超声引导下髂筋膜间隙联合骶丛神经阻滞在老年髋部手术中的应用

Application of ultrasound-guided fascia iliac block combined with sacral plexus block during elderly hip surgery

目的探讨超声引导下髂筋膜间隙联合骶丛神经阻滞在老年髋部手术中的应用价值。方法选取2018年8月至2021年8月就诊于武汉中西医结合骨科医院178例行髋部手术的老年患者为研究对象。根据麻醉方法将患者分为联合阻滞组(行超声引导下髂筋膜间隙联合骶丛神经阻滞麻醉,n=92)及轻比重单侧腰麻(HUSA)组(n=86)。采用1∶1倾向性评分匹配法筛选出52对基线资料均衡可比的匹配序列。比较两组患者神经阻滞时间、疼痛程度、血流动力学、应激指标及并发症情况。采用SPSS 22.0统计软件进行数据分析。根据数据类型,组间比较分别采用t检验、重复测量方差分析或χ^(2)检验。结果联合阻滞组多巴胺使用率及多巴胺平均用量均显著低于HUSA组(均P<0.05)。联合阻滞组感觉阻滞起效时间及完善时间均长于HUSA组,运动阻滞起效时间及完善时间均长于HUSA组,差异均有统计学意义(均P<0.05)。联合阻滞组摆侧卧位(T1)、术后12h及术后24h时点疼痛视觉模拟评分(VAS)分别低于HUSA组,切皮(T2)及术毕(T4)时点疼痛VAS分别高于HUSA组,差异均有统计学意义(均P<0.05)。联合阻滞组术后0~24 h及术后24~48 h吗啡用量分别小于HUSA组,差异均有统计学意义(均P<0.05)。联合阻滞组T1时点MAP小于HUSA组(P<0.05),手术开始30 min(T3)、T4时点大于HUSA组(P<0.05)。联合阻滞组T2、T3、T4时点MAP均较进入手术室(T0)时点下降(P<0.05);HUSA组T1时点MAP较T0时点显著升高(P<0.05),T2、T3、T4时点MAP均较T0时点显著下降(P<0.05)。联合阻滞组T1时点HR小于HUSA组(P<0.05)。HUSA组T1时点HR较T0显著升高(P<0.05)。联合阻滞组术后24h血糖与血浆皮质醇分别低于HUSA组,差异均有统计学意义(P<0.05)。联合阻滞组术后尿潴留、恶心呕吐、头晕头痛发生率分别低于HUSA组,差异均有统计学意义(P<0.05)。结论超声引导下髂筋膜间隙联合骶丛神经阻滞可维持术中血流动力学稳定、控制术后疼痛、减少应激反应和术后并发症。

Objective To explore the application value of ultrasound-guided fascia iliac block combined with sacral plexus block during elderly hip surgery.Methods A total of 178 elderly patients undergoing hip surgery in our hospital from August 2018 to August 2021 were enrolled and served as the study subjects.According to anesthesia methods,they were divided into combined block group(ultrasound-guided fascia iliac block combined with sacral plexus block anesthesia,n=92)and hypobaric unilateral spinal anesthesia(HUSA)group(n=82).Propensity score matching was used to select 52 pairs of patients with matched baseline data in a ratio of 1∶1.Nerve block time,pain degree,hemodynamic parameters,stress indicators and incidence of complications were compared between the two groups.SPSS statistics 20.0 was used for data analysis.Depending on data type,student′s t test,repeated measures analysis of variance,orχ^(2) test was employed for intergroup comparison.Results The rate of dopamine use and its average dosage were significantly lower in the combined blockade group than the HUSA group(both P<0.05).The combined block group had obviously longer onset times and durations of analgesic effect for both sensory block and motor block than the HUSA group(both P<0.05).The pain visual analog scale(VAS)scores at T1(lateral position),and 12 and 24 h after surgery were notably lower,while the scores at T2(skin incision)and T4(end of surgery)were remarkably higher in the combined block group than the HUSA group(all P<0.05).The morphine dosage in the combined blockade group was less than that in the HUSA group at 0-24 h and 24-48 h after surgery(all P<0.05).The combined block group had lower mean arterial pressure(MAP)at T1,and higher MAP at T3(30min after operation)and T4 when compared with the HUSA group(P<0.05).The MAP at T2,T3,and T4 in the combined block group were decreased than that at T0(enter the operating room)(P<0.05);The MAP at T1 in the HUSA group was significantly higher than that at T0(P<0.05),while the MAP at T2,T3,and T4 were significantly lower than that at T0(P<0.05).The heart rate(HR)at T1 in the combined block group was lower than that in the HUSA group(P<0.05).The HR of HUSA group at T1 was significantly higher than that at T0(P<0.05).The blood glucose and plasma cortisol levels were lower in the combined block group than the HUSA group in 24 h after surgery(P<0.05).The incidences of postoperative urinary retention,nausea and vomiting,dizziness and headache in the combined block group were lower than those in the HUSA group(P<0.05).Conclusion Ultrasound-guided fascia iliac block combined with sacral plexus block can maintain intraoperative hemodynamic stability,control postoperative pain,and reduce stress response and postoperative complications.