摘要
目的探讨加速康复外科(ERAS)理念下超声引导髋关节囊周围神经(PENG)阻滞联合喉罩全麻下行股骨近端髓内钉(PFNA)内固定术老年患者的镇痛效果。方法选取2021年1月至2022年3月长沙市中心医院收治的50例股骨粗隆骨折行PFNA内固定的老年患者,按照随机数字表法分为P组(超声引导下PENG阻滞联合喉罩全麻组)和F组[超声引导下髂筋膜阻滞(FICB)联合喉罩全麻组],P组26例,F组24例。两组患者术中脑电双频指数(BIS)维持在40~60范围内,根据BIS及血流动力学变化调整环泊酚及瑞芬太尼用量。术后采用羟考酮行术后镇痛(PCIA),当疼痛视觉模拟评分(VAS)≥4分时,静脉注射羟考酮1 mg补救镇痛。观察记录两组患者神经阻滞前(T_(0))、神经阻滞后10 min(T_(1))、神经阻滞后20 min(T_(2))、过床摆放体位时(T_(3))、麻醉苏醒拔除喉罩后(T_(4))、术后12 h(T_(5))、术后24 h(T_(6))以及术后48 h(T_(7))的VAS;观察记录T_(0)~T_(4)各个时间点的平均动脉压(MAP)、心律(HR)及血氧饱和度(SpO_(2));记录两组患者术中瑞芬太尼的使用剂量、T_(6)、T_(7)时的羟考酮的补救用量、Lovett肌力评分、手术时间、麻醉复苏时间以及术后麻醉相关并发症。结果两组患者T_(0)、T_(4)、T_(5)、T_(6)时VAS评分,T_(0)、T_(1)、T_(2)、T_(4)时MAP、HR及SpO_(2),术中瑞芬太尼的用量、术后T_(6)时羟考酮的补救用量、手术时间和麻醉复苏时间差异均无统计学意义(均P>0.05)。与F组患者相比,P组患者T_(1)、T_(2)、T_(3)、T_(7)时VAS评分均低于F组(均P<0.05);T_(3)时两组患者SpO_(2)差异无统计学意义(P>0.05),但P组MAP和HR均低于F组(均P<0.05),P组患者T_(7)时羟考酮的补救用量低于F组(P<0.05),镇痛效果更久;P组T_(6)、T_(7)时的Lovett肌力评分优于F组(均P<0.05)。两组患者术后并发症发生率差异无统计学意义(P>0.05)。结论与FICB比较,超声引导下PENG阻滞用于老年患者PFNA内固定术起效更快,患者术后需要阿片类镇痛药用量更少,镇痛持续时间更长,且对患者术后下肢肌力影响更小。
Objective To investigate the analgesic effect of ultrasound-guided pericapsular nerve group(PENG)block combined with laryngeal mask general anesthesia and internal fixation of proximal femoral nail antirotation(PFNA)under ERAS concept in elderly patients.Methods A total of 50 elderly patients with femoral trochanteric fractures treated with PFNA internal fixation who were admitted to Changsha Central Hospital from January 2021 to March 2022 were selected and according to the random number table method,they were divided into groups P and F,with 26 cases in group P(ultrasound-guided PENG block combined with laryngeal mask general anesthesia group)and 24 cases in group F[ultrasound-guided fascia iliaca compartment block(FICB)combined with laryngeal mask general anesthesia group].The bispectral index(BIS)of the two groups of patients was maintained within the range of 40-60,and the dosage of cyclopofol and remifentanil was adjusted according to the BIS and hemodynamic changes.Postoperative oxycodone was used for patient controlled intravenous analgesia(PCIA).When the Visual Analogue Scale(VAS)score≥4,1 mg intravenous oxycodone was administered as rescue analgesia.The VAS score was observed and recorded before nerve block(T_(0)),10 minutes after nerve block(T_(1)),20 minutes after nerve block(T_(2)),when the patients were placed in body position after bed(T_(3)),after laryngeal mask removal(T_(4)),12 h after operation(T_(5)),24 h after operation(T_(6))and 48 h after operation(T_(7)).The mean arterial pressure(MAP),heart rate(HR)and blood oxygen saturation(SpO_(2))at each time point from T_(0) to T_(4) were observed and recorded;the intraoperative dose of remifentanil,the rescue dose of oxycodone at postoperative T_(6) and T_(7),Lovett muscle strength score,anesthesia operation time,anesthesia recovery time and postoperative anesthesia-related complications were recorded.Results There was no significant difference between the two groups in VAS scores at T_(0),T_(4),T_(5) and T_(6),MAP,HR and SpO_(2) at T_(0),T_(1),T_(2) and T_(4),the dosage of remifentanil during operation,the remedial dosage of oxycodone at T_(6) after operation,anesthesia operation time and anesthesia recovery time(all P>0.05).Compared with group F,the VAS scores of group P at T_(1),T_(2),T_(3) and T_(7) were lower than those of group F(all P<0.05);At T_(3),there was no significant difference in SpO_(2) between the two groups(P>0.05),but the MAP and HR in group P was lower than that in group F(all P<0.05);The remedial dose of oxycodone at T_(7) in group P was lower than that in group F(P<0.05),and the analgesic effect was longer;Lovett muscle strength score at T_(6) and T_(7) in group P was better than that in group F(all P<0.05).There was no significant difference in the incidence of postoperative complications between the two groups(P>0.05).Conclusions Compared with FICB,ultrasound-guided PENG block used in PFNA internal fixation in elderly patients has faster effect,lower dosage of opioid analgesics,longer duration of analgesia,and less impact on postoperative lower limb muscle strength.
作者
张瑶
刘松华
王惠敏
程智刚
曹理言
Zhang Yao;Liu Songhua;Wang Huimin;Cheng Zhigang;Cao Liyan(Graduate School,Hunan University of Chinese Medicine,Changsha 410208,China;Department of Anesthesiology,Changsha Central Hospital Affiliated to South China University,Changsha 410004,China;Department of Anesthesiology&Critical Care Medicine,Xiangya Hospital,Central South University,Changsha 410008,China)
出处
《中国医师杂志》
CAS
2022年第6期823-827,832,共6页
Journal of Chinese Physician
基金
2021年长沙市中心医院科研立项项目(YNKY202102)
南华大学2020年度科研立项项目。
关键词
神经传导阻滞
关节囊
髋关节
骨折固定术
髓内
股骨骨折
加速康复外科
Nerve block
Joint capsule
Hip joint
Fracture fixation,intramedullary
Femoral fractures
Enhanced recovery after surgery
