超聲引導(dǎo)下臂叢神經(jīng)阻滯與全身麻醉在肘關(guān)節(jié)手術(shù)中的應(yīng)用比較

武科任素敏趙麗敏閆志永姜柏林

·論著·

超聲引導(dǎo)下臂叢神經(jīng)阻滯與全身麻醉在肘關(guān)節(jié)手術(shù)中的應(yīng)用比較

武科1任素敏1趙麗敏1閆志永1姜柏林2

目的對(duì)比在肘關(guān)節(jié)手術(shù)中超聲引導(dǎo)下臂叢神經(jīng)阻滯技術(shù)及全身麻醉技術(shù)的優(yōu)劣。方法選取2014年10月至2017年4月涿鹿縣中醫(yī)院行肘關(guān)節(jié)周圍骨折切開復(fù)位內(nèi)固定術(shù)的患者共60例，隨機(jī)分為臂叢神經(jīng)阻滯組（BB組，n=30）及全身麻醉組（GA組，n=30）。BB組在超聲引導(dǎo)下行腋路神經(jīng)阻滯，GA組采用氣管插管全身麻醉。對(duì)比兩組患者麻醉前（T0）、手術(shù)前（T1）、手術(shù)開始1 h后（T2）及手術(shù)結(jié)束時(shí)（T3）的平均動(dòng)脈壓及心率；對(duì)比兩組患者術(shù)中的血糖升高水平；對(duì)比兩組患者術(shù)后的視覺模擬評(píng)分（visual analogue score，VAS）、對(duì)麻醉及鎮(zhèn)痛的滿意度。結(jié)果BB組患者各時(shí)間點(diǎn)的平均動(dòng)脈壓及心率的比較差異無統(tǒng)計(jì)學(xué)意義，GA組患者的平均動(dòng)脈壓及心率存在時(shí)間效應(yīng)，各時(shí)間點(diǎn)的比較差異有統(tǒng)計(jì)學(xué)意義（F=9.568，P＜0.001；F=7.746，P=0.001）。兩組患者術(shù)中的血糖水平均高于術(shù)前，BB組血糖的升高低于GA組[（0.6±0.4） mmol/Lvs（0.9±0.6） mmol/L，t=-2.243，P=0.030］。BB組患者術(shù)后隨訪時(shí)的VAS評(píng)分低于GA組[1（1，1）vs2（1，2.25），Z=2.066，P＜0.001］。BB組患者對(duì)麻醉及鎮(zhèn)痛處理的滿意度高于 GA 組[4（3，5）vs3（2.75，4），Z=1.549，P=0.016］。結(jié)論相較于全身麻醉，超聲引導(dǎo)臂叢神經(jīng)阻滯技術(shù)可以提供更好的血流動(dòng)力學(xué)穩(wěn)定性，更為有效的抑制手術(shù)引起的應(yīng)激反應(yīng)，改善患者術(shù)后疼痛評(píng)分，提高患者術(shù)后滿意度。

臂叢神經(jīng)阻滯； 全身麻醉； 超聲； 肘關(guān)節(jié)

臂叢神經(jīng)阻滯廣泛應(yīng)用于上肢的手術(shù)及鎮(zhèn)痛[1］，腋窩入路因其安全性[2］及操作簡(jiǎn)單，是最常用的臂叢神經(jīng)阻滯方法[3］，可為肘關(guān)節(jié)及以遠(yuǎn)水平的上肢手術(shù)提供良好的麻醉效果[4］。但臂叢阻滯依賴的解剖結(jié)構(gòu)常發(fā)生變異[5］，Meta分析顯示基于神經(jīng)刺激儀及解剖結(jié)構(gòu)的傳統(tǒng)腋路神經(jīng)阻滯方法存在近20%的失敗率[6］，而需進(jìn)一步實(shí)施全身麻醉以完成手術(shù)。超聲定位技術(shù)的引入，使臂叢神經(jīng)阻滯得到了改良[7］，可加快操作速度，降低操作風(fēng)險(xiǎn)[8］，并顯著提高了成功率[3,6,9］，從而使腋路神經(jīng)阻滯在肘關(guān)節(jié)手術(shù)中全面取代全身麻醉成為了可能。而目前，超聲引導(dǎo)下腋路臂叢神經(jīng)阻滯在肘關(guān)節(jié)手術(shù)中是否優(yōu)于全身麻醉，尚缺乏足夠的研究。本研究擬從術(shù)中血流動(dòng)力學(xué)波動(dòng)、應(yīng)激反應(yīng)、術(shù)后鎮(zhèn)痛及患者滿意度等幾個(gè)方面對(duì)比兩種麻醉方法的優(yōu)劣，為臨床中肘關(guān)節(jié)手術(shù)的麻醉方法選擇提供幫助。

