断指再植术后超声引导下肘部连续靶神经阻滞对再植手指皮温和存活率的影响  

Effects of postoperative analgesia with ultrasound-guided continuous target nerve block of the wrist on skin temperature and survival of crushed fingers after microsurgical replantation

作　　者：徐杨[1] 陈勇柱[1] 吴军珍[1] 

机构地区：[1]上海交通大学附属第六人民医院麻醉科,上海200233

出　　处：《上海医学》2015年第4期272-275,I0001,共5页Shanghai Medical Journal

摘　　要：目的应用超声引导下肘部桡神经、尺神经和正中神经置管连续阻滞,对断指再植术后患者进行精准的靶神经镇痛,探讨该方法在术后48h内的镇痛效果,及其对再植手指皮温和存活率的影响。方法选择急诊行断指再植手术的患者60例,性别不限,年龄>6岁,既往均未长期服用抗凝药物,离断手指≤3根,美国麻醉医师协会分级Ⅰ或Ⅱ级,无严重合并伤。将患者随机分入研究组和对照组,每组30例。研究组患者于术后根据再植手指的不同分别行超声引导下肘部桡、尺和正中神经单独或联合置管,接镇痛泵行持续镇痛,镇痛配方为0.2%罗哌卡因共100mL,注射速度为2mL/h,术后48h拔除导管。对照组患者术后按需予肌内注射帕瑞昔布20mg镇痛。分别于术后即刻和术后12、24、36、48h各时间点,测量再植手指远端的皮温,同时记录疼痛视觉模拟评分(VAS评分)。分别记录两组患者再植手指血管危象发生率、二次手术探查率和再植手指存活率。结果研究组在术后12、24、36和48h时的疼痛VAS评分均显著低于对照组同时间点(P值均<0.05),再植手指皮温均显著高于对照组同时间点(P值均<0.05)。对照组的血管危象发生率(26.7%)和二次手术探查率(16.7%)均显著高于研究组(3.3%和3.3%,P值均<0.05)。两组的再植手指存活率均为96.7%,差异无统计学意义(P>0.05)。结论连续肘部靶神经阻滞可根据患者的具体伤情选择阻滞桡神经、尺神经或正中神经,提供良好的镇痛,达到扩张血管、增加血液灌注的目的,减少血管危象的发生。Objective To investigate the influence of ultrasound-guided continuous radial, ulnar and median nerve block analgesia of the wrist on skin temperature and survival of finger replantation. Methods Sixty patients who underwent emergency finger replantation with less than four digits for replantation, were aged older than 6 years, had no history of anticoagulants or multiple injury, American Society of Anesthesiologists （ASA） grade Ⅰ or Ⅱ , were randomized into control group and study group （n = 30）. Under ultrasonic guidance, continuous target nerve block analgesia of the wrist was conducted in study group according to the injured finger, followed by an infusion of ropivacaine 2 mL （0. 2%） per hour for up to 2 days. Parecoxibintra 20 mg was intramuscularly injected in control group when patients were in need of analgesia after surgery. Skin temperature of replantation digit and visual analog scale （VAS） scores were recorded at 0, 12, 24, 36, and 48 h after surgery. The incidence of vascular spasm, vascular embolization and the survival of reconstructive digits were observed. Results At 12, 24, 36 and 48 h after surgery, the VAS scores in study group were significantly lower than those in control group （all P〈0.05）, and the skin temperature in study group were significantly higher than those in control groups （all P〈0.05）. The incidence of vascular spasm and vascular embolization in study group were gnificantly lower than those in control group （3.3% vs. 26.7% and 3.3% vs. 16.7%, both P〈0.05）, but there was no significant difference in the survival rate of replanted fingers between groups （P〉0. 057. Conclusion Ultrasound-guided continuous target nerve block of the wrist according to the injured finger can provide more efficient postoperative analgesia. At the same time, blocking the proximal upper extremity can improve tissue perfusion after replantation of crushed fingers by preventing neurologically-mediated vasospasm.

关 键 词：超声引导 连续神经阻滞 术后镇痛 断指再植 皮温 

分 类 号：R614[医药卫生—麻醉学]