膝关节置换术麻醉的优化策略:IPACK-收肌管阻滞联合全身麻醉

Optimized strategy of anesthesia for total knee arthroplasty:IPACK-adductor canal block combined with general anesthesia

目的评价膝关节囊后间隙阻滞(IPACK)-收肌管阻滞联合全身麻醉用于膝关节置换术的优化效应。方法择期单侧全膝关节置换术患者60例,性别不限,年龄18~64岁,BMI 18~24 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法分为2组(n=30):IPACK-收肌管阻滞联合全身麻醉组(IA组)和常规麻醉组(C组):股神经阻滞-腘窝上坐骨神经阻滞联合全身麻醉。全身麻醉诱导前,超声或联合神经刺激仪引导下,IA组行IPACK、收肌管阻滞,分别注射0.375%罗哌卡因15、25 ml;C组行股神经和腘窝上坐骨神经阻滞,分别注射0.375%罗哌卡因20 ml。确认神经阻滞效果后,实施全凭静脉麻醉,维持BIS值40~60。术后采用舒芬太尼行PCIA,维持术后VAS评分≤3分。记录术后出PACU、24、48和72 h时股四头肌肌力评分;首次下地活动时间;术后患者清醒时足下垂、补救镇痛和不良反应的发生情况;术后住院时间以及患者对术后恢复满意度评分。结果与C组比较,IA组术后股四头肌肌力和术后恢复满意度评分升高,术后足下垂发生率降低,术后住院时间和首次下地活动时间缩短(P<0.05)。结论IPACK-收肌管阻滞联合全身麻醉可作为有助于膝关节置换术后转归的优化策略。

Objective To evaluate the optimized effect of infiltration between the popliteal artery and the capsule of the knee(IPACK)-adductor canal block(ACB)combined with general anesthesia when used for the total knee arthroplasty.Methods Sixty patients of both sexes,aged 18-64 yr,with body mass index of 18-24 kg/m2,of American Society of Anesthesiologists physical statusⅠorⅡ,scheduled for elective unilateral total knee arthroplasty,were divided into 2 groups(n=30 each)using a random number table method:IPACK-ACB combined with general anesthesia group(group IA)and conventional anesthesia femoral nerve block-popliteal superior sciatic nerve block combined with general anesthesia group(group C).Before induction of general anaesthesia,0.375%ropivacaine 15 ml was injected for IPACK and 0.375%ropivacaine 25 ml for ACB under the ultrasound guidance in group IA,femoral nerve block and popliteal superior sciatic nerve block was performed under the guidance of ultrasound combined with a nerve stimulator and 0.375%ropivacaine 20 ml was injected in group C.After confirming the efficacy of nerve block,total intravenous anesthesia was carried out to maintain bispectral index values at 40-60.Patient-controlled intravenous analgesia was performed with sufentanil after operation,and the visual analog scale score was maintained≤3.The quadriceps muscle strength score was recorded when discharge from postanesthesia care unit and at 24,48 and 72 h after surgery.The first postoperative off-bed time and development of foot drop in awake patients after surgery,requirement for rescue analgesia and adverse reactions were recorded.The postoperative length of hospital stay and score for patients′satisfaction with postoperative recovery were also recorded.Results Compared with group C,the postoperative quadriceps muscle strength scores and score for patients′satisfaction with postoperative recovery were significantly increased,the incidence of postoperative foot drop was decreased,and the length of hospital stay and first postoperative off-bed time were shortened in group IA(P<0.05).Conclusion IPACK-ACB combined with general anesthesia may be an optimized strategy which is helpful for outcomes after total knee arthroplasty.