資料與方法

一、一般資料

選擇2014年10月至2017年4月于涿鹿縣中醫(yī)院行肘關(guān)節(jié)周圍骨折切開復(fù)位內(nèi)固定術(shù)的患者共60例，隨機(jī)分為臂叢神經(jīng)阻滯組（BB組，n=30）及全身麻醉組（GA組，n=30）。納入標(biāo)準(zhǔn)：（1）年齡18～80歲；（2）美國(guó)麻醉醫(yī)師學(xué)會(huì)（American society of anesthesiologists，ASA）分級(jí)I ～ Ⅱ級(jí)，無合并嚴(yán)重的全身系統(tǒng)疾??；（3）骨折僅限于肘關(guān)節(jié)周圍，閉合性骨折，無血管、神經(jīng)損傷。排除標(biāo)準(zhǔn)：（1）病理性骨折患者；（2）多發(fā)骨折，或需同期處理其他部位損傷的患者；（3）不宜行腋路臂叢神經(jīng)阻滯或全麻氣管插管的患者；（4）患者拒絕。退出標(biāo)準(zhǔn)：發(fā)生嚴(yán)重不良事件，臂叢阻滯無法完成手術(shù)需中轉(zhuǎn)全麻者。

二、麻醉方法

所有患者常規(guī)術(shù)前準(zhǔn)備，入室后持續(xù)監(jiān)測(cè)血壓、心率、血氧飽和度，儲(chǔ)氧面罩吸氧，予右美托咪定持續(xù)泵入（負(fù)荷劑量1 μg/kg輸注15 min后，改為0.4 μg/kg/h持續(xù)泵注）。BB組患者在超聲引導(dǎo)下行腋路神經(jīng)阻滯：0.5%羅哌卡因30 ml中加入地塞米松5 mg，采用平面內(nèi)多點(diǎn)注射技術(shù)，依次于橈神經(jīng)、正中神經(jīng)、尺神經(jīng)、肌皮神經(jīng)周圍分別注射局麻藥物7 ml，確認(rèn)腋動(dòng)脈實(shí)現(xiàn)局麻藥物的完全包繞。GA組患者采用氣管插管全身麻醉：丙泊酚2.0 mg/kg、舒芬太尼0.3 μg/kg、羅庫(kù)溴銨0.6 mg/kg誘導(dǎo)，丙泊酚4～6 mg/kg/h、瑞芬太尼0.1～0.2 μg/kg/min持續(xù)泵入維持。兩組患者術(shù)畢均采用靜脈自控鎮(zhèn)痛（patient controlled intravenous analgesia，PCIA）技術(shù)控制術(shù)后疼痛。

三、觀察及隨訪

分別記錄患者麻醉前（T0）、手術(shù)前（T1）、手術(shù)開始1 h后（T2）及手術(shù)結(jié)束時(shí)（T3）的平均動(dòng)脈壓及心率；于手術(shù)前及手術(shù)開始1 h后抽取患者血?dú)夥治?，記錄患者血糖水平。手術(shù)結(jié)束12 h后訪視患者，通過視覺模擬評(píng)分法（visual analogue score，VAS）記錄患者的疼痛評(píng)分（0分表示無痛，10分表示難以忍受的劇烈疼痛），并通過李克特5級(jí)量表評(píng)測(cè)患者對(duì)麻醉及疼痛管理的滿意程度（1分代表非常不滿意，5分代表非常滿意）。

