肌間溝臂叢神經(jīng)阻滯中應(yīng)用右美托咪定超前鎮(zhèn)痛的臨床價(jià)值

丁依依,葉克平,楊亦平,符新春,王文偉

(浙江臺(tái)州市第一人民醫(yī)院麻醉科，318020)

·論著·

肌間溝臂叢神經(jīng)阻滯中應(yīng)用右美托咪定超前鎮(zhèn)痛的臨床價(jià)值

丁依依,葉克平,楊亦平,符新春,王文偉

(浙江臺(tái)州市第一人民醫(yī)院麻醉科，318020)

[摘要]目的探討右美托咪定超前鎮(zhèn)痛在肌間溝臂叢神經(jīng)阻滯中的應(yīng)用價(jià)值。方法選取行肌間溝臂叢神經(jīng)阻滯麻醉的上肢手術(shù)患者108例為研究對(duì)象，以隨機(jī)數(shù)字表法分組，觀察組與對(duì)照組各54例，觀察組術(shù)前5 min靜脈滴注0.5 μg/kg右美托咪定，對(duì)照組術(shù)前5 min給予等劑量0.9%氯化鈉注射溶液。觀察兩組麻醉阻滯情況、術(shù)后疼痛程度、患者自控鎮(zhèn)痛(PCA)用藥劑量及不良反應(yīng)發(fā)生情況。結(jié)果觀察組感覺阻滯起效時(shí)間[(8.33±1.25)min比(10.05±1.62)min，t=6.177，P<0.001]與運(yùn)動(dòng)阻滯起效時(shí)間[(16.17±2.48)min比(20.32±3.16)min，t=7.592，P<0.001]同對(duì)照組比較均明顯縮短，麻醉維持時(shí)間[(8.43±0.86)min比(7.29±0.92)min，t=6.652，P<0.001]與對(duì)照組比較顯著延長(zhǎng)，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；術(shù)后2 h[(1.45±0.21)分比(1.51±0.24)分，t=1.383，P=0.170]兩組視覺模擬評(píng)分(VAS)比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，術(shù)后4 h[(1.78±0.33)分比(2.29±0.41)分，t=7.121，P<0.001]、術(shù)后6 h[(2.56±0.37)分比(3.62±0.48)分，t=12.853，P<0.001]、術(shù)后12 h[(3.53±0.39)分比(4.75±0.51)分，t=13.964，P<0.001]、24 h[(4.62±0.64)分比(5.90±0.76)分，t=9.467，P<0.001]觀察組VAS評(píng)分與對(duì)照組比較均明顯較低，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；觀察組24 h內(nèi)PCA用藥劑量同對(duì)照組比較，明顯較低，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；觀察組術(shù)后不良反應(yīng)發(fā)生率[(4例(7.41%)比14例(25.93%)，t=6.667，P=0.010]與對(duì)照組比較明顯較低，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論在肌間溝臂叢神經(jīng)阻滯中應(yīng)用右美托咪定超前鎮(zhèn)痛，可提高麻醉阻滯效果，減輕術(shù)后疼痛，降低術(shù)后阿片類藥物使用劑量，減少不良反應(yīng)發(fā)生。

[關(guān)鍵詞]神經(jīng)傳導(dǎo)阻滯；右美托咪定；疼痛管理

臂叢神經(jīng)阻滯是上肢手術(shù)常用麻醉方法，其具有局部鎮(zhèn)痛完全、安全性高、患者術(shù)中可保持清醒等特點(diǎn)，其中肌間溝是主要入路位置[1]。有研究指出[2]，手術(shù)創(chuàng)傷所引起的術(shù)后疼痛對(duì)治療效果及患者生活質(zhì)量均有較大影響，采用有效鎮(zhèn)痛方法減輕患者術(shù)后疼痛具有重要意義。超前鎮(zhèn)痛作為一種新型鎮(zhèn)痛理念，在臨床中得到廣泛運(yùn)用，本研究將右美托咪定超前鎮(zhèn)痛應(yīng)用于肌間溝臂叢神經(jīng)阻滯中，報(bào)告如下。

