不同镇痛方式用于股骨颈骨折老年患者硬膜外麻醉穿刺时的作用  

Effect of different analgesia regimens in elderly patients with femoral neck fracture during epidural anesthesia

作　　者：张高峰[1] 马志爽 王彬[1] 尹曾[1] 杨佩[3] 孙立新[1] 王明山[1] 

机构地区：[1]青岛市市立医院东院麻醉科,266071 [2]青岛市妇女儿童医院麻醉科 [3]青岛市市立医院东院急诊科,266071

出　　处：《临床麻醉学杂志》2017年第1期29-32,共4页Journal of Clinical Anesthesiology

基　　金：青岛市2015年度医药科研指导计划(2015-WJZD019)

摘　　要：目的比较不同镇痛方式用于老年股骨颈骨折患者硬膜外麻醉穿刺时的作用。方法选择行人工股骨头置换的股骨颈骨折患者90例,男35例,女55例,年龄65~90岁,体重48~78kg,ASAⅡ或Ⅲ级。按随机数字表法分为三组:股神经阻滞组(FNB组)、髂筋膜腔隙阻滞组(FIC组)和静脉注射芬太尼镇痛组(IV组),每组30例。硬膜外穿刺前30min,FNB组在神经刺激仪引导下行股神经阻滞,FIC组在超声引导下行髂筋膜腔隙阻滞,两组按患者体重给予相应容量的罗哌卡因(<50kg,20ml;50~70kg,25ml;>70kg,30ml);IV组于穿刺前3 min时静脉注射芬太尼0.5μg/kg。三组穿刺期间VAS评分≥4分时,静脉注射芬太尼0.25μg/kg,VAS评分<4分后摆放体位。采取患侧在上、L1~2硬膜外穿刺,硬膜外导管置入完成后改平卧位。记录入室后(T0)、硬膜外麻醉前(T1,FNB组和FIC组阻滞30min后,IV组静脉注射首剂芬太尼3min后)、硬膜外穿刺前变换体位时(患侧在上,T2)、麻醉穿刺成功改为平卧位即刻(T3)和改为平卧位后3 min(T4)的VAS评分;记录硬膜外穿刺时间、穿刺期间芬太尼用量和心血管事件、低氧血症的发生情况。结果与IV组比较,T1、T2时FNB组和FIC组芬太尼用量明显减少[(38±9)μg、(38±11)μg vs.(110±18)μg],硬膜外穿刺时间明显缩短[(9±4)min、(9±4)min vs.(17±5)min],心血管事件和低氧血症发生率明显降低(10%、7%vs.37%)(P<0.05或0.01);FNB组和FIC组上述各指标差异无统计学意义。结论股神经阻滞和髂筋膜腔隙阻滞对老年股骨颈骨折患者硬膜外麻醉穿刺期间有明显的芬太尼节俭效应,并能减少心血管事件和低氧血症的发生。Objective To compare the efficacy of different analgesia regimens in elderly patients with femoral neck fracture undergoing posture changing during epidural anesthesia.Methods Ninety patients（35 males,55 females,aged 65-90 years,48-78kg）with femoral neck fracture who would be treated with artificial femoral head replacement were randomly divided into 3groups（n=30each）：femoral nerve block group（group FNB）,fascia iliaca compartment block group（group FIC）and intravenous group（group IV）.Femoral nerve block or fascia iliaca compartment block was performed 30 min before epidural anesthesia（EA）in FNB group or FIC group respectively.Fentanyl 0.5μg/kg was injected intravenously 3min before EA.In the three groups,additional 0.25μg/kg fentanyl was administrated intravenously to keep the VAS scores4before positioning.EA was performed between L1-2in a position of troubled leg upper,and patients returned to supine position after epidural catheterization.The VAS scores at T0（after entering the operation room）,T1（in supine posture before EA）,T2（before posture changing）,T3（while supine from lateral posture after EA）,T4（3min after T3）,the time for achieving EA,the fentanyl consumption,the cases of cardiovascular events and hypoxemia was recorded.Results Compared with group IV,VAS scores at T1,T2,the fentanyl consumption,time for achieving EA,and incidence of cardiovascular events and hypoxemia in group FNB and group FIC decreased significantly（P〈0.05 or 0.01）.There was no significant difference between group FNB and group FIC.Conclusion Preemptive analgesiaregimens through both femoral nerve block and fascia iliaca compartment block during epidural anesthesia can reduce the fentanyl consumption,as well as decrease the incidence of cardiovascular events and hypoxemia.

关 键 词：筋膜 股神经 神经传导阻滞 体位 股骨颈骨折 老年 

分 类 号：R614[医药卫生—麻醉学]