四、統(tǒng)計(jì)學(xué)分析

采用SPSS 20.0統(tǒng)計(jì)軟件對(duì)數(shù)據(jù)進(jìn)行分析。計(jì)量資料中，正態(tài)數(shù)據(jù)以±s表示，組間比較采用t檢驗(yàn)，采用重復(fù)測(cè)量方差分析處理組內(nèi)時(shí)間效應(yīng)和組間效應(yīng)；非正態(tài)數(shù)據(jù)以M（P25，P75）表示，組間比較采用Kolmogorov-Smirnov Z檢驗(yàn)，采用Spearman相關(guān)計(jì)算相關(guān)性；計(jì)數(shù)資料以例數(shù)（%）表示，組間比較采用χ2檢驗(yàn)。以P ＜0.05作為差異具有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

60例患者均完成了麻醉、手術(shù)及術(shù)后隨訪。兩組患者均無嚴(yán)重并發(fā)癥發(fā)生。BB組患者均在臂叢神經(jīng)阻滯下順利完成了手術(shù)，無需轉(zhuǎn)換為全身麻醉者。兩組患者的年齡、性別、美國(guó)麻醉醫(yī)師協(xié)會(huì)（ASA）分級(jí)、骨折部位及手術(shù)時(shí)間的組間比較差異均無統(tǒng)計(jì)學(xué)意義（表1）。

觀察期間內(nèi)，BB組患者各時(shí)間點(diǎn)的平均動(dòng)脈壓及心率的比較差異無統(tǒng)計(jì)學(xué)意義（F=2.321，P=0.102；F=0.369，P=0.726）。GA組的平均動(dòng)脈壓及心率存在時(shí)間效應(yīng)，各時(shí)間點(diǎn)的比較差異有統(tǒng)計(jì)學(xué)意義（F=9.568，P ＜0.001 ；F=7.746，P=0.001）。兩組患者平均動(dòng)脈壓及心率的組間比較，差異無統(tǒng)計(jì)學(xué)意義（F=0.002，P=0.968；F=0.727，P=0.397），見圖 1。

兩組患者術(shù)中的血糖水平均高于術(shù)前，差異有統(tǒng)計(jì)學(xué)意義[（5.9±0.7）mmol/L vs（6.5±0.8）mmol/L，t=-8.098，P ＜0.001；（5.8±0.9）mmol/L vs （6.7±1.1）mmol/L，t=-7.471，P ＜0.001］。BB組血糖的升高低于GA組，差異有統(tǒng)計(jì)學(xué)意義[（0.6±0.4）mmol/L vs（0.9±0.6）mmol/L，t=-2.243，P=0.030］，見表 2。

BB組患者術(shù)后隨訪時(shí)的VAS評(píng)分低于GA組，差異有統(tǒng)計(jì)學(xué)意義[1（1，1）vs 2（1，2.25），Z=2.066，P ＜0.001］。BB 組 患者對(duì)麻醉及鎮(zhèn)痛處理的滿意度高于GA組，差異有統(tǒng)計(jì)學(xué) 意 義[4（3.00，5）vs 3（2.75，4）， Z=1.549，P=0.016］?；颊叩腣AS評(píng)分及滿意度間存在顯著負(fù)相關(guān)（r=-0.549，P ＜0.001），見表 2。

圖1 兩組患者各觀察時(shí)間點(diǎn)的平均動(dòng)脈壓及心率比較

表2 兩組患者血糖、VAS評(píng)分及滿意度的比較

討 論

臂叢神經(jīng)阻滯廣泛應(yīng)用于肘部骨科手術(shù)，安全性高[2］。因?yàn)楸蹍灿谝父C處位置表淺，十分適于通過超聲引導(dǎo)穿刺。超聲技術(shù)的可視化，可以使臂叢神經(jīng)阻滯實(shí)現(xiàn)神經(jīng)旁精準(zhǔn)給藥，減少了局麻藥用量，降低了操作風(fēng)險(xiǎn)，并顯著提高了阻滯的成功率[3,6,9］。超聲下多點(diǎn)穿刺技術(shù)的應(yīng)用可以較一點(diǎn)法或兩點(diǎn)法提供更佳的麻醉效果[10］。這些技術(shù)的革新使臂叢阻滯完全替代全身麻醉成為肘關(guān)節(jié)手術(shù)的首選麻醉方法成為了可能。本研究中所有臂叢神經(jīng)阻滯組的患者均順利完成了手術(shù)，無需復(fù)合應(yīng)用全身麻醉。相較于全身麻醉，臂叢神經(jīng)阻滯的術(shù)中及術(shù)后管理更為簡(jiǎn)單，麻醉風(fēng)險(xiǎn)更小，對(duì)患者身體狀況的要求更低[11］。同時(shí)，臂叢神經(jīng)阻滯的麻醉費(fèi)用更低，超聲下腋路阻滯的技術(shù)難度較小，易于掌握，適于在基層醫(yī)院推廣應(yīng)用。