1 對(duì)象與方法

1.1 研究對(duì)象 選取2015年12月至2017年11月行肌間溝臂叢神經(jīng)阻滯麻醉的上肢手術(shù)患者108例為研究對(duì)象，以隨機(jī)數(shù)字表法分組。觀察組54例，男性33例，女性21例；年齡范圍19～73歲，年齡(44.6±6.1)歲；體質(zhì)量范圍43～83 kg，體質(zhì)量(64.27±7.93)kg；手術(shù)部位：11例為手部橈側(cè)，18例為前臂橈側(cè)，25例為上臂。觀察組54例，男性35例，女性19例；年齡范圍20～71歲，年齡(44.9±6.1)歲；體質(zhì)量范圍41～84 kg，體質(zhì)量(64.36±7.91)kg；手術(shù)部位：12例為手部橈側(cè)，16例為前臂橈側(cè)，26例為上臂。兩組患者一般資料差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，存在可比性。本研究經(jīng)本院倫理委員會(huì)審查并批準(zhǔn)，患者均簽署知情同意書。

1.2 納入與排除標(biāo)準(zhǔn) 納入標(biāo)準(zhǔn)：年齡≥18歲；無臂叢神經(jīng)阻滯禁忌證；ASA麻醉分級(jí)Ⅰ～Ⅱ級(jí)；生命體征穩(wěn)定；手術(shù)指征明確；意識(shí)清楚，無認(rèn)知障礙；對(duì)本研究知情且同意。排除標(biāo)準(zhǔn)：患肢神經(jīng)損傷或感覺異常者；有鎮(zhèn)痛、鎮(zhèn)靜藥物依賴史；對(duì)本研究所用藥物有過敏史；凝血功能障礙者；血壓、心率嚴(yán)重異常；慢性疼痛病史者；精神疾病患者；重要臟器嚴(yán)重功能不全者。

1.3 方法 兩組患者均行肌間溝臂叢神經(jīng)阻滯麻醉，患者取平臥位，上肢自然放于體側(cè)，以肌間溝與環(huán)狀軟骨水平線交叉點(diǎn)作為穿刺點(diǎn)，在超聲掃描下對(duì)目標(biāo)神經(jīng)干予以尋找，確認(rèn)定位準(zhǔn)確后，注入0.5%羅哌卡因(AstraZeneca AB生產(chǎn)，5 mg/10 mL)30 mL。觀察組術(shù)前5 min靜脈滴注0.5 μg/kg右美托咪定(四川國(guó)瑞藥業(yè)有限責(zé)任公司生產(chǎn))，對(duì)照組術(shù)前5 min靜脈滴注等劑量0.9%氯化鈉注射溶液。兩組患者術(shù)后均行靜脈自控鎮(zhèn)痛，藥物配方氯胺酮(江蘇恒瑞醫(yī)藥股份有限公司生產(chǎn))50 mg+舒芬太尼(宜昌人福藥業(yè)有限責(zé)任公司生產(chǎn))50 μg+0.9%氯化鈉注射溶液100 mL，持續(xù)維持量1 mL/h，單次劑量2 mL，鎖定時(shí)間15 min，鎮(zhèn)痛時(shí)間>24 h。

1.4 觀察指標(biāo) 注藥完畢后，每5分鐘對(duì)患者阻滯情況予以評(píng)估，記錄感覺阻滯起效時(shí)間(麻醉后至患者開始出現(xiàn)感覺缺失時(shí)間)、運(yùn)動(dòng)阻滯起效時(shí)間(麻醉后至患者下肢體無法伸縮時(shí)間)及麻醉維持時(shí)間(手術(shù)完成后患者VAS超過3分時(shí)所需時(shí)間)。分別于術(shù)后2 h、術(shù)后4 h、術(shù)后6 h、術(shù)后12 h及術(shù)后24 h，通過視覺模擬評(píng)分法(VAS)對(duì)患者疼痛程度予以評(píng)估，在紙上劃10 cm橫線，1 cm代表1分，分值越高，疼痛越明顯，患者根據(jù)自主感受在橫線相應(yīng)位置標(biāo)記。同時(shí)記錄兩組患者術(shù)后24 h內(nèi)患者自控鎮(zhèn)痛(PCA)用藥劑量。觀察兩組患者術(shù)后不良反應(yīng)發(fā)生情況。

