超声引导下髂筋膜间隙联合骶丛神经阻滞在老年全髋关节置换术中的应用

目的评价超声引导下髂筋膜间隙联合骶丛神经阻滞在老年全髋关节置换后外侧入路手术中的应用效果。方法选择择期行单侧人工全髋关节置换术(后外侧入路)患者60例,男24例,女36例,年龄65~90岁,ASAⅡ或Ⅲ级,随机分为研究组(NB组)和对照组(SA组),每组30例。NB组在超声引导下先行髂筋膜间隙阻滞(0.4%罗哌卡因50ml),然后行骶丛神经阻滞(0.5%罗哌卡因20ml);SA组行轻比重单侧腰麻2.0~2.5ml(0.5%布比卡因2ml+灭菌注射用水1ml)。记录两组的感觉、运动阻滞起效及完善时间。记录患者入室时(T_0)、摆放体位前1min(T_1)、摆体位时(T_2)、手术切皮时(T_3)、手术开始后30min(T_4)、手术结束时(T_5)、术后24h(T_6)的VAS评分。记录两组患者术中辅助使用多巴胺、阿托品的情况及并发症的发生情况。结果 NB组感觉、运动阻滞起效及完善时间明显长于SA组(P0.05)。T_1、T_2、T_6时NB组VAS评分明显低于SA组,T_3、T_5时NB组VAS评分明显高于SA组(P0.05)。NB组使用多巴胺2例(6.7%),明显少于SA组的8例(26.7%)(P0.05)。NB组头痛、恶心、呕吐、尿潴留发生率明显低于SA组(P0.05)。结论超声引导下髂筋膜间隙联合骶丛神经阻滞应用于老年全髋关节置换后外侧入路手术,可减轻摆放体位所致的疼痛,减少血管活性药物的用量,且术后早期镇痛效果好,不良反应较少。     

超声引导下髂筋膜间隙不同角度多点阻滞与单点阻滞效果的比较

目的比较超声引导下髂筋膜间隙多点阻滞与单点阻滞的效果。方法选择髋关节置换患者125例,ASAⅠ或Ⅱ级,男67例,女58例。进行前瞻随机分为研究组(n=62例)和对照组(n=63例)。研究组采用超声引导下多点阻滞方法,对照组髂筋膜间隙阻滞采用超声引导下单次阻滞方法,局麻药为罗哌卡因150mg复合地塞米松7.5mg,容量为30ml。记录股神经、闭孔神经和股外侧皮神经感觉阻滞的起效时间,并评价其阻滞成功率。结果研究组股外侧皮神经、闭孔神经感觉阻滞起效时间分别为(9.1±3.6)min、(9.2±3.6)min,明显短于对照组的(11.2±4.7)min、(13.8±5.3)min(P0.05)。对照组的股外侧皮神经和闭孔神经的阻滞成功率分别为87.3%、82.5%,明显低于研究组的98.4%、95.2%(P0.05)。两组股神经的感觉阻滞起效时间和阻滞成功率差异无统计学意义。结论超声引导下髂筋膜间隙不同角度多点阻滞较单点阻滞起效迅速,神经阻滞成功率高。     

超声引导下髋关节囊周神经丛阻滞对股骨颈骨折老年患者摆放侧卧位时疼痛的影响

目的比较超声引导下髋关节囊周神经丛阻滞(PENGB)和腹股沟上髂筋膜间隙阻滞(S-FICB)对股骨颈骨折患者麻醉前摆放侧卧位时疼痛的影响。方法择期腰-硬联合麻醉下行髋关节置换术的股骨颈骨折患者42例,男18例,女24例,年龄≥65岁,BMI 18～28 kg/m~2,ASAⅡ或Ⅲ级,所有患者在腰-硬联合麻醉体位变动之前,在超声引导下进行单次神经阻滞,根据神经阻滞入路不同,随机分为两组,每组21例。P组行PENGB,S组行S-FICB,两组均给予0.25%罗哌卡因30 ml。记录阻滞前(T_1)和阻滞后5 min(T_2)、10 min(T_3)、15 min(T_4)及摆放侧卧位即刻(T_5)和侧卧位后即刻(T_6)的VAS疼痛评分、MAP和HR,记录超声成像时间、穿刺注药时间、超声成像清晰度评分、患者满意度和配合度评分及相关并发症。结果与T_1时比较,T_2—T_6时两组VAS疼痛评分明显降低(P0.05)。与S组比较,T_2—T_6时P组VAS疼痛评分明显降低(P0.05)。与T_1时比较,T_2—T_4和T_6时两组MAP明显降低(P0.05)。与T_1时比较,T_3、T_4时P组HR明显减慢(P0.05)。与S组比较,P组超声成像时间明显缩短(P0.05),镇痛满意度评分明显提高(P0.05)。两组穿刺注药时间、超声成像清晰度评分和配合度评分差异无统计学意义。两组均无一例穿刺相关并发症。结论超声引导下PENGB和S-FICB对股骨颈骨折患者术前摆放侧卧位时都有良好的镇痛效果,PENGB超声成像时间更短,起效更快,患者满意度更高。     

