不同麻醉方式对小儿桡骨远端骨折早期预后的影响:一项单中心前瞻性随机对照研究

Effects of different anesthetic methods on early outcomes of distal radius fractures in children:a single-center,prospective,randomized controlled study

目的探讨不同麻醉方式对小儿桡骨远端骨折早期预后的影响。方法本研究为单中心、前瞻性、随机对照研究。以2019年1月至2020年1月中国医科大学附属盛京医院年龄6~12岁、接受桡骨远端骨折切开复位内固定术的90例患儿为研究对象,使用随机数余数分组法分为神经阻滞麻醉组(RA组,n=45)和全身麻醉组(GA组,n=45)。GA组接受常规全身麻醉,RA组接受超声引导下锁骨下臂丛神经阻滞。主要研究结局包括术后1个月的关节活动度评分、握力测试评分、腕关节患儿自我评分及40项恢复质量评分(quality of recovery 40,QoR-40)。次要研究结局包括术前、术后即刻、术后2 h、术后8 h、术后24 h、术后48 h、术后72 h、术后2周及术后1个月的疼痛评分;术后疼痛高峰的出现时间及强度;术后第1天(P_(1))、第2天(P_(2))及第3天(P_(3))氨酚待因消耗量、术后1~3 d氨酚待因累计消耗量(T_(1-3))及首次给予氨酚待因的时间;术后24 h内恶心呕吐的发生率、术后非计划性入院的发生率及麻醉满意度。结果GA组共44例、RA组共43例完成了所有时间点数据的收集,两组一般资料比较,差异均无统计学意义(P>0.05)。RA组术后即刻[7(0,10)分比0(0,4)分]、术后2 h[4(0,8)分比0(0,4)分]和术后8 h[4(0,7)分比2(0,5)分]的疼痛评分低于GA组,差异具有统计学意义(P<0.05)。RA组术后疼痛峰值出现时间晚于GA组[1(1,20)min比12(8,24)min],差异具有统计学意义(P<0.05)。RA组术后第1天氨酚待因消耗量、术后1~3 d氨酚待因累计消耗量低于GA组,差异具有统计学意义(P<0.05)。RA组术后首次口服氨酚待因的时间晚于GA组,差异具有统计学意义(P<0.05)。RA组术后1个月的关节活动度评分及握力测试评分与GA组比较,差异均无统计学意义(P>0.05)。RA组术后1个月的腕关节患儿自我评分低于GA组,差异具有统计学意义(P<0.05)。RA组术后1个月的QoR-40总分[175.0(158.0,186.5)分比152.0(143.0,185.0)分]、情感状态[55.0(50.0,60.0)分比42.0(37.0,47.0)分]、生理舒适[57.0(56.0,59.3)分比32.0(23.0,50.0)分]及心理支持[33.0(27.0,35.0)分比11.0(7.0,15.0)分]项目评分均高于GA组,差异具有统计学意义(P<0.05)。结论臂丛神经阻滞麻醉较全身麻醉可更有效地缓解术后早期疼痛,减少患儿对镇痛药物的依赖,降低恶心呕吐的发生率,更有助于术后1个月腕关节功能恢复。这一结果将进一步提升神经阻滞技术在小儿骨科中的应用。

Objective To explore the effects of different anesthetic methods on early outcomes of distal radius fracture in children.Methods For this single-center,prospective,randomized controlled study,90 children aged 6-12 years undergoing open reduction and internal fixation of distal radius fractures were randomly divided into two groups of nerve block anesthesia(RA,n=45)and general anesthesia(GA,n=45).GA group received routine general anesthesia while RA group ultrasound-guided subclavian brachial plexus block.The major outcomes were range-of-motion score,grip strength test score,40-item recovery quality score and patient-rated wrist evaluation at Month 1 post-operation.The secondary outcomes were pain scores at preoperative,immediately post-operation,2/8/24/48/72 h,2 weeks and 1 month post-operation.Tme and intensity of postoperative peak pain;consumption of paracetamol and codeine tablets at Day 1(P_(1)),Day 2(P_(2))and Day 3(P_(3))post-operation,cumulative consumption of paracetamol and codeine tablets 1-3(T_(1-3))post-operation and time of initial dosing of paracetamol and codeine tablets;incidence of nausea and vomiting within 24 h post-operation,incidence of unplanned postoperative hospital admission and anesthetic satisfaction.Results Finally 44 cases in GA group and 43 cases in RA group completed the data collection at all timepoints.No inter-group statistical significance existed in general profiles(P>0.05).Pain scores of RA group were lower than those of GA group at immediately post-operation and 2/8h post-operation.And the difference was statistically significant(P<0.05).Pain score at 24 h post-operation in RA group was higher than that in GA group and the difference was statistically significant(P<0.05).Peak time of postoperative pain was later in RA group than that in GA group.And the difference was statistically significant(P<0.05).The consumption of paracetamol and codeine tablets at Day 1 post-operation in RA group was significantly lower than that in GA group(P<0.05).And cumulative consumption of paracetamol and codeine tablets at Day 1 to Day 3 post-operation was significantly lower in RA group than that in GA group(P<0.05).Time of initial oral administration of paracetamol and codeine tablets was significantly later in RA group than that in GA group(P<0.05).No significant inter-group difference existed in joint range-of-motion score or grip strength test score.Patient-rated wrist evaluation score was lower in RA group than that in GA group at Month 1 post-operation(P<0.05).Total scores of QOR-40,emotional state,physical comfort and psychological support items at Month 1 post-operation were all higher in RA group than those in GA group(P<0.05).Conclusion Brachial plexus block anesthesia is more effective than general anesthesia in relieving early postoperative pain,reducing dependence on analgesics and lowering the incidence of nausea and vomiting.More importantly,brachial plexus block anesthesia offers better recovery quality and patient-rated wrist evaluation scores than general anesthesia at Month 1 post-operation.And the application of nerve block technology is promising in pediatric orthopedics.