手術(shù)和創(chuàng)傷會(huì)導(dǎo)致免疫抑制，從而增加感染的風(fēng)險(xiǎn)[12］，疼痛反應(yīng)、心血管反應(yīng)和應(yīng)激反應(yīng)被視為軀體對(duì)手術(shù)和傷害性刺激綜合反應(yīng)的不同方面。通常認(rèn)為，手術(shù)引起的代謝和內(nèi)分泌紊亂會(huì)導(dǎo)致多種副反應(yīng)，這些紊亂和不良的臨床預(yù)后相關(guān)[13］。全身麻醉消除了對(duì)手術(shù)刺激的感知，但并沒有完全消除機(jī)體對(duì)有害刺激的反應(yīng)。所有的靜脈及吸入全麻藥物對(duì)內(nèi)分泌和生理功能都沒有幫助作用，而神經(jīng)阻滯則可直接減少神經(jīng)的傳入刺激，從而改善內(nèi)分泌和代謝反應(yīng)，較全身麻醉更好的抑制機(jī)體的應(yīng)激反應(yīng)[14］。本研究中，臂叢神經(jīng)阻滯組的心率和血壓在各時(shí)間點(diǎn)均無顯著性改變，而在全身麻醉組則出現(xiàn)了顯著性波動(dòng)，這提示臂叢神經(jīng)阻滯可以較全身麻醉更好的抑制手術(shù)和創(chuàng)傷引起的心血管反應(yīng)，有利于血流動(dòng)力穩(wěn)定。在臂叢神經(jīng)阻滯組術(shù)中血糖的升高顯著低于全身麻醉組，而血糖的波動(dòng)反映了血漿皮質(zhì)醇水平及機(jī)體應(yīng)激水平的改變[13］，這提示臂叢神經(jīng)阻滯可以較全身麻醉更為有效的抑制手術(shù)引起的應(yīng)激反應(yīng)，從而可能提供潛在的預(yù)后改善作用[12］。

表1 兩組患者一般資料的比較

對(duì)于大多數(shù)患者，良好預(yù)后的關(guān)鍵是良好的鎮(zhèn)痛和早期活動(dòng)。臂叢神經(jīng)阻滯較靜脈應(yīng)用止痛藥物可以提供更好的術(shù)后鎮(zhèn)痛效果[15］。通過在局麻藥物中添加小劑量的地塞米松，臂叢神經(jīng)的阻滯時(shí)間可以顯著延遲，術(shù)后鎮(zhèn)痛的作用時(shí)間顯著增加[16-17］，減少術(shù)后阿片類藥物使用，改善術(shù)后疼痛評(píng)分[18］。在肱骨近端骨折手術(shù)的研究中發(fā)現(xiàn)[19］，由于臂叢神經(jīng)阻滯提供了術(shù)畢早期的有效鎮(zhèn)痛，可以允許患者早期活動(dòng)、加快功能鍛煉，相較全身麻醉患者，臂叢神經(jīng)阻滯患者在早期隨訪時(shí)，主被動(dòng)活動(dòng)范圍更大，功能評(píng)分更佳。本研究中，臂叢神經(jīng)阻滯組顯示了更優(yōu)的術(shù)后鎮(zhèn)痛效果和對(duì)麻醉及鎮(zhèn)痛的滿意度。

