超声引导下不同入路持续髂筋膜间隙阻滞在全髋关节置换术中的应用

Application of ultrasound-guided continuous fascia iliaca compartment block through different approaches in total hip arthroplasty

目的探讨超声引导下髂筋膜间隙阻滞在全髋关节置换术中应用的效果,同时比较内侧入路和传统外侧入路平面内穿刺置管法的不同。方法选择2017年3月至9月择期行单侧全髋关节置换术患者90例,男47例,女43例,年龄35～92岁,ASAⅠ—Ⅲ级。使用计算机随机分为三组:内侧入路组(N组)、外侧入路组(W组)和对照组(C组),每组30例。N组气管插管全麻后,在超声引导下行内侧入路平面内穿刺置管持续髂筋膜阻滞;W组气管插管全麻后,在超声引导下行传统外侧入路平面内穿刺置管持续髂筋膜阻滞;C组常规采用气管插管全麻。记录三组术中舒芬太尼用量,术后拔管时间,PACU停留时间,第1次下床活动时间,48 h内患者自控镇痛(PCA)的按压次数,使用附加镇痛药物情况和48 h镇痛满意度评分。记录三组患者术后24、48 h的静息和活动时VAS评分。记录N组和W组导管重新固定情况、超声准备和成像时间、穿刺注药时间、置管时间、置管深度和术后48 h罗哌卡因用量。记录N组和W组术后24、48 h股神经和股外侧皮神经阻滞满意率,记录三组患者术后恶心呕吐发生情况。结果 N组和W组术中舒芬太尼用量和使用附加镇痛药物率明显低于C组(P<0.05),术后拔管时间、PACU停留时间和第1次下床活动时间明显短于C组(P<0.05),48 h PCA按压次数明显少于C组(P<0.05),48 h镇痛满意度评分明显高于C组(P<0.05)。N组48 h PCA按压次数明显低于W组(P<0.05)。术后24、48 h N组和W组静息和活动时VAS评分明显低于C组(P<0.05)。N组导管重新固定率和术后48 h罗哌卡因总用量明显低于W组(P<0.05)、置管时间明显短于、置管深度明显深于W组(P<0.05);术后24、48 h股外侧皮神经阻滞满意率明显高于W组(P<0.05);两组超声准备和成像时间,穿刺注药时间差异无统计学意义。N组和W组恶心呕吐发生率明显低于C组(P<0.05)。结论内外侧入路持续髂筋膜间隙阻滞均能为全髋关节置换术患者提供良好的术后镇痛,减少镇痛药物的使用,促进患者术后恢复。内侧入路法能提高术后股外侧皮神经阻滞满意率,减少罗哌卡因用量,并且置管操作更具优势。

Objective To explore the feasibility of ultrasound-guided fascia iliaca compartment block in total hip arthroplasty,and to compare the different effects of puncture and catheterization between medial and traditional lateral approach.Methods Ninety patients with unilateral total hip arthroplasty from March to September 2017,47 males and 43 females,aged 35-92 years,ASA physical statusⅠ-Ⅲwere selected.According computer-generated randomization number sequence,they were randomly divided into three groups(n=30):group N,group W and group C.group N:after the tracheal intubation general anesthesia,the medial approach was adopted,a catheter was inserted into the fascia iliaca space under the in-plane ultrasound guidance.Group W:after the tracheal intubation general anesthesia,the traditional lateral approach was adopted,a catheter was inserted into the fascia iliaca space under the in-plane ultrasound guidance.Group C:routine tracheal intubation general anesthesia.The dosage of sufentanil,postoperative extubation time,the time in post anesthesia care unite(PACU),the time first getting out of bed,the total press times of patient controlled analgesia(PCA)in 48 hours,using of additional analgesic drugs,the score of analgesia satisfaction in 48 hours,and resting and active VAS score of patients at 24 and 48 hours after operation were recorded among three groups.The case number of re-tightening due to catheter dropped out partially,ultrasound imaging time,puncture and injection time,catheterization time and depth,and the total dosage of ropivacaine at 48 hours after operation,the satisfaction rate of the femoral nerve and the lateral femoral cutaneous nerve block at 24 and 48 hours after operation were recorded in group W and N.The incidence of postoperative nausea and vomiting(PONV)among three groups was recorded.Results In group N and group W,the dosage of sufentanil and using of additional analgesic drugs were lower than those in group C(P<0.05),the postoperative extubation time,the time in PACU and the time first getting out of bed were shorter than those in group C(P<0.05),the total press times of PCA in 48 hours were less than that in group C(P<0.05),the score of analgesia satisfaction in 48 hours were significantly higher than that in group C(P<0.05).The total press times of PCA in 48 hours in Group N was less than that in group W(P<0.05).The resting and active VAS score of patients at 24 and 48 hours after operation in Group N and Group W were lower than those in group C(P<0.05).Compared with group W,the case number of re-tightening and the total dosage of ropivacaine in postoperative 48 hours were lower(P<0.05),the catheterization time was shorter(P<0.05),the catheterization depth was deeper(P<0.05)and the satisfaction rate of the lateral femoral cutaneous nerve block at 24 and 48 hours after operation were higher in group N(P<0.05).The incidence of PONV in Group N and W was lower than that in group C(P<0.05).Conclusion Continuous fascia iliaca compartment block through medial and lateral approach can both improve postoperative analgesia for total hip arthroplasty,reduce the use of analgesic drugs and promote postoperative recovery.While the medial approach can improve the satisfaction rate of lateral femoral cutaneous nerve block,reduce the dosage of ropivacaine,and have more advantages in catheterization.