股神经阻滞联合无止血带技术在全膝关节置换术中的应用及效果

目的探讨股神经阻滞联合无止血带技术在全膝关节置换术(TKA)中的应用,并分析其在减轻术后疼痛中的作用及对术后认知功能的影响。方法本院2016年1月至2018年1月行TKA患者251例,男117例,女134例,年龄18～80岁,BMI 16.9～31.7 kg/m~2,ASAⅠ—Ⅲ级,随机分为四组:止血带下膝关节置换+静脉镇痛组(PT1组,n=56);止血带下膝关节置换+股神经阻滞镇痛组(PT2组,n=63);无止血带下膝关节置换+静脉镇痛组(P1组,n=56);无止血带下膝关节置换+股神经阻滞镇痛组(P2组,n=76)。分别于术前1 d、术后1、2、3 d测量术侧大腿中上1/3处周长,并于同时点采集外周静脉血测定白细胞计数(WBC)、中性粒细胞百分比(NEUT%)、C-反应蛋白(CRP)浓度。分别于术前1 d、术后1、2、3、7 d和3个月评测患侧膝关节活动度(AROM),采用视觉模拟疼痛评分法(VAS)评估静息和活动时的疼痛VAS评分。分别于术前1 d、术后1、2、3 d采用蒙特利尔认知评估量表(MoCA)评估患者认知功能,记录术后3 d内认知功能损害发生情况和恶心呕吐(PONV)发生情况。结果术后1、2、3 d PT1组和PT2组大腿周长增加值明显大于P1组和P2组(P0.05)、CRP浓度明显低于P1组和P2组(P0.05)。术后1、2 d PT1和P1组AROM明显小于PT2组和P2组(P0.05),PT1组静息和活动时VAS评分明显高于PT2组、P1组和P2组(P0.05),且P1组活动时VAS评分明显高于PT2组和P2组(P0.05)。术后1 d PT1组和PT2组MoCA评分明显高于P1组和P2组(P0.05)。术后3 d内PT1组和PT2组认知功能损害总发生率明显低于P1组和P2组(P0.05),PT1组和P1组PONV的总发生率明显高于PT2组和P2组(P0.05)。结论持续股神经阻滞联合无止血带技术用于全膝关节置换术,患者术后大腿肿胀及疼痛程度较轻,利于膝关节功能锻炼,关节活动度恢复快,但术后全身炎症反应较重且术后早期认知功能损害发生率增加。     

A randomized controlled trial: Comparison of one-per-mil tumescent technique and tourniquet in surgery for burn hand contracture in creating clear operative field and assessment of functional outcome

BackgroundThis study aims to compare the use of one-per-mil tumescent solution (a mixture of epinephrine and 0.2% lidocaine in a ratio of 1:1,000,000 in normal saline solution) and tourniquet to create clear operative fields and to evaluate the functional outcomes after post burn hand contracture surgery.MethodsThe subjects of this randomized controlled trial were divided into one-permil tumescent technique and tourniquet group for a similar surgical procedure. Three independent assessors evaluated the clarity of the operative fields through recorded videos for the first 15 min and the first 10-minute of each hour of the surgery. Functional outcome was evaluated at least three months postoperatively using total active and passive motion (TAM and TPM) of each digit. Malondialdehyde (MDA) and tumor necrosis factor alpha (TNF-α) were tested during baseline (5 min before the procedures), ischemia phase, and reperfusion phase (a phase when the blood flow returned to the tissue).Results35 subjects were included in this study: 17 in the tumescent group and 18 in the tourniquet group. We found a significant difference in the clarity of operative field between tumescent and tourniquet groups, 5 vs 35 bloodless operative fields, respectively (p < 0.05). TAM and TPM of each digit before surgery and 3 months postoperatively showed no significant difference between both groups (p > 0.05). Furthermore, we found no difference in MDA and TNF-α levels between both groups at their respective phases.ConclusionsThe use of one-per-mil tumescent technique does not replace tourniquet use to create bloodless operative fields in burned hand contracture surgery. However, the postoperative functional results were similar in both groups showing that tumescent technique can be used as an alternative to tourniquet without compromising outcomes. The MDA and TNF-α examinations do not provide conclusive outcomes regarding ischemia and reperfusion injury.     

