Combined paravertebral lumbar plexus and parasacral sciatic nerve block for reduction of hip fracture in four patients with severe heart failure

We experienced four cases of anesthesia for hip fracture reduction in patients with severe heart failure, where anesthesia was attempted with combined paravertebral lumbar plexus and parasacral sciatic nerve block instead of spinal anesthesia. The anesthesia was successful without any sequelae. The patients' characteristics are as follows. Case 1: 97-year-old woman with severe heart failure and old myocardial infarction. Case 2: 91-year-old man with pacemaker, heart failure and heart valve disease. Case 3: 93-year-old woman with severe heart failure and multi-vessel coronary artery stenosis. Case 4: 83-year-old woman with congestive heart failure and heart valve disease. Paravertebral lumbar plexus block was performed with Touhy needle which was directed to lumbar transverse process, then re-directed caudally. Psoas compartment was felt with loss of resistance. Twelve ml of 0.25% bupivacaine was injected. Sciatic nerve block was performed with a needle which was inserted at the midpoint between the greater trochanter and the sacral hiatus without (case 1, 2) or with nerve stimulator (case 3, 4). Eight ml of 0.25% bupivacaine was injected. During the anesthesia, propofol was injected for light sedation. Although this combined nerve block is difficult to perform compared with spinal anesthesia, this could be applicable for hip fracture reduction anesthesia, especially in patients with severe heart failure.     

髋关节置换手术患者实施超声定位神经阻滞麻醉的护理

对37例全髋关节置换手术患者实施超声定位神经阻滞麻醉,麻醉科护士对患者进行术前访视与宣教,提前准备麻醉所需仪器、药品和物品,熟悉神经阻滞麻醉的过程,主动配合麻醉医生操作,手术过程中严密监测患者生命体征,协助麻醉医生做好患者呼吸道管理和液体管理,阻滞麻醉后苏醒期观察与评估患者出入液量、疼痛情况、感觉阻滞平面、运动阻滞平面等。结果所有患者神经阻滞效果良好,均顺利完成手术。提出麻醉科护士在超声定位神经阻滞麻醉过程中发挥重要作用,提高了麻醉质量和效率。     

腰丛联合坐骨神经阻滞在高龄患者髋关节置换中的应用

目的探讨腰丛联合坐骨神经阻滞对高龄髋关节置换术患者术后疼痛的缓解作用及对认知功能的保护机制。 方法选取2016年6月至2018年5月于海南省万宁市人民医院行单次全髋关节置换术的高龄患者120例,年龄80~100岁,纳入标准：年龄范围为80~100岁,美国麻醉医师协会(ASA)分级Ⅱ~Ⅲ级;符合全髋关节置换术相关手术指征;认知功能正常。排除标准：合并严重原发疾病者;合并精神病或神经系统疾病者;依从性较差者;对本研究麻醉方案过敏者。所有患者采用随机数字表法分为两组：全身麻醉组(GA组),腰丛-坐骨神经阻滞组(PCSNB组),每组各60例。比较两组术中情况(麻醉操作时间、手术时间、术中出血量、术中补液量),手术前后血清碱性成纤维细胞生长因子(bFGF)水平。采用视觉模拟量表(VAS)评估两组患者术后疼痛程度,采用简易精神状态量表(MMSE)及蒙特利尔认知评估量表(MoCA)评估两组患者认知功能。正态分布的计量资料采用t检验,同一指标在3个以上不同时间点上比较,采用重复测量方差分析。 结果PCSNB组麻醉操作时间显著高于GA组(t＝17.74,P<0.001),术中出血量及术中补液量均显著低于GA组(t＝7.56、14.59、7.60,均为P<0.001)。术后1 d两组血清bFGF水平均有所下降(t＝13.14、6.82,均为P<0.001),但PCSNB组血清bFGF水平显著高于GA组(t＝7.43,P <0.001)。PCSNB组术后2、12及24 h的VAS评分显著低于对照组(F＝8.03、6.56,均为P <0.001)。术后1 d,PCSNB组MMSE评分及MoCA评分均显著低于对照组(t＝3.89、4.58,均为P <0.001)。 结论腰丛联合坐骨神经阻滞可减轻高龄髋关节置换术患者术后疼痛,对患者认知功能具有保护作用,可能与bFGF水平有关。     

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。     

Lumbar plexus block with perineural catheter and sciatic nerve block for total hip arthroplasty

This case series describes the use of continuous lumbar plexus block with sciatic nerve block as an alternative anesthetic for total hip arthroplasty (THA). A retrospective chart review was performed on 10 consecutive patients who underwent THA at Walter Reed Army Medical Center using continuous lumbar plexus block and sciatic nerve block for anesthesia. Continuous lumbar plexus block with sciatic nerve block without concurrent general anesthesia has not been described previously for THA. Peripheral nerve block may provide superior intraoperative outcomes, as suggested by lower operative blood loss and potentially lower transfusion exposure. Lumbar plexus block with perineural catheter and sciatic nerve block with perioperative sedation is an effective alternative to general anesthesia for THA.     

