神经刺激术在超声引导锁骨下臂丛神经阻滞中的应用：一项前瞻性随机研究  

作　　者：Emmanuel Dingemans Stephan R. Williams Geneviève Arcand Philippe Chouinard Patrick Harris Monique Ruel Frangois Girard 刘雁(译) 王多友(校) 

机构地区：[1]Department of Anesthesiology and Surgery, Centre Hospitalier de I'Universitē de Montrēal, Hapital Notre-Dame, Canada [2]不详

出　　处：《麻醉与镇痛》2008年第2期56-62,共7页Anesthesia & Analgesia

摘　　要：超声引导（ultrasound guidance，USG）锁骨下臂丛神经阻滞可提供实时的进针程度和局麻药分布图像。但在USG下行臂丛神经阻滞时，局麻药扩散情况能否取代神经刺激反应作为局麻药的注药指征，目前尚无正式的研究报道。因此，我们进行了此项前瞻性随机研究实验：以72例择期行手和前臂手术的患者作为观察对象，将患者分为单独应用超声引导组（U组）和超声引导与神经刺激联合应用组（S组），比较两组完成神经阻滞操作的时间以及锁骨下阻滞的效果。U组患者采用尽可能少的注药次数注入局麻药，在腋动脉的后方及两侧呈U形分布（其注射次数为1、2和3次的患者数分别为29、6和3例）。S组患者则应用0．3—0．6mA的刺激电流产生远端运动反应之后，行单次注药。注入的麻醉药液为1．5％的利多卡因与0．125％的布比卡因混合液内含1：200000的肾上腺素（最终浓度），药物容量为0．5ml／kg。与S组患者比较，U组患者的阻滞操作时间明显缩短（分别为3．1±1．6分钟及5．2±4．7分钟；P=0．006）。S组患者中，37％的患者局麻药液向腋动脉前方扩散，而63％的患者局麻药液向腋动脉后方扩散。注药后30分钟产生肌皮神经、正中神经、桡神经和尺神经区域完全性感觉阻滞效果的U组患者为86％，而S组患者中仅占57％（P=0．007）。U组患者单次注药与多次注药所产生的完全阻滞率相同，均为86％。U组患者需要追加给药率为8％，而S组为26％（P=0．049）。S组中有1例患者由于20分钟之后仍不能获得远端刺激反应而阻滞失败。由此，我们得出如下结论，在超声引导行锁骨下臂丛神经阻滞时，以观察药液分布情况作为注入局麻药的指征，可缩短操作时间，提高麻醉成功率。局麻药围绕腋动脉的后一侧方向扩散可预示阻滞成功，并免除了直接观察神经的必要。Ultrasound guidance （USG） for infradavicular blocks provides real time visualization of the advandng needle and local anesthetic distribution. Whether visualization of local anesthetic spread can supplant neurostimulation as the end point for local anesthetic injection during USG block has never been formally evaluated. Therefore, for this prospective randomized study, we recruited 72 patients scheduled for hand or forearm surgery and compared the speed of execution and quality of USG infradavicular block with either USG alone （Group U） or USG combined with neurostimulation （Group S）. In Group U, local anesthetic was deposited in a U-shaped distribution posterior and to each side of the axillary artery using as few injections as possible （1,2, and 3 injections in 29, 6, and 3 patients, respectively）. In Group S, a single injection was made after obtaining a distal motor response with a stimulating current between 0.3 and 0.6 mA. The anesthetic solution consisted of 0.5 ml/kg of lidocaine 1.5%, bupivacaine 0. 125%, and epinephrine 1：200 000 （final concentrations）. Procedure times were significantly shorter in Group U compared with Group S （3.1 ± 1.6 min and 5.2 ± 4.7 min, respectively; P = 0. 006）. In Group S, anesthetic spread was mainly anterior to the axillary artery in 37% of patients and mainly posterior in 63% of patients. Thirty minutes after the injection, 86% of patients in Group U had complete sensory block in the musculocutaneous, median, radial, and ulnar nerve territories compared with 57% in Group S （P = 0. 007）. Patients blocked in Group U with a single injection had the same rate of complete block （86%） as those blocked with more than one injection （86%）. Block supplementation rates were 8% in Group U versus 26% in Group S （P = 0. 049）. Block failure occurred in one patient in Group S because of an inability to obtain a distal stimulation after 20 rain. We conclude that USG infraclavicular block is more rapidly performed and yields a higher success rate w

关 键 词：锁骨下臂丛神经阻滞 前瞻性随机研究 超声引导 神经刺激术 局麻药液 布比卡因混合液 单次注药 麻药扩散 

分 类 号：R614.4[医药卫生—麻醉学] R657.4[医药卫生—外科学]