臂丛神经阻滞在肩关节结核手术中的作用

目的 探讨肌间沟臂丛神经阻滞在肩关节结核手术中的作用。方法 选择2014年10月至2018年10月首都医科大学附属北京胸科医院择期行肩关节结核手术的42例患者,按照随机数字表法将患者分为A组(23例,采用臂丛神经阻滞+全身麻醉)与B组(19例,采用全身麻醉)。其中A组有1例患者肩因关节结核并发颈淋巴结结核病变未行臂丛神经阻滞,1例患者因阻滞效果不好予以剔除,最终纳入21例。两组患者在相同麻醉深度下,记录患者手术切皮前、切皮时的心率(HR)和平均动脉压(MAP)值,以及术中瑞芬太尼使用量、盐酸尼卡地平应用情况;同时使用数字等级评定量表(numerical rating scale,NRS)进行疼痛评分,记录患者术后6与24h 的NRS 评分和镇痛药物输注量。结果 A组患者切皮时的MAP值(75.6±10.7)mm Hg;1mm Hg=0.133kPa]、 HR值(75.1±13.6)次/min],及术中降压药的使用率(14.3%,3/21)均明显低于B组分别为(88.2±10.0)mm Hg、(80.9±14.8)次/min、52.6%(10/19)](t=3.816,P=0.000;t=2.166,P=0.037;χ ²=6.686,P=0.017)。A组患者瑞芬太尼使用量(0.4±0.1)mg]、术后6h镇痛泵用药量(9.1±0.3)ml]、术后6h疼痛评分(1.7±1.2)分]、术后24h镇痛泵用药量(38.4±4.1)ml]均明显低于B组分别为(0.7±0.1)mg、(12.0±1.6)ml、(3.3±1.1)分、(42.7±5.8)ml](t=10.364,P=0.000;t=2.845,P=0.010;t=4.921,P=0.000;t=2.650,P=0.013)。结论 肌间沟臂丛神经阻滞+全身麻醉在肩关节结核手术中能减少切皮时血压波动,以及术中降压药和阿片类药物的使用量,对手术的顺利实施和术后镇痛及康复有重要作用。

Effect of brachial plexus block in shoulder joint tuberculosis surgery

Objective To evaluate the efficacy of brachial plexus block in surgical treatment of tuberculosis of the shoulder joint. Methods 42 patients with tuberculosis of the shoulder joint underwent surgical treatment, who were admitted in Beijing Chest Hospital, Capital Medical University during October 2014 to October 2018, were divided into group A (n=23, brachial plexus block plus general anesthesia) and B (n=19, general anesthesia only). There were two cases were excluded in group A due to one case with cervical lymph node tuberculosis and another case with failure of brachial plexus block. The heart rate (HR) and mean arterial pressure (MAP) were recorded before skin incision and at the time of incision. The intraoperative infusion rate of propofol was regulated under the guidance of BIS. The use of remifentanil and nicardipine were recorded. The numerical rating scale (NRS) of pain and the dosage of opium at 6 hours, 24 hours after operation were recorded. Results The MAP and HR at skin incision ,and the rate of use of antihypertensive drug in group A were significantly less than those in group B ((75.6±10.7)mm Hg and (88.2±10.0)mm Hg (1mm Hg=0.133kPa), (75.1±13.6)bpm and (80.9±14.8)bpm, 14.3% (3/21) and 52.6% (10/19), respectively (t=3.816,P=0.000;t=2.166,P=0.037;χ ²=6.686,P=0.017)). The dosage of remifentanil,the NRS pain score in 6h after operation and the dosage of opium in 6h and 24h after operation in the group A was significantly lower than those ((0.4±0.1)mg and (0.7±0.1)mg, (9.1±0.3)ml and (12.0±1.6)ml, (1.7±1.2) and (3.3±1.1), (38.4±4.1)ml and (42.7±5.8)ml) in the group B (t=10.364, P=0.000; t=2.845, P=0.010; t=4.921, P=0.000; t=2.650, P=0.013). Conclusion Brachial plexus block plus general anesthesia can reduce of the blood pressure fluctuation during skin resection and the dosage of antihypertensive drugs and opioid drugs during the operation of shoulder tuberculosis. It is important for the smooth implementation of the operation and postoperative analgesia and rehabilitation.