oxygen saturation were monitored continuously after arrival.Supplemental oxygen and pulse oximetry were applied throughout the procedure.All patients were premeditated with dexmedetomidine(1μg/kg of loading dose for 15 min of infusion and later transferred to 0.4μg/kg/h for continuous infusion)prior to anesthesia.In group BB,0.5%bupivacaine 30 ml with dexam ethasone 5 m g was prepared as local anesthetics.Through in-plane multiple-injection technique,7 ml of local anesthetics were incrementally injected around radial nerve,median nerve,ulnar nerve and musculocutaneous nerve,.The axillary nerve was confirmed to be wrapped in the local anesthetic drug.In group GA,the anesthesia was induced with propofol(2.0 mg/kg),sufentanil(0.3μg/kg)and rocuronium(0.6 mg/kg)via endotracheal intubation.The anesthesia was maintained with propofol(4-6 mg·kg-1·h-1)and remifentanil(0.1-0.2μg·kg-1·min-1).Patient controlled intravenous analgesia(PCIA)was used for post-operation analgesia in both groups.(3)Observation and follow-ups.The mean arterial pressure and the heart rate were recorded before the anesthesia(T0),before the surgery(T1),1 h after the surgical incision(T2),at the end of surgery(T3).2 blood samples were collected at T1 and T2 to measure the blood glucose level.The pain scales were assessed via the visual analogue score(0 point presented as no pain and 10 points presented as unbearable pain)12 h after the operation,and the satisfactions of anesthesia and analgesia were assessed according to the Likert scale(1 point presented as extremely dissatisfied and 5 points presented as very satisfied).(4)Statistical analysis.The SPSS 20.0 statistical software was u sed to analyze the data.In the measurement data,normal data presented as x-±s were compared by t test.The intra group time effect and inter group effect were processed by repeated measurement of variance analysis;non-normal data presented as M(P25,P75)were compared by Kolmogorov-Smirnov Z test and the correlation was calculated by Spearman rank relational coefficient;the enumeration data was presented as case number(%),andχ2 test was used in the comparison between groups.P<0.05 was considered as statistically significant as the difference.Results Anesthesia,surgical operation and postsurgical follow-up were completed in all patients.There was no severe complication during and after surgery in either group.With successful brachial plexus block and analgesics,no patient in BB group underwent general anesthesia.There was no significant difference in demographic data,surgical performance times and locations of fracture between the 2 groups.There was no significant difference in mean arterial pressures and heart rates at different time points of m easurement for BB group.Changes in the mean arterial pres sure and the heart rate were statistically significant for GA group(F=9.568,P<0.001;F=7.746,P=0.001).The values of mean arterial pressure and heart rate did not differ significantly between groups.The concentrations of plasma glucose(mmol/L)1 h after the surgical incision were significantly higher than those before the surgery in both groups(5.9±0.7 vs 6.5±0.8,t=-8.098,P<0.001;5.8±0.9 vs 6.7±1.1,t=-7.471,P<0.001),and the increment in BB group was significantly lower than that in GA group(0.6±0.4 vs 0.9±0.6,t=-2.243,P=0.030).The VAS score in BB group was significantly lower than that in GA group 12 h postoperatively[1(1,1)vs 2(1,2.25),Z=2.066,P<0.001].The satisfaction for anesthesia and analgesia was significantly higher in BB group[4(3,5)vs 3(2.75,4),Z=1.549,P=0.016].The negative correlation between the VAS score and the satisfaction for anesthesia was statistically significant(r=-0.549,P<0.001).Conclusion The ultrasound guidance axillary brachial plexus block can take place of general anesthesia in anesthesia and analgesia for surgery of elbow joint.Compared to general anesthesia,ultrasound guidance brachial plexus block is more effective in suppressing hemodynamic fluctuation and stress response to surgery and improving post-operational pain rating and patients'satisfaction for anesthesia and analgesia.