Evidence for safe tourniquet use in 500 consecutive upper extremity procedures

Background

Although pneumatic tourniquets are widely used in upper extremity surgery, further evidence is needed to support their safe use. Excessive pressure and prolonged ischemic time can cause soft-tissue injury. The purpose of this study was to determine the safety of tourniquet use in a yearlong, consecutive series of patients.

Methods

A retrospective review of all patients who underwent upper extremity surgery by two board-certified hand surgeons over a 1-year period was performed. Demographic variables, comorbidities, and complications were noted along with tourniquet parameters, including application site, ischemic pressure, and time.

Results

A total 505 patients were included in the study because a tourniquet was used during their operation. Patients ranged in age from 3 months to 90 years old (mean 40.1 years). More than half of the population was overweight (mean body mass index (BMI) 27.1), and 77.1 % of adults had at least one cardiac risk factor. No immediate or delayed tourniquet-related injuries were identified. The average operative time was 35.9 min, with an average tourniquet time of 33.1 min. Tourniquet inflation pressure of 250 or 225 mmHg was utilized in 78 and 21 % of adult patients, respectively; no patients had a pressure setting exceeding 275 mmHg.

Conclusion

In this series of more than 500 operations, there were no immediate or delayed tourniquet-related events using parameters determined perioperatively by the attending surgeon. Tourniquet pressures of 250 mmHg or less in adult patients with less than 2 h of ischemic time appear to be safe, even in the elderly and patients with multiple medical comorbidities.     

Outcomes of post burn flexion contracture release under tourniquet versus tumescent technique in children

Objective

To compare the clinical outcomes of release of flexion contractures after burn of the hand in children using tourniquet or tumescent technique in terms of operative time, postoperative pain score, and percentage of graft take.

下腔静脉呼吸变异度预测下肢驱血带引起容量变化的研究

目的在全麻机械通气条件下运用下腔静脉呼吸变异度(VIVC)评估下肢骨科手术中上驱血带引起的容量变化。方法选取2017年3月至2017年10月拟在全麻联合神经阻滞下行单下肢lisfranc损伤手术患者37例,男19例,女18例,年龄25～50岁,BMI 20～30kg/m2,ASAⅠ或Ⅱ级。所有患者在全身麻醉联合神经阻滞下记录上驱血带前即刻和上驱血带后即刻HR、平均动脉压(MAP)、每搏量(SV)和上驱血带前即刻下腔静脉呼吸变异率(VIVC)。根据上驱血带前即刻和上驱血带后即刻SV增加百分比(ΔSV)是否≥13%将患者分为有反应组(ΔSV≥13%,R组)和无反应组(ΔSV13%,NR组),R组18例,NR组19例。分析VIVC与ΔSV的相关性,绘制VIVC的受试者工作特征曲线(ROC曲线),评估VIVC评测使用上驱血带造成的容量变化的临床价值。结果R组上驱血带前即刻SV明显低于上驱血带后即刻(P0.05)。上驱血带前即刻R组VIVC明显高于NR组(P0.05)。VIVC与ΔSV呈线性正相关关系(r=0.627,P0.001)。将诊断金标准定为ΔSV≥13%,进行VIVC的ROC曲线绘制,计算得出曲线下面积(AUC)是0.886(95%CI0.734～1.000,P 0.01)。VIVC判断容量变化的阈值是15.97%,灵敏度88.9%,特异度为93.3%。结论在下肢骨科手术中,上驱血带前VIVC与上驱血带引起的SV变化值呈线性正相关关系,使用超声测量的VIVC能对驱血引起的容量变化进行预测,当VIVC为15.97%时,其预测灵敏度88.9%,特异度为93.3%。     