2 結(jié)果

2.1 麻醉阻滯情況對(duì)比 觀察組感覺阻滯起效時(shí)間與運(yùn)動(dòng)阻滯起效時(shí)間同對(duì)照組比較，均明顯較短(P<0.05)。見表1。

表1 兩組患者麻醉阻滯情況對(duì)比

表2 兩組患者術(shù)后各階段VAS評(píng)分及術(shù)后24 h內(nèi)PCA用藥劑量對(duì)比

注：VAS為視覺模擬評(píng)分；PCA為患者自控鎮(zhèn)痛

2.2 術(shù)后疼痛程度及PCA用藥劑量對(duì)比 術(shù)后2 h兩組VAS評(píng)分同比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后4、6、12、24 h觀察組VAS評(píng)分低于對(duì)照組(P<0.05)。觀察組24 h內(nèi)PCA用藥劑量低于對(duì)照組(P<0.05)。見表2。

2.3 不良反應(yīng)發(fā)生情況對(duì)比 觀察組術(shù)后不良反應(yīng)發(fā)生率為7.41%，同對(duì)照組25.93%比較，明顯較低，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表3。

表3 兩組患者術(shù)后不良反應(yīng)發(fā)生率對(duì)比[例(%)]

3 討論

臂叢神經(jīng)阻滯麻醉在上肢手術(shù)中較為常用，其中肌間溝穿刺入路定位確切，誤入血管少，操作簡(jiǎn)單[3]。但有學(xué)者發(fā)現(xiàn)，患者可能出現(xiàn)阻滯不全，且術(shù)后存在明顯疼痛[4-5]。有報(bào)道發(fā)現(xiàn)，手術(shù)創(chuàng)傷引起的疼痛刺激，可導(dǎo)致大量?jī)翰璺影芳捌渌麘?yīng)激性激素釋放，造成血流動(dòng)力學(xué)異常，降低治療安全性[6-7]。有研究指出，術(shù)后疼痛可使患者出現(xiàn)焦慮、煩躁、抑郁等負(fù)性情緒，影響心理健康[8]。手術(shù)后疼痛刺激可對(duì)患者生理、心理造成不同程度危害，如何有效或減輕術(shù)后疼痛，減少疼痛刺激，避免繼發(fā)性損傷，是臨床研究熱點(diǎn)[9]。臨床減輕術(shù)后疼痛通常采用患者自控鎮(zhèn)痛技術(shù)，但有研究指出，自控鎮(zhèn)痛所用阿片類藥物可引起多種不良反應(yīng)，從而降低患者生活質(zhì)量[10]。

超前鎮(zhèn)痛理念即在疼痛刺激前給予鎮(zhèn)痛藥物，對(duì)手術(shù)創(chuàng)傷引起的傷害性傳入刺激到達(dá)中樞神經(jīng)系統(tǒng)進(jìn)行阻斷，從而避免脊髓內(nèi)部神經(jīng)產(chǎn)生的疼痛連鎖反應(yīng)。本研究將右美托咪定超前鎮(zhèn)痛應(yīng)用于肌間溝臂叢神經(jīng)阻滯中，結(jié)果顯示觀察組麻醉阻滯情況明顯優(yōu)于對(duì)照組，且術(shù)后疼痛程度明顯較對(duì)照組輕。提示右美托咪定超前鎮(zhèn)痛不僅能有效減輕患者術(shù)后疼痛，在增強(qiáng)阻滯效果方面也有積極作用。

