超声引导下不同剂量"角袋"区臂丛神经阻滞与臂丛神经周围阻滞对膈肌麻痹的影响

Effect of different doses of brachial plexus block and peripheral nerve block in"corner pocket"area on diaphragmatic pa⁃ralysis under ultrasound guidance

目的探讨超声引导下"角袋"区臂丛神经阻滞与臂丛神经周围阻滞对膈肌麻痹的影响。方法选取2018年1月至2019年12月需行肩关节以下上肢手术的患者88例,采用随机数字表法分为对照组和试验组,每组44例。对照组给予超声引导下罗哌卡因臂丛神经丛周围注射,0.375%罗哌卡因5 ml注射在"角袋"+15 ml注射在神经丛周围;试验组给予超声引导下罗哌卡因"角袋"区注射,0.375%罗哌卡因15 ml注射在"角袋"+5 ml注射在神经丛周围。记录并比较两组患者麻醉前及麻醉后15、30 min的第一秒用力呼气量(forced expiratory volume in first second,FEV_(1))、用力肺活量(forced vital capacity,FVC)、平静呼吸和用力呼吸的膈肌移动度,麻醉后平静呼吸和用力呼吸的膈肌麻痹率;针刺法测定患者腋神经、肌皮神经、尺神经、桡神经和正中神经所属区域皮肤痛觉消失时间;记录和比较麻醉阻滞时间、麻醉持续时间及术后24 h不良反应发生情况。结果与麻醉前比较,麻醉后15、30 min两组患者FEV_(1)、FVC、平静呼吸和用力呼吸膈肌移动度均降低(P<0.05)。麻醉后15、30 min,试验组FEV_(1)、FVC均明显高于对照组(P<0.05),平静呼吸和用力呼吸膈肌移动度均明显大于对照组(P<0.05);试验组麻醉后平静呼吸和用力呼吸膈肌总麻痹率明显低于对照组(P<0.05)。试验组患者麻醉后腋神经、肌皮神经、尺神经、桡神经所属区域皮肤痛觉消失时间均低于对照组(P<0.05),正中神经所属区域皮肤痛觉消失时间与对照组比较差异无统计学意义(P>0.05)。试验组麻醉阻滞时间低于对照组,麻醉持续时间高于对照组,总不良反应发生率低于对照组,但差异均无统计学意义(P>0.05)。结论超声引导下"角袋"区臂丛神经阻滞可显著降低患者膈肌麻痹率,改善肺功能,缩短术区神经麻醉时间,安全性好。

Objective To compare the effect of ultrasound⁃guided brachial accessory nerve block in the"horn pocket"area and traditional peri⁃plexus block on diaphragmatic palsy.Methods A total of 88 patients who required upper limb surgery below the shoulder joint from January 2018 to December 2019 were selected.According to the random number table method,they were divid⁃ed into two groups(n=44):a control group and an experimental group.Patients in the control group underwent ropivacaine brachial plexus perineural injection,including 0.375%ropivacaine(5 ml)in the"corner pocket"+15 ml around the plexus.Patients in the exper⁃imental group were given ropivacaine under the guidance of ultrasound,including 0.375%ropivacaine(15 ml)in the"corner pocket"+5 ml around the plexus.Then,the two groups were compared for the forced expiratory volume in the first second(FEV_(1)),forced vital ca⁃pacity(FVC),diaphragmatic mobility during calm breathing and forced breathing,and diaphragmatic paralysis rate after calm breathing and forced breathing before anesthesia and 15 min and 30 min after anesthesia.The time of disappearance of skin pain in the axillary nerve,the musculocutaneous nerve,the ulnar nerve,the radial nerve and the median nerve was measured by acupuncture.The time of anesthesia block,duration of anesthesia and adverse reactions 24 h after operation were recorded.Results Compared with those be⁃fore both groups presented decreases in anesthesia,FEV_(1),FVC,diaphragmatic mobility of calm breathing and forced breathing 15 min and 30 min after anesthesia(P<0.05).Then,15 min and 30 min after anesthesia,the experimental group presented significantly higher FEV_(1)and FVC than the control group(P<0.05),and higher diaphragm mobility of calm breathing and forced breathing than the control group(P<0.01).After anesthesia,the total paralysis rate of diaphragm in the experimental group was significantly lower than that in the control group(P<0.05).After anesthesia,the time of disappearance of skin pain in the axillary nerve,the musculocutaneous nerve,the ulnar nerve and the radial nerve in the experimental group was lower than that in the control group(P<0.05),and there was no signifi⁃cant difference in the time of disappearance of skin pain in the median nerve between the two groups(P>0.05).The experimental group showed shorter time of anesthesia block,longer anesthesia duration,and a lower total incidence of adverse reactions than the control group,without statistical differences(P>0.05).Conclusions Ultrasound⁃guided brachial nerve block in the"corner pocket"area can significantly reduce the rate of diaphragmatic paralysis,improve pulmonary function and shorten the time of neuroanesthesia in the operating area,with good safety.