超声引导下不同置管长度连续股神经阻滞对老年患者膝关节周围骨折术后的镇痛效果

Postoperative analgesic efficacy of different length of catheter for continuously femoral nerve block guided by ultrasound in elderly patients with knee peripheral fracture

目的评价超声引导下不同置管长度连续股神经阻滞对老年膝关节周围骨折术后的镇痛效果。方法选择嘉定区中心医院麻醉科2016年6月至2018年5月在全身麻醉下行初次膝关节周围骨折内固定术的老年患者120例(ASA分级Ⅰ～Ⅱ),按照随机数表法分为三组,每组各40例。A组术后在超声引导下沿股神经置入导管2 cm,B组置管10 cm,A组、B组通过导管给予0.5%盐酸利多卡因20 mL后,连接镇痛泵持续给予0.2%罗哌卡因用于术后持续股神经阻滞镇痛(CFNB);C组不行股神经置管,术后用0.01%的舒芬太尼行传统的患者自控静脉镇痛(PCIA),比较三组患者术后镇痛的临床疗效。记录A组和B组置管侧下肢感觉、运动阻滞起效时间和置管操作时间;观察和记录三组术后6 h、12 h、24 h、36 h、48 h静息状态与功能锻炼的视觉模拟评分(VAS);分别记录各组发生恶心、呕吐、嗜睡等并发症的例数,48 h内需要静脉追加止痛药的例数以及患者对镇痛效果的满意率。结果 A组和B组患者的感觉和运动阻滞起效时间比较差异无统计学意义(P>0.05),但A组操作时间为(3.56±1.46) min,明显短于B组的(8.35±2.62) min,差异有统计学意义(P<0.05);在各观察时点A组与B组患者静息状态、功能锻练时的VAS评分均明显低于C组,差异均有统计学意义(P<0.05),而A组患者的VAS评分与B组比较,差异均无统计学意义(P>0.05);C组患者发生恶心、呕吐、嗜睡等不良反应的发生率分别为43%、23%、15%,均明显高于A组的10%、5%、0与B组的15%、8%、0,差异均有统计学意义(P<0.05);C组患者术后补救用镇痛药27例,明显高于A组的17例和B组的15例,差异均有统计学意义(P<0.05),而A组和B组在各时间段的给补救镇痛药的例数比较差异无统计学意义(P>0.05);患者对术后镇痛满意率A组为94.4%,B组为90.6%,均明显高于C组的82.5%,差异均有统计学意义(P<0.05)。结论超声引导下沿股神经置入导管2 cm和10 cm用于膝关节周围骨折术后行CFNB镇痛均能获得较好的镇痛效果,比PCIA不良反应发生率低。置管2 cm还具有操作简便、置管时间较少的优点,可在临床推广应用。

Objective To assess the analgesic efficacy of different length of catheter for continuously postoperative femoral nerve block guided by ultrasound in elderly patients with knee peripheral fracture.Methods In the study,120 patients with ASAⅠ-Ⅱwith knee peripheral fracture undergoing fracture fixation by general anesthesia during June 2016 and May 2018 in the Department of Anesthesiology in Jiading District Center Hospital were randomly divided into three groups by random number table method.Group A(n=40)was given continuous femoral nerve block(CFNB)after the surgery guided by ultrasound and a femoral nerve catheter was inserted 2 cm.In group B(n=40),the catheter was inserted 10 cm,patient-controlled analgesia pumps was connected after load of 20 mL 0.5%lidocaine via the catheters,0.2%ropivacaine 4 m L/h was given through femoral nerve catheter.Group C(n=40)was not inserted catheter but received 0.01%sufentanly as patient-controlled intravenous analgesia(PCIA).Operation time of inserting catheter,sensory and motor block of the femoral nerve onset time were recorded in group A and group B.Visual analog scale(VAS)scores of patients at resting or function exercise in all three groups at 6 h,12 h,24 h,36 h,48 h during postoperative analgesia were observed.The adverse effects,the number of cases of additional analgesics,and patient’s satisfaction on analgesia therapy were also recorded.Results There was no significant difference in sensory and motor blockade onset time between group A and group B(P>0.05).Time of placing catheter in group A was(3.56±1.46)min,significantly shorter than(8.35±2.62)min in group B(P<0.05).The VAS scores at resting,and function exercise in group C were significantly higher than those in group A and group B at all observation time points after operation(P<0.05).The incidence of adverse reactions such as nausea,vomiting,excessive sleepiness in group C was 43%,23%,15%,significantly higher than 10%,5%,0 in group A and 15%,8%,0 in group B(P<0.05).The number of cases using additional analgesics within 48 h in group C were 27,significantly more than 17 in group A and 15 in group B(P<0.05).The degree of patients’satisfaction about the quality of postoperative analgesia in group A(94.4%)and group B(90.6%)was better than that in group C(82.5%),P<0.05.Conclusion When CFNB is used for postoperative analgesia after internal fixation of knee peripheral fracture in the elderly,the catheter that is inserted 2 cm or 10 cm can provide similar and satisfying analgesia effect,and lower incidence of adverse reactions than PCIA.However,the catheter that is inserted 2 cm has advantage for shorter time of inserting catheter procedure,which is worth popularizing and applying in clinic.