右美托咪定混合罗哌卡因用于缓解上肢长时间手术中止血带反应的效果观察

目的：探讨右美托咪定混合罗哌卡因在肌间沟复合腋路臂丛神经阻滞应用于上肢长时间手术中的疗效观察。方法60例急诊断指（多指）、断腕或断臂手术患者,ASAⅠ~Ⅱ级,手术时间8~10 h,随机分配为2组（n =30）：罗哌卡因组（R 组）采用1%罗哌卡因15 mL +2%利多卡因10 mL 加生理盐水至40 mL;右美托咪定混合罗哌卡因组（DR 组）采用1%罗哌卡因15 mL+2%利多卡因10 mL +盐酸右美托咪定1μg/ kg 加生理盐水至40 mL。以神经刺激器定位肌间沟臂丛神经分支（腋神经）及腋路臂丛神经主分支（尺神经、桡神经、正中神经和肌皮神经）,止血带充气压力200~250 mmHg,压迫时间90 min。观察并记录入室时（T0）、阻滞后1.5 h（T1）、3 h（T2）、4.5 h（T3）、6 h（T4）、7.5 h（T5）、9 h（T6）及术毕（T7）患者的一般生命体征（MAP、HR）,同时以VAS 评分法评估患者止血带反应的程度,若无法忍受止血带反应,臂丛加药后试验结束。记录患者止血带耐受情况,并以 Ramsay评分评价 R 组及 DR 组的镇静程度,记录术中出现的不良反应。结果与 R 组相比,DR 组患者对止血带耐受率明显升高,且差异有统计学意义（P ﹤0.05）,止血带疼痛时间出现延迟（P ﹤0.05）;与 R 组比较,DR 组 T1~ T5时 HR 减慢（P ﹤0.05）,DR 组有7例出现窦性心动过缓,两组均未出现止血带严重并发症。结论1μg/ kg 右美托咪定混合1%罗哌卡因对减轻上肢长时间手术带来的止血带疼痛安全、有效,并可延迟止血带疼痛出现的时间。     

右美托咪定混合罗哌卡因用于缓解上肢长时间手术中止血带反应的效果观察

目的 探讨右美托咪定混合罗哌卡因在肌间沟复合腋路臂丛神经阻滞应用于上肢长时间手术中的疗效观察。 方法 60例急诊断指(多指)、断腕或断臂手术患者,ASAⅠ～Ⅱ级,手术时间8～10 h,随机分配为2组 (n=30):罗哌卡因组(R组)采用1%罗哌卡因15 mL+2%利多卡因10 mL加生理盐水至40 mL;右美托咪定混合罗哌卡因组(DR组)采用1%罗哌卡因15 mL+2%利多卡因10 mL+盐酸右美托咪定1 μg/kg加生理盐水至40 mL。以神经刺激器定位肌间沟臂丛神经分支(腋神经)及腋路臂丛神经主分支(尺神经、桡神经、正中神经和肌皮神经),止血带充气压力200～250 mmHg,压迫时间90 min。观察并记录入室时(T0)、阻滞后1.5 h(T1)、3 h(T2)、4.5 h(T3)、6 h(T4)、7.5 h(T5)、9 h(T6)及术毕(T7)患者的一般生命体征(MAP、HR),同时以VAS评分法评估患者止血带反应的程度,若无法忍受止血带反应,臂丛加药后试验结束。记录患者止血带耐受情况,并以Ramsay评分评价R组及DR组的镇静程度,记录术中出现的不良反应。结果 与R组相比,DR组患者对止血带耐受率明显升高,且差异有统计学意义(P <0.05),止血带疼痛时间出现延迟(P <0.05) ;与R组比较, DR组T1～T5时HR减慢(P <0.05),DR组有7例出现窦性心动过缓,两组均未出现止血带严重并发症。 结论 1 μg/kg右美托咪定混合1%罗哌卡因对减轻上肢长时间手术带来的止血带疼痛安全、有效,并可延迟止血带疼痛出现的时间。