臂丛神经阻滞在肩关节结核手术中的作用

doi:10.3969/j.issn.1000-6621.2019.04.012

摘要/Abstract

摘要：

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。

关键词: 结核, 骨关节, 外科手术, 麻醉, 局部, 麻醉, 全身, 麻醉药, 联用, 对比研究

Abstract:

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.

Key words: Tuberculosis, osteoarticular, Surgical procedures, operative, Anesthesia, local, Anesthesia, general, Anesthetics, combined, Comparative study

刘涛,罗太君,陈玢,曹晓曼,刘伟. 臂丛神经阻滞在肩关节结核手术中的作用[J]. 中国防痨杂志, 2019, 41(4): 430-433. doi: 10.3969/j.issn.1000-6621.2019.04.012

Tao LIU,Tai-jun LUO,Bin CHEN,Xiao-man CAO,Wei LIU. Effect of brachial plexus block in shoulder joint tuberculosis surgery[J]. Chinese Journal of Antituberculosis, 2019, 41(4): 430-433. doi: 10.3969/j.issn.1000-6621.2019.04.012

图/表 3

表1

两组患者临床资料比较

组别	性别[例(构成比,%)]		年龄 (岁, $x ˉ$ ±s)	体质量 (kg, $x ˉ$ ±s)	手术时间 (min, $x ˉ$ ±s)	ASA分级[例(构成比,%)]
组别	男	女	年龄 (岁, $x ˉ$ ±s)	体质量 (kg, $x ˉ$ ±s)	手术时间 (min, $x ˉ$ ±s)	Ⅰ级	Ⅱ级
A组(21例)	11(52.4)	10(47.6)	51.9±18.1	65.7±8.3	89.8±13.7	13(61.9)	8(38.1)
B组(19例)	10(52.6)	9(47.4)	54.9±15.9	60.9±9.5	90.4±13.0	10(52.6)	9(47.4)
统计值	χ²=0.000		t=0.562	t=1.070	t=0.049	χ²=0.351
P值	0.987		0.577	0.291	0.961	0.554

表1

表2

两组患者手术切皮前后MAP、HR及降压药使用情况

组别	切皮前MAP值 (mm Hg, $x ˉ$ ±s)	切皮时MAP值 (mm Hg, $x ˉ$ ±s)	切皮前后对比		切皮前HR值 (次/min, $x ˉ$ ±s)	切皮时HR值 (次/min, $x ˉ$ ±s)	切皮前后对比		降压药使用情况 [例(使用率,%)]
组别	切皮前MAP值 (mm Hg, $x ˉ$ ±s)	切皮时MAP值 (mm Hg, $x ˉ$ ±s)	t值	P值	切皮前HR值 (次/min, $x ˉ$ ±s)	切皮时HR值 (次/min, $x ˉ$ ±s)	t值	P值	降压药使用情况 [例(使用率,%)]
A组(21例)	74.7±13.2	75.6±10.7	0.623	0.537	70.9±10.1	75.1±13.6	1.869	0.069	3(14.3)
B组(19例)	72.9±8.1	88.2±10.0	6.942	0.000	69.7±12.0	80.9±14.8	2.477	0.018	10(52.6)
统计值	t=0.516	t=3.816			t=0.589	t=2.166			χ²=6.686
P值	0.609	0.000			0.559	0.037			0.017

表2

表3

参考文献 15

[1]	Deshmukh A, Deo S, Salgia AK , et al. A Rare Unusual Case Presentation of the Tuberculosis of the Shoulder Joint. J Orthop Case Rep, 2013,3(4):23-25. doi: 10.13107/jocr.2250-0685.126 URL
[2]	刘国庆, 何泽清, 刘兴华 , 等. 肩关节结核的CT、MRI诊断. 中华解剖与临床杂志, 2011,16(2):117-119. doi: 10.3969/j.issn.1671-7163.2011.02.008 URL
[3]	Chumsaengsri C, Salee P, Louthrenoo W , et al. Clinical features and treatment outcomes of bone joint infection between bacteria and Mycobacterium tuberculosis. Open Forum Infect Dis, 2017,4 Suppl 1: S102.
[4]	Qian Y, Han Q, Liu W , et al. Characteristics and management of bone and joint tuberculosis in native and migrant population in Shanghai during 2011 to 2015. BMC Infect Dis, 2018,18(1):543. doi: 10.1186/s12879-018-3456-3 URL
[5]	李露, 李秋军, 周海滨 , 等. 全身麻醉复合臂丛神经阻滞提高肩关节镜术的麻醉质量. 国际麻醉学与复苏杂志, 2013,34(3):230-233. doi: 10.3760/cma.j.issn.1673-4378.2013.03.009 URL
[6]	Mahure SA, Rokito AS, Kwon YW . Transcutaneous electrical nerve stimulation for postoperative pain relief after arthroscopic rotator cuff repair: a prospective double-blinded randomized trial. J Shoulder Elbow Surg, 2017,387(9):1-9. doi: 10.1016/j.tox.2017.06.005 URL pmid: 28735847
[7]	Santonocito C, Noto A, Crimi C , et al. Remifentanil-induced postoperative hyperalgesia:current perspectives on mechanisms and therapeutic strategies. Local Reg Anesth, 2018,11:15-23. doi: 10.2147/LRA.S143618 URL
[8]	Holmberg A, Sauter AR, Klaastad Ø , et al. Pre-operative brachial plexus block compared with an identical block performed at the end of surgery: a prospective, double-blind, randomised clinical trial. Anaesthesia, 2017,72(8):967-977. doi: 10.1111/anae.2017.72.issue-8 URL
[9]	曲智俊 . 肌间沟臂丛神经阻滞复合静脉全麻在肩关节镜手术麻醉中的应用. 山东医药, 2017,57(26):79-81. doi: 10.3969/j.issn.1002-266X.2017.26.024 URL
[10]	Comelon M, Raeder J, Stubhaug A , et al. Gradual withdrawal of remifentanil infusion may prevent opioid-induced hyperalgesia. Br J Anaesth, 2016,116(4):524-530. doi: 10.1093/bja/aev547 URL
[11]	贾娟, 石翊飒 . 瑞芬太尼诱发痛觉过敏相关受体机制的研究进展. 中国疼痛医学杂志, 2016,22(9):696-699. doi: 10.3969/j.issn.1006-9852.2016.09.012 URL
[12]	Rivosecchi RM, Rice MJ, Smithburger PL , et al. An evidence based systematic review of remifentanil associated opioid induced hyperalgesia. Expert Opin Drug Saf, 2014,13(5):587-603. doi: 10.1517/14740338.2014.902931 URL pmid: 24669819
[13]	李晓声 . 臂丛神经阻滞复合全身麻醉在老年患者肩关节术的应用. 航空航天医学杂志, 2015,26(7):805-807.
[14]	Chalifoux F, Colin F, St-Pierre P , et al. Low dose intravenous dexamethasone (4 mg and 10 mg) significantly prolongs the analgesic duration of single-shot interscalene block after arthroscopic shoulder surgery:a prospective randomized placebo-controlled study. Can J Anaesth, 2017,64(3):280-289. doi: 10.1007/s12630-016-0796-6 URL pmid: 28050801
[15]	周玉弟, 姜慧丽, 汤洋 , 等. 超声引导下选择性颈神经根阻滞在肩关节镜术后镇痛中的应用. 临床麻醉学杂志, 2017,33(12):1167-1170.