罗哌卡因膈神经阻滞治疗胸外科术后同侧肩膀痛的临床研究  

Management of ipsilateral shoulder pain after thoracotomy with phrenic nerve infiltration using ropivacaine

作　　者：孙敏莉[1] 梁雅芬[2] 缪长虹[1] 方浩[1] 葛圣金[1] 谭黎杰[3] 薛张纲[1] 王群[3] 

机构地区：[1]复旦大学附属中山医院麻醉科,上海200032 [2]哈佛大学附属麻省总医院麻醉科,波士顿021142621 [3]复旦大学附属中山医院胸外科,上海200032

出　　处：《复旦学报（医学版）》2011年第5期440-444,共5页Fudan University Journal of Medical Sciences

摘　　要：目的观察罗哌卡因膈神经阻滞用于治疗胸外科术后同侧肩膀痛的有效性和安全性,探讨其可能的作用机制。方法择期行后外侧开胸手术患者63例(肺部手术35例,食管手术28例),随机分为治疗组(n=31)和对照组(n=32)。均采用全身麻醉联合硬膜外阻滞,治疗组于关胸前予0.25%罗哌卡因10mL膈神经阻滞,对照组给予等容量生理盐水。观察不同时点(拔管后即刻、拔管后0.5、1、2、3、4h)两组患者同侧肩膀痛的发生率和严重程度,同时随访血气,了解有无CO2潴留。结果 60例患者完成本实验(对照组31例,治疗组29例)。对照组有22例发生同侧肩膀痛,占71.0%(22/31);治疗组有5例发生同侧肩膀痛,占17.2%(5/29),两组比较差异有统计学意义(P<0.001)。治疗组患者观察期内视觉模拟评分(visual analogues score,VAS)明显低于对照组(P<0.01)。两组患者术后PaCO2比较差异无统计学意义(P>0.05)。结论罗哌卡因膈神经阻滞是治疗胸外科术后同侧肩膀痛安全有效的方法,其阻滞效果与手术方式无关。疼痛发生可能与手术操作、胸腔引流管对胸膜、心包、膈肌的伤害性刺激经膈神经传导,牵涉到同侧肩膀。Objective To investigate the efficacy and safety of phrenic nerve infiltration in managing ipsilateral shoulder pain after thoracotomy,and also to postulate a reasonable mechanism concerning this kind of pain.Methods Sixty-three patients,undergoing selective lateroposterior thoracotomy（lung surgery：n=35;esophageal surgery：n=28） were randomly divided into two groups：patients in treatment group were given phrenic nerve infiltration with 0.25% ropivacaine just before thoracic closure,while those in control group were given the same volume of saline.Surgery was taken under standard epidural block combined with general anesthesia.Any pain in the ipsilateral shoulder unrelated with incision pain was recorded and assessed with VAS（visual analogues score） at the time of extubation,0.5 hour after extubation,then with one hour interval until 4 hours after extubation.At the same time,arterial blood gas was analyzed to see if any CO2 retention occurred as the side effect of phrenic nerve infiltration.Results Sixty patients accomplished the experiment,among which 22/31（71.0%） patients in the control group developed ipsilateral shoulder pain compared with 5/29（17.2%） in the treatment group（P0.001）.There was significant difference on the overall tendency of VAS in the whole investigation period,with the control group had a much higher VAS（P0.01）.Postoperative PaCO2 was not increased in treatment group compared with control group（P0.05）.Conclusions We conclude that phrenic nerve infiltration with ropivacaine is an effective and safe way to manage post-thoracotomy ipsilateral shoulder pain.Surgery type has no significant influence on the efficacy of phrenic nerve infiltration.This study implicates that nociceptive signals from the pericardium,pleural surface or diaphragm by surgery or drainage tubes might be transmitted via phrenic nerve and referred to the ipsilateral shouder.

关 键 词：罗哌卡因 同侧肩膀痛 胸外科手术 膈神经阻滞 

分 类 号：R614.4[医药卫生—麻醉学]