右美托咪定滴鼻联合髂筋膜间隙阻滞在老年髋部骨折患者围术期的应用效果

目的 探讨右美托咪定滴鼻联合髂筋膜间隙阻滞在老年髋部骨折患者围术期的应用效果。方法 选择择期行腰-硬联合麻醉下髋部骨折手术的老年患者59例,男14例,女45例,年龄≥65岁,BMI 14.1～30.3 kg/m²,ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组：右美托咪定滴鼻联合髂筋膜间隙阻滞组(D组,n=29)和髂筋膜间隙阻滞组(F组,n=30)。术前1 d晚间D组给予右美托咪定滴鼻后在超声引导下行患侧髂筋膜间隙阻滞,F组仅在超声引导下行患侧髂筋膜间隙阻滞。记录右美托咪定滴鼻前(T₁)、髂筋膜间隙阻滞后1 h(T₂)、过转运床即刻(T₃)、过手术床即刻(T₄)、摆体位时(T₅)的HR、MAP、SpO₂和疼痛数字评价量表(NRS)评分。记录术前1 d、手术当日及术后1、2 d的汉密尔顿焦虑(HAM-A)评分和里兹睡眠问卷(LSEQ)评分。记录术后7 d内谵妄发生情况及术后住院时间。记录低血压、心动过缓以及术后48 h内恶心呕吐、头晕、...     

改良髂筋膜间隙阻滞在股骨骨折术中的效果

目的探讨超声引导下改良髂筋膜间隙阻滞在股骨骨折患者手术中的麻醉和镇痛效果。方法选取股骨骨折手术患者203例为研究对象,分为对照组101例、观察组102例。两组患者均给与全麻,对照组患者全麻后给予超声引导下髂筋膜间隙阻滞,观察组患者全麻后给予超声引导下改良髂筋膜间隙阻滞。比较两组患者术后疼痛情况、麻醉效果、不良反应。结果术后2小时、术后6小时观察组VAS疼痛评分明显低于对照组(P0.05);观察组瑞芬太尼用量、完全苏醒时间、术后镇痛补救次数明显低于对照组(P0.05);观察组不良反应发生率5.88%略低于对照组11.88%(P0.05)。结论超声引导下改良髂筋膜间隙阻滞对股骨骨折手术患者具有较好的镇痛和麻醉效果,不良反应较少。     

超声引导下髂筋膜间隙阻滞在行髋关节置换术老年患者中的临床应用效果研究

目的评估超声引导下髂筋膜间隙阻滞在髋关节置换术老年患者中的临床应用效果。方法择期行单侧髋关节置换术的高龄患者80例,年龄65~79岁,ASA分级Ⅰ~Ⅱ级。患者采用计算机随机软件随机分为髂筋膜间隙阻滞组(F组)和空白对照组(C组),每组各40例。记录两组患者麻醉前(T_0)、麻醉后30分钟(T_1)、麻醉后60分钟(T_2)及拔管即刻(T_3)的平均动脉压(MAP)和心率(HR)。评估患者术后6、12、24、48小时静止和活动状态下视觉模拟评分(VAS)。记录术后48小时内PCIA泵有效按压次数、总按压次数及术后恶心呕吐(PONV)、嗜睡、皮肤瘙痒等并发症发生情况。结果 F组患者T_1~T_3时点MAP和HR均显著低于C组患者,差异有统计学意义(P0.05)。F组患者术后6、12、24小时VAS评分显著低于C组患者,差异有统计学意义(P0.05)。F组患者PCIA有效按压次数和总按压次数均显著少于C组患者,差异有统计学意义(P0.05)。F组患者术后嗜睡、PONV、皮肤瘙痒发生率均显著低于C组患者,差异有统计学意义(P0.05)。结论髂筋膜间隙阻滞能够在行髋关节置换术的老年患者中发挥良好的术后镇痛效果,同时还能维持术中血流动力学稳定,降低术后阿片类药物用量。     

