以髂筋膜间隙阻滞为基础的无阿片镇痛在糖尿病足膝上截肢围术期中的应用

Perioperative application of opioid free analgesia based on fascia iliaca compartment block in diabetic foot patients undergoing upper knee amputation

目的观察超声引导下以腹股沟韧带上髂筋膜间隙阻滞(SFICB)为基础的无阿片镇痛(OFA)用于糖尿病足患者膝上截肢围术期的镇痛和康复效果。方法选择2016年1月至2022年12月在廊坊市人民医院行糖尿病足膝上截肢术患者40例作为研究对象。按镇痛方法的不同将患者分为阿片镇痛(OA)组和OFA组,每组20例。OA组行腰硬联合麻醉,术毕行阿片患者自控静脉镇痛(OPCIA);OFA组行SFICB和腰硬联合麻醉,术毕行无阿片患者自控静脉镇痛(OFPCIA)。观察并记录麻醉前(T1)、平卧转侧卧(T2)、侧卧弓腰(T3)、麻醉后24 h(T4)时疼痛数字等级评价量表(NRS)评分和术后正常饮食时间、无痛期持续时间、有效按压容量、补救镇痛药用量,以及术后48 h内恶心/呕吐、皮肤瘙痒、谵妄、幻觉、重度疼痛等不良事件的发生情况。结果OA组T2、T3、T4时NRS评分均明显高于OFA组(分:5.35±1.76比3.15±0.75,4.10±1.07比2.50±0.69,2.90±0.97比1.65±0.59,均P<0.05)。OA组正常饮食时间、患者自控静脉镇痛(PCIA)有效按压容量、补救镇痛药用量均明显高于OFA组〔正常饮食时间(h):6.60±2.41比3.45±1.32,PCIA有效按压容量(mL):22.75±2.45比11.70±4.78,补救镇痛药用量(mg):108.00±35.63比30.00±27.53,均P<0.05〕,无痛期持续时间较OFA组明显缩短(h:4.25±1.68比23.60±5.14,P<0.05)。OA组术后48 h内恶心/呕吐、皮肤瘙痒、谵妄、重度疼痛发生率明显高于OFA组〔分别为60.0%(12/20)比15.0%(3/20),65.0%(13/20)比10.0%(2/20),30.0%(6/20)比5.0%(1/20),60.0%(12/20)比10.0%(2/20),均P<0.05〕,幻觉发生率明显低于OFA组〔0%(0/20)比20.0%(4/20),P<0.05〕。结论行超声引导下以SFICB为基础的OFA较OA安全有效地降低了糖尿病足膝上截肢术患者围术期阿片类药物的不良反应,并加速了患者康复。

Objective To observe the analgesic and rehabilitation effects of opioid-free analgesia(OFA)based on supra-inguinal fascia iliaca compartment block(SFICB)in patients undergoing diabetic foot Upper knee amputation.Methods A total of 40 patients in Langfang People's Hospital between January 2016 and December 2022 scheduled for diabetic foot upper knee amputation were selected as the research objects.The patients were divided into opioid analgesia(OA)group and OFA group according to different analgesic methods,with 20 cases in each group.OA group received combined spinal epidural anesthesia(CSEA)and opioid patient controlled intravenous analgesia(OPCIA)after the end of operation;OFA group received SFICB and CSEA,and opioid free patient controlled intravenous analgesia(OFPCIA)after the end of operation.Numerical rating scale(NRS)score at pre-anesthesia(T1),supine to lateral position(T2),lateral decubitus position(T3),post-anesthesia 24 hours(T4),normal eating time,painless period,effective pressing capacity,and rescue analgesic dose was observed and recorded.The incidence of nausea/vomiting,pruritus,postoperative delirium,hallucination,and severe pain within 48 hours after operation were also recorded.Results The NRS scores at T2,T3 and T4 in OA group were significantly higher than those in OFA group(5.35±1.76 vs.3.15±0.75,4.10±1.07 vs.2.50±0.69,2.90±0.97 vs.1.65±0.59,all P<0.05).The time of normal eating,patient controlled intravenous analgesia(PCIA)effective pressing capacity,and rescue analgesic dose in OA group were significantly higher than those in OFA group[time of normal eating(hours):6.60±2.41 vs.3.45±1.32,PCIA effective pressing capacity(mL):22.75±2.45 vs.11.70±4.78,rescue analgesic dose(mg):108.00±35.63 vs.30.00±27.53,all P<0.05].The painless period in OA group was significantly less than that in OFA group(hours:4.25±1.68 vs.23.60±5.14,P<0.05).The incidence of nausea/vomiting,pruritus,postoperative delirium,and severe pain within 48 hours post operation in OA group were significantly higher than those in OFA group[60.0%(12/20)vs.15.0%(3/20),65.0%(13/20)vs.10.0%(2/20),30.0%(6/20)vs.5.0%(1/20),60.0%(12/20)vs.10.0%(2/20),respectively,all P<0.05].The incidence of hallucination within 48 hours post operation in OA group was significantly less than that in OFA group[0%(0/20)vs.20.0%(4/20),P<0.05].Conclusion OFA based on SFICB safely and effectively reduced adverse reaction of opioids and enhanced recovery compared to OA during the perioperative period in patients undergoing diabetic foot upper knee amputation.