右美托咪定屬于新型強(qiáng)效高選擇性α2腎上腺素受體激動(dòng)劑，可同分布于中樞及外周神經(jīng)系統(tǒng)的α-受體產(chǎn)生作用，使細(xì)胞膜超極化，從而對(duì)疼痛信號(hào)向中樞系統(tǒng)傳導(dǎo)予以抑制，達(dá)到鎮(zhèn)痛效果。有研究指出[11]，右美托咪定可有效阻斷外周傷害性刺激傳入，減少手術(shù)引起的交感神經(jīng)興奮效應(yīng)，保持血流動(dòng)力學(xué)穩(wěn)定性，抑制應(yīng)激反應(yīng)。因此在上肢手術(shù)中，在麻醉前給予右美托咪定，可起到良好鎮(zhèn)痛作用。另有報(bào)道表明，右美托咪定蛋白質(zhì)結(jié)合率達(dá)到94%，生物利用度較高，對(duì)呼吸系統(tǒng)影響輕微，安全性良好[12]。本研究中，觀察組患者術(shù)后PCA用藥劑量明顯較對(duì)照組少，僅出現(xiàn)1例頭暈及3例惡心、嘔吐，不良反應(yīng)發(fā)生率明顯低于對(duì)照組，提示右美托咪定超前鎮(zhèn)痛可通過提高鎮(zhèn)痛效果，減少患者靜脈自控藥使用劑量，降低阿片類藥物所引起的不良反應(yīng)，從而提高治療安全性。

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Observationontheapplicationofdexmedetomidineforpreemptiveanalgesiainmuscleditchbrachialplexusblock

DingYiyi,YeKeping,YangYiping,FuXinchun,WangWenwei

(DepartmentofAnesthesiology，theFirstHospitalofTaizhou,Taizhou318020,China)

[Abstract]ObjectiveTo investigate the value of dexmedetomidine for preemptive analgesia in muscle ditch brachial plexus block.Methods108 patients of upper limb surgery with muscular ditch brachial plexus block anesthesia were selected as subjects and divided into the observation group and the control group according to the random number table,with 54 cases in each group.The observation group received intravenous drip of 0.5 μg/kg dexmedetomidine 5 min before the operation,and the control group received the same dose of normal saline 5 min before the operation.The anesthetic block,the degree of postoperative pain,the dosage of PCA and the adverse reactions were observed in the two groups.ResultsThe onset time of sensory block in the observation group [(8.33±1.25)min vs (10.05±1.62)min,t=6.177,P<0.001] and motor block onset time [(16.17±2.48)min vs (20.32±3.16)min,t=7.592,P<0.001] were significantly shorter compared with the control group,and the duration of anesthesia maintenance [(8.43±0.86)min vs (7.29±0.92)min,t=6.652,P<0.001] was significantly longer than that that of the control group(P<0.05),with the difference statistically significant (P<0.05);the difference in the comparison of visual analogue score(VAS) of two groups at 2h [(1.45±0.21) points vs (1.51±0.24) points,t=1.383,P=0.170] after surgery was not statistically significant (P>0.05),and the VAS of the observation group was less than that of the control group at 4 h[(1.78±0.33) points vs (2.29±0.41) points,t=7.121,P<0.001],6 h[(2.56±0.37) points vs (3.62±0.48) points,t=12.853,P<0.001],12 h[(3.53±0.39) points vs (4.75±0.51) points,t=13.964,P<0.001],24 h[(4.62±0.64) points vs (5.90±0.76) points,t=9.467,P<0.001] after operation,and the difference was statistically significant (P<0.05);the dosage of PCA in the observation group was significantly lower than that in the control group in 24 h (P<0.05),and the difference was statistically significant (P<0.05);the incidence of adverse reaction in the observation group [(4 cases (7.41%) compared with 14 cases (25.93%),t=6.667,P=0.010] was significantly lower compared with the control group,and the difference was statistically significant (P<0.05).Conclusion

The application of dexmedetomidine for preemptive analgesia in muscle ditch brachial plexus block can improve anesthetic block effect,relieve postoperative pain,reduce the dosage of opioid and the occurrence of adverse reactions.

[Keywords]Nerve block；Dexmedetomidine；Pain management

中圖分類號(hào)：R614.4

A

10.3969/J.issn.1672-6790.2018.03.009

作者簡(jiǎn)介：丁依依，醫(yī)師，Email：757967598@qq.com

2018-01-07)