超声引导下连续髂筋膜间隙阻滞用于老年髋部骨折患者围术期镇痛的研究

目的:研究超声引导下髂筋膜间隙阻滞对老年髋部骨折患者围手术期疼痛控制及术后并发症的影响。方法:选择2021年1月至2021年9月收治的老年髋部骨折手术患者127例,按照镇痛方法不同分为连续髂筋膜间隙阻滞组(F组)和静脉镇痛对照组(C组)。其中F组62例,男19例,女43例;年龄66~95(82.4±7.2)岁;股骨颈骨折25例,股骨转子间骨折37例。C组65例,男18例,女47例;年龄65~94(81.4±8.7)岁;股骨颈骨折29例,股骨转子间骨折36例。观察两组患者围术期不同时间点的疼痛视觉模拟评分(visual analogue scale,VAS)、简易精神状态评价量表(minimental state examination,MMSE)评分、警觉-镇静评分(observer''s assessment of alertness/sedation,OAA/S)、改良Bromage评分、术后并发症及患者住院期间情况。结果:F组实施阻滞后30 min、麻醉摆放体位时,术后6、24、48 h的静息及运动VAS低于C组(P<0.05)。F组术前12 h,术后1、3 d的MMSE评分及术后3 d的OAA/S评分高于C组(P<0.05)。F组不良反应发生率、需要额外镇痛人数低于C组(P<0.05)。F组围术期镇痛满意度及住院时间均优于C组(P<0.05)。两组患者在各时间点患肢Bromage评分及术后30 d死亡率比较,差异无统计学意义(P>0.05)。结论:超声引导下连续髂筋膜间隙阻滞可为老年髋部骨折患者提供安全、有效的围术期镇痛效果,改善术后认知功能,减少术后并发症,从而缩短住院时间,提高住院期间生活质量。     

超声引导下髂筋膜联合腰方肌阻滞用于髋关节置换术后镇痛的效果

目的观察超声引导下髂筋膜联合腰方肌阻滞用于髋关节置换术后镇痛的效果。方法选择2017年3—12月拟行择期髋关节置换术患者60例,男26例,女34例,年龄55～75岁,体重45～70 kg,ASAⅠ或Ⅱ级。采用随机数字表法将患者随机分为两组:髂筋膜组(N组)和髂筋膜联合腰方肌组(T组),每组30例。T组术后行超声引导下髂筋膜联合腰方肌阻滞,各注射0.375%罗哌卡因15 ml。N组术后行超声引导下髂筋膜阻滞,注射0.375%罗哌卡因30 ml。术后两组均采用PCIA至术后48 h。记录阻滞操作前(T_0)、术后3 h(T_1)、6 h(T_2)、12 h(T_3)、24 h(T_4)、36 h(T_5)、48 h(T_6)时静息状态VAS评分以及T_4—T_6时运动状态VAS评分;记录阻滞后0～4 h、4～8 h、8～12 h、12～24 h、24～36 h、36～48 h各时段PCIA有效按压次数;记录T_3—T_6时术侧髋关节最大屈曲和外展活动度;记录术后不良反应。结果 T组T_1—T_6时静息状态VAS评分和T_4—T_6时运动状态VAS评分明显低于N组(P0.01)。阻滞后48 h内各时段T组PCIA有效按压次数明显少于N组(P0.01)。T组髋关节最大屈曲和外展活动度明显大于N组(P0.01)。T组术后恶心呕吐和尿储留发生率明显低于N组(P0.05)。结论超声引导下髂筋膜联合腰方肌阻滞用于髋关节置换术后镇痛效果显著,镇痛作用确切,不良反应发生率低。     