本研究納入的病例數(shù)量尚少，且對(duì)研究者未設(shè)盲，隨訪時(shí)間短。進(jìn)一步的完善設(shè)計(jì)，擴(kuò)大研究例數(shù)，延遲隨訪時(shí)間，尤其是增加術(shù)后早期及長(zhǎng)期功能恢復(fù)的隨訪，將會(huì)提供更具意義的結(jié)果。本研究中，采用的臂叢阻滯方法為腋路阻滯，該方法相較更高位入路的阻滯方法，難以提供足夠有效的止血帶耐受[20］，而需復(fù)合右美托咪定等基礎(chǔ)麻醉方法。但超聲下腋路阻滯操作簡(jiǎn)單安全，更易于掌握，適于基層醫(yī)院推廣。

綜上所述，本研究顯示超聲引導(dǎo)臂叢神經(jīng)阻滯技術(shù)可以有效的替代全身麻醉應(yīng)用于肘關(guān)節(jié)手術(shù)，相較于全身麻醉，臂叢神經(jīng)阻滯技術(shù)可以提供更好的血流動(dòng)力學(xué)穩(wěn)定性，更為有效的抑制手術(shù)引起的應(yīng)激反應(yīng)，改善患者術(shù)后VAS評(píng)分，提高患者術(shù)后滿意度。

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Comparison between ultrasound-guided brachial plexus block and general anesthesia for surgery of elbow joint

Wu Ke1, Ren Sumin1, Zhao Limin1, Yan Zhiyong1, Jiang Bailin2.1Department of Anesthesiology, Zhuolu County Hospital of Traditional Chinese Medicine, Zhangjiakou 075699,China;2Department of Anesthesiology, Peking University People's Hospital, Beijing 100044, China

Jiang Bailin, Email: jiangbailin@139. com

BackgroundBrachial plexus block is commonly used for surgery and analgesia of the upper extremity. Due to the simplicity of operation and the safety of approaches to brachial plexus block, the axillary brachial plexus block, which provides effective anesthesia distal to the elbow, is the most widely performed approach. Being decisional for traditional method, the anatomical structures however, express variations sometimes. A meta-analysis demonstrated that the failure rate of axillary brachial plexus block using anatomical-based traditional approach or nerve stimulation was nearly 20%. Consequently, further general anesthesia is required for the completion of surgery. The development of precise nerve localization modalities using ultrasound shortens the performance time, reduces the incidence of vascular puncture, and improves block success, which makes it possible for axillary brachial plexus block to take the place of general anesthesia for the surgery of elbow joint completely. Currently, there is still few evidence of the superiority of ultrasound guidance axillary brachial plexus block compared to general anesthesia in anesthesia and analgesia for the surgery of elbow joint. The goal of this study was to determine whether ultrasound guidance axillary brachial plexus block is more effective thangeneral anesthesia in the suppression of hemodynamic and stress response to the elbow joint surgery.Methord（1）General data. Sixty patients who