Sciatic nerve palsy after total hip arthroplasty in a patient receiving continuous lumbar plexus block

We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve. IMPLICATIONS: A case is presented of sciatic palsy developing after total hip arthroplasty in a patient receiving a continuous lumbar plexus block. The case highlights various issues in the use of continuous peripheral nerve blocks for postoperative analgesia.     

右美托咪定用于老年患者腰丛联合坐骨神经阻滞下全髋关节置换术的辅助效果

目的 评价右美托咪定用于老年患者腰丛联合坐骨神经阻滞下全髋关节置换术的辅助效果.方法 择期行单侧全髋关节置换术患者50例,性别不限,年龄80 ～ 93岁,体重指数17 ～ 25kg/m2,ASA分级Ⅱ或Ⅲ级.采用随机数字表法,将患者随机分为2组(n=25):生理盐水组(NS组)和右美托咪定组(D组).神经刺激仪引导腰丛联合坐骨神经阻滞后20 min,D组静脉输注右美托咪定负荷剂量0 5 μg/kg(输注时间10 min),继以0.2μg·kg-1·h-1维持输注至术毕,NS组以同样方式输注等容量的生理盐水.阻滞效果欠佳时静脉注射丙泊酚20 mg或氯胺酮10 mg.于入室时、静脉给药即刻、手术开始即刻、10、30 min及术毕(T0-5)时记录MAP、HR、SpO2、RR,记录术中不良反应发生情况、丙泊酚或氯胺酮的使用情况及术者的满意情况.结果 与T0时比较,NS组T2-5时MAP升高、HR增快(P＜0.05),D组各时点血液动力学指标比较差异无统计学意义(P＞0.05).与NS组比较,D组MAP和HR、呼吸抑制和躁动发生率、丙泊酚或氯胺酮使用率降低,术者满意率升高(P＜0.05),RR和SpO2差异无统计学意义(P＞0.05).两组患者均未发生心动过缓和低血压.结论 右美托咪定用于老年患者腰丛联合坐骨神经阻滞下全髋关节置换术的辅助效果确切,血液动力学平稳,不良反应少.     

Posterior approach to the lumbar plexus combined with a sciatic nerve block using lidocaine

A combination of lumbar plexus block, by a posterior technique, and sciatic nerve block can be a useful technique for outpatient anaesthesia. The purpose of this study was to examine the clinical characteristics of these blocks using lidocaine and to measure the serum lidocaine concentrations. Forty-five patients, undergoing lower extremity surgery, were studied. Sciatic nerve and lumbar plexus blocks were made with lidocaine, 680 mg with adrenaline 0.3 mg. For each patient the following data were collected: weight, age, sex, site of surgery, time to perform each block, needle depth, speed of onset of the sensory and motor blocks in the territories of the sciatic, femoral, obturator and lateral cutaneous (sensory) nerves and postoperative analgesic requirements. Lidocaine serum concentrations were measured in ten of these patients at 0, 2, 5, 10, 30, 60, 90 and 120 min after the second block. Analgesia was complete in 88% (40/45) of the patients. The remaining five patients needed analgesics (fentanyl 150 μg or less). Despite the high dose of lidocaine, the serum concentrations were within safe limits (mean ± SD) (C_MAX = 3.66 ± 2.21 μg · ml^?1). Only one patient had a serum concentration > 5 μg · ml^?1 (C_MAX = 9.54 μg · ml^?1). This was associated with a contra-lateral extension of the block. We conclude that this combination of blocks is a valuable alternative for unilateral lower extremity anaesthesia. However, clinicians must be aware of the implications of a contra-lateral extension of the block.     

超声引导腰丛和坐骨神经阻滞中两种体位的比较

目的 比较俯卧位和侧卧位下超声引导腰丛和臀大肌下入路坐骨神经阻滞的效果.方法 择期下肢手术患者40例,随机分为侧卧位组和俯卧位组,在超声联合神经刺激器引导下行腰丛和臀大肌下入路坐骨神经阻滞.超声测量穿刺深度,记录实际穿刺深度,对比操作时间和调整穿刺方向次数,评价手术麻醉效果并记录术后并发症.结果 俯卧位组腰丛阻滞操作时间短于侧卧位组(P<0.01),但俯卧位下行坐骨神经阻滞时常需改变体位方能成功,两组阻滞效果差异无统计学意义.结论 俯卧位和侧卧位均可用于腰丛和坐骨神经阻滞,腰丛阻滞时俯卧位优于侧卧位,臀大肌下入路坐骨神经阻滞侧卧位优于俯卧位.     