术前连续髂筋膜间隙阻滞对老年髋部骨折患者围术期睡眠质量及术后谵妄的影响

目的 探讨术前超声引导下连续髂筋膜间隙阻滞对老年髋部骨折患者围术期睡眠质量及术后谵妄的影响。
方法 选择老年髋部骨折患者121例,男55例,女66例,年龄65~90岁, BMI 18.5~25.0 kg/m²,ASA Ⅰ—Ⅲ级,采用随机数字表法分为两组：超声引导下连续髂筋膜间隙阻滞组（F组,n=61）和对照组（C组,n=60）。F组于入院后给予经超声引导下连续髂筋膜间隙阻滞,C组常规术前处理。两组采用相同的椎管内麻醉方案实施侧入路股骨头置换术,术后采用相同的术后镇痛方案。采用简易精神状态检查表（MMSE）评估入院后基础认知状态;采用匹兹堡睡眠质量指数（PSQI）评估入院前1个月整体睡眠质量。记录入院时（T1）、髂筋膜间隙阻滞后30 min（C组为入院后相同时间点）（T2）、入室时（T3）、摆放体位时（T4）的疼痛数字评分（NRS）。记录术前及术后7 d每天的里兹睡眠问卷（LSEQ）评分,记录术后7 d内谵妄的发生情况及术后住院时间。记录术后恶心、呕吐、日间嗜睡等不良反应的发生情况。
结果 与C组比较,F组T2—T4时NRS评分明显降低（P<0.05）,术前及术后1~3 d LSEQ评分明显升高（P<0.05）,术后7 d内谵妄发生率明显降低(P<0.05),谵妄持续时间、术后住院时间明显缩短(P<0.05),日间嗜睡发生率明显降低(P<0.05)。
结论 术前超声引导下连续髂筋膜间隙阻滞可改善老年髋部骨折患者围术期睡眠质量,降低术后谵妄发生率及缩短谵妄持续时间。     

髂筋膜间隙阻滞复合髂腹下-髂腹股沟神经阻滞在患儿髋脱位术后早期镇痛的效果

目的观察髂筋膜间隙阻滞复合髂腹下-髂腹股沟神经阻滞在患儿髋脱位手术术后早期镇痛的效果。方法选择首次行单侧发育性髋脱位手术患儿40例,年龄2~6岁,随机均分为两组:F组采用髂筋膜间隙阻滞复合髂腹下-髂腹股沟神经阻滞,C组行单纯髂筋膜间隙阻滞,神经阻滞在超声引导下进行。记录送入PACU即刻(T0)、术后1h(T1)、2h(T2)、4h(T3)、6h(T4)的FLACC评分,手术时间、PACU停留时间及在PACU期间芬太尼追加例数,记录术后不良反应的发生情况。结果与C组比较,T0~T3时F组FLACC评分明显降低(P0.05)。F组PACU停留时间明显短于C组(P0.05)。在PACU停留期间F组有3例(15%),C组有8例(40%)追加芬太尼,差异无统计学意义。术后F组4例(20%),C组2例(10%)发生恶心呕吐,差异无统计学意义。结论与单纯髂筋膜间隙阻滞比较,髂筋膜间隙阻滞复合髂腹下-髂腹股沟神经阻滞用于患儿髋脱位手术,术后早期镇痛效果更好。     

‘Small blocks’ in paediatric patients

Regional anaesthetic techniques are now extensively used in paediatric anaesthesia. A better understanding and conceptualization of them has led us to define a new category of blocks, termed compartment blocks, in which the structure that has to be identified is a fascial plane, not the nerve to be blocked itself. Some of these compartment blocks, most of which have been described decades ago but fell into disuse, have now been rediscovered as they offer many advantages in terms of safety, efficiency and simplicity. These ‘small blocks’ share the same high benefit/risk ratio and, basically, the same technique of fascial plane localization; this makes them look very similar even though they involve various structures and nerves with no real anatomical link. In this category are included the peri-umbilical, ilioinguinal/iliohypogastric, pudendal, penile, fascia iliaca, saphenous nerve, metacarpal and laryngeal nerve blocks. These small blocks provide adequate analgesia for a number of very common procedures in paediatric patients; they do not require special skills, training, complicated or expensive devices. Their success rate is extremely high and they have no true contraindications or significant adverse effects. They are effective with only small amounts of local anaesthetics and thus, due to their many advantages, should be used extensively in children.     