open reduction and internal fixation surgeries for fractures around elbow joints in zhuolu county hospital of traditional Chinese medicine from October 2014 to April 2017 were enrolled in this study. Inclusion criteria: ①age ranges from 18-80 years old; ②class I-II based on American Society of Anesthesiologists （ASA）scale without severe systematic diseases;③closed fractures of elbow joint without neurovascular injuries. Exclusive criteria: ① pathologic fractures; ② multiple fractures or injuries of other parts required to be treated at the same time;③patients who do not undergo axillary brachial plexus block or general anesthesia and endotracheal intubation;④patient rejection. Exclusion criteria: serious adverse effects occurred; the operation could not be conducted under brachial plexus block and should be transferred to general anesthesia. All patients were randomly assigned into 2 groups：the brachial plexus block group （group BB,n=30） and the general anesthesia group （group GA,n=30）.（2）Anesthetic management. All patients underwent routine preoperative preparation.The blood pressure, heart rate and blood oxygen saturation were monitored continuously after arrival.Supplemental oxygen and pulse oximetry were applied throughout the procedure. All patients were premeditated with dexmedetomidine （1 μg/kg of loading dose for 15 min of infusion and later transferred to 0.4 μg/kg/h for continuous infusion） prior to anesthesia. In group BB, 0.5 % bupivacaine 30 ml with dexamethasone 5 mg was prepared as local anesthetics. Through in-plane multiple-injection technique, 7 ml of local anesthetics were incrementally injected around radial nerve, median nerve, ulnar nerve and musculocutaneous nerve,. The axillary nerve was confirmed to be wrapped in the local anesthetic drug. In group GA, the anesthesia was induced with propofol （2.0 mg/kg）, sufentanil （0.3 μg/kg） and rocuronium （0.6 mg/kg） via endotracheal intubation. The anesthesia was maintained with propofol（4-6 mg·kg-1·h-1） and remifentanil （0.1-0.2 μg·kg-1·min-1）. Patient controlled intravenous analgesia （PCIA） was used for post-operation analgesia in both groups.（3）Observation and follow-ups. The mean arterial pressure and the heart rate were recorded before the anesthesia（T0）, before the surgery （T1）, 1 h after the surgical incision （T2）, at the end of surgery （T3）.2 blood samples were collected at T1 and T2 to measure the blood glucose level. The pain scales were assessed via the visual analogue score （0 point presented as no pain and 10 points presented as unbearable pain） 12 h after the operation, and the satisfactions of anesthesia and analgesia were assessed according to the Likert scale （1 point presented as extremely dissatisfied and 5 points presented as very satisfied）.（4）Statistical analysis . The SPSS 20.0 statistical software was used to analyze the data. In the measurement data, normal data presented asx-±swere compared byttest. The intra group time effect and inter group effect were processed by repeated measurement of variance analysis; non-normal data presented as M （P25，P75） were compared by Kolmogorov-SmirnovZtest and the correlation was calculated by Spearman rank relational coefficient; the enumeration data was presented as case number （%）, and χ2test was used in the comparison between groups.P＜0.05 was considered as statistically significant as the difference.ResultsAnesthesia, surgical operation and postsurgical follow-up were completed in all patients. There was no severe complication during and after surgery in either group. With successful brachial plexus block and analgesics, no patient in BB group underwent general anesthesia. There was no significant difference in demographic data, surgical performance times and locations of fracture between the 2 groups. There was no significant difference in mean arterial pressures and heart rates at different time points of measurement for BB group. Changes in the mean arterial pressure and the heart rate were statistically significant for GA group （F=9.568,P＜0.001;F=7.746,P=0.001）.The values of mean arterial pressure and heart rate did not differ significantly between groups. The concentrations of plasma glucose （mmol/L） 1 h after the surgical incision were significantly higher than those before the surgery in both groups （5.9±0.7 vs 6.5±0.8,t=-8.098,P＜0.001; 5.8±0.9vs6.7±1.1,t=-7.471,P＜0.001）, and the increment in BB group was significantly lower than that in GA group （0.6±0.4vs0.9±0.6,t=-2.243,P=0.030）. The VAS score in BB group wassignificantly lower than that in GA group 12 h postoperatively [1（1, 1）vs2（1, 2.25）,Z=2.066,P＜0.001］. The satisfaction for anesthesia and analgesia was significantly higher in BB group [4（3,5）vs3（2.75, 4）,Z=1.549,P=0.016］. The negative correlation between the VAS score and the satisfaction for anesthesia was statistically significant （r=-0.549,P＜0.001）.ConclusionThe ultrasound guidance axillary brachial plexus block can take place of general anesthesia in anesthesia and analgesia for surgery of elbow joint. Compared to general anesthesia, ultrasound guidance brachial plexus block is more effective in suppressing hemodynamic fluctuation and stress response to surgery and improving post-operational pain rating and patients' satisfaction for anesthesia and analgesia.

Brachial plexus block； General anesthesia； Ultrasound； Elbow joint

2017-04-10）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.008

北京大學(xué)人民醫(yī)院研究與發(fā)展基金（RDC2014-09）

075699 張家口，涿鹿縣中醫(yī)院麻醉科1; 100044 北京大學(xué)人民醫(yī)院麻醉科2

姜柏林, Email: jiangbailin@139.com

武科, 任素敏,趙麗敏,等. 超聲引導(dǎo)下臂叢神經(jīng)阻滯與全身麻醉在肘關(guān)節(jié)手術(shù)中的應(yīng)用比較[J/CD].中華肩肘外科電子雜志 ,2017,5（2）：119-124.