L3椎旁神经阻滞联合骶前-腰大肌后间隙阻滞对全膝关节置换术后患者自控静脉镇痛的影响

Effects of L3 paravertebral nerve block combined with the compartment block between the psoas muscle and the sacrum on patient-controlled intravenous analgesia after total knee arthroplasty

目的探讨L3椎旁神经阻滞联合骶前-腰大肌后间隙阻滞对全膝关节置换术(total knee arthroplasty,TKA)术后患者自控静脉镇痛(patient-controlled intravenous analgesia,PCIA)的影响。方法在全身麻醉下初次行单侧TKA的患者53例,ASA分级I、II级,按随机数字表法分成两组:PCIA组(A组)和L3椎旁神经阻滞联合骶前-腰大肌后间隙阻滞+PCIA组(B组)。两组患者常规行麻醉诱导和全身麻醉维持,B组患者麻醉诱导前行L3椎旁神经阻滞联合骶前-腰大肌后间隙阻滞。B组神经阻滞后20 min内测定阻滞平面,观察阻滞后20 min内血流动力学变化。术毕两组均采用PCIA。记录术后30 min、6 h、12 h、24 h、48 h的静息VAS评分和术后12、24、48 h下肢活动时VAS评分,并记录术后24、48 h的PCIA按压次数、输注总量及术后给予氟比洛芬酯的总量。观察术后恶心呕吐、瘙痒、呼吸抑制等不良反应的发生情况。结果B组阻滞后20 min内,血流动力学与神经阻滞前比较无明显波动(P>0.05);B组阻滞后20 min可获得L3-S2范围内的阻滞平面(冰块法),各神经节段的阻滞概率不同。与A组比较,B组静息VAS评分在术后6、12、24 h降低(P<0.05),在术后30 min和48 h两组差异无统计学意义(P>0.05),下肢活动时VAS评分在术后12 h较A组降低(P<0.05),术后24、48 h差异无统计学意义(P>0.05)。与A组比较,B组术后镇痛泵按压次数、镇痛泵输注总量和氟比洛芬酯应用总量均减少(P<0.05),术后A组和B组发生恶心、呕吐等不良反应的病例数差异无统计学意义(P>0.05)。结论L3椎旁神经阻滞联合骶前-腰大肌后间隙阻滞用于TKA患者可明显减少术后阿片类和其他镇痛药物的用量,且阻滞前后无明显生命体征变化,不增加术后不良反应发生率。

Objective To investigate the effect of paravertebral nerve block combined with the compartment block between the psoas muscle and the sacrum on patient-controlled intravenous analgesia(PCIA)after total knee arthroplasty(TKA).Methods A total of 53 patients with American Society of Anesthesiologists(ASA)I or II grade who initially underwent unilateral TKA under general anesthesia were selected.They were randomly divided into two groups:a PCIA group(group A)and a PCIA+L3 paravertebral nerve block combined with the compartment block between the psoas muscle and the sacrum group(group B).Patients in group A routinely received anesthesia induction and maintenance,while those in group B underwent L3 paravertebral nerve block combined with the compartment block between the psoas muscle and the sacrum before induction.Block plane was measured within 20 min after block in group B,and hemodynamic changes were observed within 20 min after block.PCIA was adopted in both groups.The scores of Visual Analogue Scale(VAS)at rest were recorded 30 min,6 h,12 h,24 h and 48 h after operation,and the scores of VAS at low limb movement 12,24,48 h after operation were recorded.The number of PCIA pressing,the total infusion volume 24 h and 48 h after operation and the total amount of flurbiprofen axetil after operation were recorded.The incidence of adverse reactions such as nausea,vomiting,itching and respiratory depression was observed.Results In group B,there was no significant fluctuation in hemodynamics before and 20 min after nerve block(P˃0.05).The block plane(ice block method)in the range of L3-S2 was obtained in group B 20 min after block,with different blockage probabilities at each nerve segment.Compared with group A,group B presented remarkable decreases in the VAS score at rest 6,12,24 h after operation(P<0.05).There was no significant difference between the two groups 30 min and 48h after operation(P>0.05).Compared with group A,group B presented remarkable decreases in the VAS score at lower limb movement 12 h after operation(P<0.05).There was no significant difference between the two groups 24 h and 48 h after operation(P>0.05).Compared with group A,the number of PICA pressing,the total infusion volume and the total amount of flurbiprofen ester were significantly decreased in group B(P<0.05).There was no significant difference in the number of adverse reactions such as nausea and vomiting between group A and group B(P>0.05).Conclusions L3 paravertebral nerve block combined with the compartment block between the psoas muscle and the sacrum can significantly reduce the dosage of opiums and other analgesics after TKA,without significant changes in vital signs before and after block and increases in the incidence of adverse reactions after operation.