不同入路腹股沟上髂筋膜间隙阻滞在高龄患者直接前方入路全髋关节置换术中的应用

The efficacy of different approaches of supra-inguinal fascia iliaca compartment block on postoperative analgesia in elderly patients undergoing total hip arthroplasty of the direct anterior approach

目的探讨不同入路(“领结征”入路和“深部”入路)腹股沟上髂筋膜间隙阻滞与“鸡尾酒”镇痛在侧卧位直接前方入路(DAA)下全髋关节置换术(THA)高龄患者术后短、中期镇痛及临床康复的效果。方法选择拒绝或不能实施椎管内麻醉的单侧DAA下THA高龄患者104例,采用随机数字表法分为3组,“领结征”入路腹股沟上髂筋膜间隙阻滞(BSIFIB)组(B组)35例、“深部”入路腹股沟上髂筋膜间隙阻滞(DSIFIB)组(D组)34例、“鸡尾酒”组(C组)35例,均予以0.33%罗哌卡因30 mL,患者在侧卧位下行DAA下THA。记录不同时间点平均动脉压、心率,丙泊酚、瑞芬太尼、去甲肾上腺素用量;记录复苏情况、术后48 h累计舒芬太尼用量;不良反应。术后1个月随访,记录关节功能康复WOMAC评分、影像学Harris评分以及视觉模拟评分(VAS)。结果与C组比较,B、D组术中丙泊酚、瑞芬太尼、去甲肾上腺素用量、拔管时间、麻醉恢复室(PACU)停留时间、术后48 h累计舒芬太尼用量减少(P<0.05);与B组相比,D组术中瑞芬太尼、去甲肾上腺素用量和术后48 h累计舒芬太尼用量减少。B、D组MAP在手术5 min(T_(2))低于C组,D组在手术30 min(T_(3))高于C组(P<0.05)。D组患者术后24、48 h静息时,B、D组术后24、48 h运动时VAS评分低于C组(P<0.05)。术后1个月,B、D组患者运动时VAS评分、WOMAC评分低于C组(P<0.05),Harris评分高于C组(P<0.05)。结论BSIFIB和DSIFIB应用于老年患者DAA下THA,相对于“鸡尾酒”镇痛,能提供安全、有效的围术期镇痛,具有显著的阿片类药物节俭作用,良好的关节康复效果。对比BSIFIB,DSIFIB阻滞准确度更高,镇痛效果更可靠。

Objective To explore the efficacy of postoperative short-and long-term analgesia and rehabilitative effect among bow-tie sign supra-inguinal fascia iliaca block(BSIFIB)and deep supra-inguinal fascia iliaca block(DSIFIB)and periarticular infiltration in elderly patients undergoing total hip arthroplasty(THA)of the direct anterior approach(DAA)in the lateral decubitus position.Methods The 104 elderly patients undergoing THA of DAA were randomly divided into three groups:group B,D and C.35 patients were in group B and C and 34 in group D,who were effectively followed up for at least one month.The hemodynamics,total remifentanil,noradrenaline and propofol during operation,extubation time,time in postanesthesia care unit(PACU),postoperative pain scores,sulfentanil consumption and adverse reactions were recorded.The function rehabilitation,imaging Harris score,WOMAC score and VAS of the hip joint were also recorded.Results Compared with group C,MAP at 5 min after operation in group B and D were lower(P<0.05).MAP at 30 min after operation in group D were higher(P<0.05).Compared with group C,the dosage of propofol,remifentanil,norepinephrine during operation,extubation time,PACU stay time and the cumulative dosage of sulfentanil 48h after operation in group B and D were significantly lower than those in group C(P<0.05).Compared with group B,dosage of remifentanil and norepinephrine and the cumulative amount of sufentanil 48 hours after operation in group D were significantly lower(P<0.05).The VAS of rest in group D at 24 h and 48 h of postoperation was significantly lower than that of in group C(P<0.05),while that of group B and D at moving at 24 h and 48 h of post-operation was lower.One month after the surgery,compared with group C,VAS at moving and WOMAC score in group B and D were significantly lower than those in group C(P<0.05).Harris score was significantly higher than those in group C(P<0.05).Conclusions The application of BSIFIB and DSIFIB to THA of DAA in lateral position could provide safe and effective analgesia with significant opioid saving effect and hip joint rehabilitation.Compared with BSIFIB,the advantage of DSIFIB is more accuracy,it provides more reliable perioperative analgesia effect.