超声引导下改良前路坐骨神经阻滞用于全麻骨科手术患者的效果

Efficacy of ultrasound-guided modified anterior approach to sciatic nerve block for orthopedic surgery with general anesthesia

目的评价超声引导下改良前路坐骨神经阻滞用于全麻骨科手术患者的效果。方法择期行膝关节或远端部位骨科手术患者90例,年龄18~64岁,性别不限,体重指数19~28 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法分为3组(n=30):改良前路组(穿刺针与超声束几乎垂直)、前路组和后路组。超声引导下行坐骨神经阻滞(注射0.5%罗哌卡因20 ml)联合股神经阻滞(注射0.5%罗哌卡因15~20 ml)。在喉罩联合静吸复合全麻下完成手术。当通气频率≥20次/min和/或心率增加幅度超过基础值的20%时,静脉注射舒芬太尼1 μg/次。术后24 h内VAS评分≥4分时,口服塞来昔布胶囊0.2 g进行镇痛。记录坐骨神经深度、进针深度、超声下穿刺针显像清晰度评分、坐骨神经阻滞操作时间和持续时间;分别于术后6、8、10、12和24 h时记录静态和动态VAS评分;记录术中舒芬太尼用量和术后24 h内塞来昔布胶囊使用情况。记录术后穿刺部位血肿、恶心呕吐等不良反应的发生情况。结果与后路组比较,改良前路组和前路组坐骨神经深度和进针深度增加,坐骨神经阻滞操作时间延长,持续时间缩短,术中舒芬太尼用量增加,术后10 h时静态和动态VAS评分升高,改良前路组穿刺针显像清晰度评分升高(P<0.05)。与前路组比较,改良前路组穿刺针显像清晰度评分升高(P<0.05)。3组间术后24 h内塞来昔布胶囊使用率和不良反应发生率差异无统计学意义(P>0.05)。结论虽然超声引导下改良前路坐骨神经阻滞用于全麻骨科手术患者的效果与前路坐骨神经阻滞无差异,且不如后路坐骨神经阻滞,但改良前路坐骨神经阻滞便于操作,且超声下显像清晰。

Objective To evaluate the efficacy of ultrasound-guided modified anterior approach to sciatic nerve block (SNB) for orthopedic surgery with general anesthesia. Methods Ninety American Society of Anesthesiology physical status Ⅰ or Ⅱpatients of both sexes, aged 18-64 yr, weighing 19-28 kg/m2, scheduled for elective knee joint or distal orthopedic surgery, were divided into 3 groups (n=30 each) using a random number table method: modified anterior approach (the puncture needle was almost perpendicular to the ultrasound beam)group, anterior approach group and posterior approach group.SNB (injecting 0.5% ropivacaine 20 ml) combined with femoral nerve block (injecting 0.5% ropivacaine 15-20 ml) was performed under ultrasound guidance.Surgery was completed under combination of the laryngeal mask and combined intravenous-inhalational anesthesia.When the respiratory rate ≥20 beats/min and/or the increase in heart rate was more than 20% of the baseline value, sufentanil 1 μg/time was intravenously injected.When visual analog scale (VAS) score ≥4 within 24 h after surgery, celecoxib capsules 0.2 g was taken orally for analgesia.The depth of sciatic nerve, needling depth, sharpness score of needle imaging under ultrasound, and operation time and duration of SNB were recorded.VAS scores at rest and during activity were recorded at 6, 8, 10, 12 and 24 h after surgery.The amount of sufentanil consumed during surgery and use of celecoxib capsules within 24 h after surgery were recorded.The development of adverse reactions such as hematoma at the puncture site, nausea and vomiting was also recorded after surgery. Results Compared with posterior approach group, the depth of sciatic nerve and needling depth were significantly increased, the operation time of SNB was prolonged, the duration of SNB was shortened, the intraoperative consumption of sufentanil was increased, VAS scores at rest and during activity were increased at 10 h after surgery, and the sharpness score of needle imaging was increased in modified anterior approach and anterior approach groups (P<0.05). Compared with anterior approach group, the sharpness score of needle imaging was significantly increased, and VAS scores during activity were decreased at 24 h after surgery in modified anterior approach group(P<0.05). There was no significant difference in the requirement for celecoxib capsules within 24 h after surgery or occurrence of adverse reactions among the three groups (P>0.05). Conclusion Although ultrasound-guided modified anterior approach to SNB provides comparable efficacy with anterior approach to SNB and is not as good as posterior approach to SNB when used for orthopedic surgery with general anesthesia, modified anterior approach to SNB is easy to operate, with clear images under ultrasound.