不同浓度罗哌卡因用于腰丛-坐骨神经阻滞的药代动力学

目的研究不同浓度罗哌卡因用于腰丛-坐骨神经阻滞的药代动力学。方法择期行单侧膝关节镜手术的成年患者16例,ASAⅠ或Ⅱ级,随机分为2组(n=8):0．5％罗哌卡因组(A组)和0．75％罗哌卡因组(B组)。均以神经刺激仪定位,刺激频率为2 Hz,起始电流设为1 mA。先行腰大肌间隙腰丛阻滞,以各脊椎棘突连线为正中线,与两侧髂嵴最高点连线相交,向术侧旁开4．5-5 cm,即为穿刺点。引出股四头肌收缩并带动膝盖颤动,逐渐减小电流至0．4mA以下,仍可见肌肉收缩时,即由助手固定穿刺针。然后以经典的Labat径路行坐骨神经阻滞,成功引出足背伸或跖屈后,由另外的助手两点同时注药,A组和B组分别给予0．5％和0．75％罗哌卡因腰丛20 ml和坐骨神经10ml。分别于给药前即刻和给药后5、15、20、30、45、60、90、120、180 min采桡动脉血,用反相高效液相色谱法测定血浆罗哌卡因浓度,用药代动力学计算程序(3p97)统计处理。结果A组和B组的主要药代动力学参数:Cmax分别为(1．4±0．3)mg／L和(2．7±0．9)mg/L;AUC分别为(3．88±0．28)mg·L-1·h-1和(7．13±0．65)mg·L-1·h-1;t1/2α分别为(0．44±0．19)h和(0．60±0．34)h;t1/2β分别为(3．4±0．4)h和(2．4±0．5)h。B组Cmax高于A组,其中B组2例Cmax分别为3．57、3．52 mg/L,接近局麻药中毒的血浆浓度。结论不同浓度罗哌卡因用于腰丛-坐骨神经阻滞时血浆罗哌卡因浓度-时间曲线符合二室模型,采用0．5％罗哌卡因30 ml更安全。     

Patient satisfaction and effectiveness of lumbar plexus and sciatic nerve block for total knee arthroplasty

The purpose of this study was to evaluate the efficacy of combined lumbar plexus block techniques for total knee arthroplasty. Long-acting local anesthetics were used to ensure adequate intraoperative and postoperative anesthesia and analgesia. All patients undergoing total knee arthroplasty at our institution were offered lumbar plexus block after obtaining informed consent. Patients for study were a continuous group of 87 patients over a 1-year period. A subset of 40 patients was studied for postoperative analgesia effect. All patients were contacted by phone for a satisfaction survey. There were 87 patients who received initial lumbar plexus and sciatic nerve blocks, 78% (68 of 87) of whom had adequate initial blocks. Sixteen patients (22%) required conversion to general anesthesia intraoperatively because of inadequate anesthesia. A subset of patients studied for postoperative analgesia revealed an average time of 13 hours before the first request for supplemental narcotics. There were no complications related to the lumbar plexus block in our study group of patients. There was a 92% overall satisfaction rate with the anesthesia provided by the lumbar plexus block. Lumbar plexus block can be used successfully for total knee arthroplasty. Lumbar plexus block appears to have advantages for early postoperative analgesia, leading to increased patient comfort and satisfaction.     

超声引导下腰骶丛神经阻滞联合全麻在高龄患者髋关节置换术的临床应用

目的观察超声引导下腰骶丛神经阻滞联合全麻在老年髋关节置换术的临床应用效果。方法择期行单侧髋关节置换术的老年患者80例,男35例,女45例,年龄65~85岁,随机均分为全麻组(G组)和腰骶丛神经阻滞联合全麻组(N组)。G组行全凭静脉麻醉,N组在超声引导下实施腰丛、骶丛神经阻滞后行无肌松静脉麻醉,两组均采用喉罩通气。术中两组均维持BIS 45~55,记录术中舒芬太尼用量、术后拔管时间、下床活动时间和出院时间;记录术后2、4、8、24h疼痛VAS评分及术后24h静脉自控镇痛(PCA)药物用量,并记录术后30d死亡率,对术后认知功能障碍(POCD)和术后谵妄(POD)情况和术后心血管和肺部并发症进行评估。结果术后30d两组患者均无死亡。N组患者术中舒芬太尼的使用量、PCA药物用量明显少于,术后拔管时间、下床活动时间和出院时间均明显短于G组(P0.05);术后2、4、8和24h时N组VAS评分明显低于G组(P0.05);G组1例患者术后出现严重肺部感染,术后N组POCD、POD发生率明显低于G组(P0.05)。结论与全麻比较,超声引导下腰骶丛神经阻滞联合全麻应用于老年髋关节置换术,减少了术中阿片类药物的用量,术后早期镇痛效果更好,明显缩短了下床活动时间和出院时间,且降低了老年患者POCD和POD的发生率。     

神经刺激器定位下行腰丛复合坐骨神经阻滞对老年髋关节置换术患者免疫功能的影响

目的 探究神经刺激器定位下行腰丛复合坐骨神经阻滞对老年髋关节置换术患者术后免疫功能的影响.方法 前瞻性收集本院2016年2月至2018年10月收治的86例接受髋关节置换术治疗的老年患者为研究对象,依据随机数字表的方式分组,每组43例.其中,对照组进行硬膜外麻醉,观察组进行神经刺激器定位下腰丛复合坐骨神经阻滞麻醉.观察对...