超声引导下三点阻滞与椎旁阻滞用于剖腹肝胆手术术后镇痛的比较

目的观察术前给予超声引导下三点法阻滞(低位前锯肌阻滞、肋缘下腹横肌平面阻滞和腹直肌后鞘阻滞)或单侧胸椎旁阻滞对肝胆手术患者术后镇痛及相关围术期转归的影响。方法选择择期右上腹部切口行肝胆手术的患者95例,男69例,女26例,年龄18～65岁,ASAⅠ或Ⅱ级。随机分为三点组(n=48)和椎旁组(n=47)。三点组患者入室后采用0.375%罗哌卡因行超声引导下低位前锯肌阻滞(10 ml)、肋缘下腹横肌平面阻滞(15 ml)复合腹直肌后鞘阻滞(15 ml),椎旁组采用0.375%罗哌卡因20 ml行超声引导下T_(7-9)椎旁阻滞。记录术后24 h舒芬太尼用量;记录切皮前、切皮后1和5 min时HR和SBP的变化、麻醉后恢复室内和术后24 h VAS疼痛评分,以及患者过敏、局麻药中毒、穿刺损伤等不良反应发生情况。结果两组患者术后24 h内舒芬太尼用量差异无统计学意义[(0.98±0.33)μg/kg vs (0.95±0.28)μg/kg]。患者麻醉后恢复室内和术后24 h VAS疼痛评分差异无统计学意义。椎旁组术中低血压发生率31例(66.0%) vs 11例(22.9%)和去甲肾上腺素用量[(3.5±1.6)μg/kg vs (1.2±0.4)μg/kg]明显高于三点组(P0.01)。两组患者均未见过敏、局麻药中毒、穿刺损伤等不良反应。结论低位前锯肌阻滞、肋缘下腹横肌平面阻滞、腹直肌后鞘阻滞三点阻滞复合可以产生与单侧椎旁阻滞相当的术中和术后镇痛作用,而且前者的低血压发生率明显低于椎旁阻滞,是一种可供临床选择的上腹部神经阻滞方式。     

腰方肌阻滞临床应用的研究进展

腰方肌阻滞是一种将局麻药物注射至腰方肌周围的躯干神经阻滞技术。近年来,腰方肌阻滞的临床应用已成为研究热点,是广受欢迎的镇痛方式。腰方肌阻滞逐渐被应用于剖宫产手术、胃肠道手术、泌尿手术、下肢手术等围术期多模式镇痛,并且在慢性疼痛治疗中也有报道。全文就腰方肌阻滞的应用解剖、穿刺入路、临床应用及可能的作用机制进行综述,为其临床应用提供参考。     

59. Die Regionalanaesthesie in der Abdominal-Chirurgie

Summary Spinal and peridural anesthesia are most useful in lower abdominal operations. For upper laparotomies needing analgesia, good relaxation and quiet ventilation, intercostal block and peridural anesthesia with light general anesthesia are suitable techniques to avoid hypertension and metabolic responses (hyperglycemia, cortisol). During the postoperative period, regional blocks improve lung function and bowel motility, and afford early ambulation.     

腰丛-坐骨神经联合阻滞用于老年患者下肢手术的临床研究

目的探讨腰丛-坐骨神经联合阻滞在老年患者下肢手术应用的可行性。方法40例60岁以上拟行单侧下肢手术的患者随机均分为两组。A组采用神经刺激器定位技术,正确定位腰丛和坐骨神经后分别给予0.375%罗哌卡因20～25ml和0.5%罗哌卡因15～20ml;B组选择L2～3或L3～4间隙行硬膜外麻醉,给予0.75%罗哌卡因10～15ml。观察两组血流动力学变化、阻滞效果及其不良反应。结果B组麻醉15min后各时点的SBP、DBP均明显低于麻醉前及A组(P<0.05或P<0.01);A组镇痛持续时间长于B组(P<0.05),但运动阻滞持续时间短于B组(P<0.05);B组术中使用麻黄碱的例数及输液量高于A组(P<0.05);B组患者围术期恶心、呕吐、尿潴留等不良反应的发生率明显高于A组(P<0.01)。结论腰丛-坐骨神经联合阻滞对血流动力学影响小,术后镇痛时间长,并发症少,适用于老年患者下肢手术。     

The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks.ResultsAn initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption.ConclusionLocal periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.     

Complicaciones asociadas a tres técnicas de bloqueo del plexo braquial: revisión sistemática y metaanálisis

BackgroundBrachial plexus block has become one of the most widely-used anaesthetic techniques in the world for upper limb anaesthesia. There are three different brachial blocks techniques: supraclavicular, infraclavicular and axillary block. However, its execution is not exempt from possible clinical complications, and it is not clear which of these is associated with a lower complication rate and greater anaesthetic success.Materials and methodsSystematic review and meta-analysis following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify controlled clinical trials reporting the three techniques. The main outcome was the incidence of anaesthetic complications, and the secondary ones were an anaesthetic success, time of performance and anaesthetic latency.Results25 controlled clinical trials, with 2012 patient, were included. The methodological quality of the included studies is moderate to high. For the main outcome, the main complication reported was a vascular puncture, followed by transient neurological injury, symptomatic diaphragmatic paralysis and pneumothorax. No differences were found in complications associated with the three anaesthetic techniques. Additionally, no differences were found regarding anaesthetic success.ConclusionsAnesthetic complications associated with the three brachial block techniques are low, with no medium and long-term sequelae; however, none of the three techniques seems to be superior among them to reduce these complications. All three techniques are highly successful when performed using ultrasound imaging.