足踝手术中超声引导腘窝坐骨神经阻滞最佳给药部位的临床研究  

Analgesic effect of ultrasound-guided popliteal sciatic nerve block in foot and ankle surgery: subparaneural versus extraparaneural injection of local anesthetics

作　　者：张娜 蔡光玉 罗俊杰 凌丹丹 陈小瑞 余斌[1] ZHANG Na;CAI Guang-yu;LUO Jun-jie;LING Dan-dan;CHEN Xiao-rui;YU Bin(Dept.of Anesthesiology,Tongji Hospital,Tongji University,Shanghai 200065,China)

机构地区：[1]同济大学附属同济医院麻醉科,上海200065

出　　处：《同济大学学报（医学版）》2018年第4期72-77,共6页Journal of Tongji University(Medical Science)

基　　金：上海市卫生系统先进适宜技术推广项目(2013SY032);上海市科委项目(SKW1507)

摘　　要：目的探讨超声引导腘窝坐骨神经鞘膜下和鞘膜外阻滞在足踝手术中的最佳给药部位。方法选择同济大学附属同济医院2016年5月—2017年4月择期行单侧足踝手术患者40例,通过简单随机化分成两组:神经鞘膜下注药组(X组,n=20)和神经鞘膜外注药组(W组,n=20)。在超声引导下,使用新型连续外周神经阻滞针对两组患者分别实施腘窝坐骨神经鞘膜下和鞘膜外阻滞并留置导管,局部麻醉药物持续滴定的同时采用神经传导监测技术观察远端腓肠肌的复合性肌肉动作电位(compound muscle action potentials,CMAP)波幅变化,记录两组患者波幅下降为0~0.5 m V时的时间、局部麻醉药用量,手术结束后观察两组患者连续神经阻滞的镇痛效果、患者满意度及神经损伤等并发症。结果 X组与W组比较,完全阻滞所需局部麻醉药量[(10.9±1.7)mL vs(16.1±1.2)mL]和完全阻滞耗时[(19.9±3.5)min vs(30.3±2.5)min]差异有统计学意义(P<0.05);X组术后6、24、48 h镇痛局部麻醉药用量较少(P<0.05);而W组术后6、24、48 h自控镇痛次数明显增加(P<0.05);术后6 h,W组静止疼痛评分高于X组(P<0.05),术后24、48 h静止疼痛评分差异无统计学意义;在术后6、24、48 h,两组间活动疼痛评分相比较,W组均高于X组,且差异有统计学意义(P<0.05);X组患者满意度评分较高(P<0.05);两组均无神经损伤临床表现。结论足踝手术应用连续腘窝坐骨神经阻滞麻醉,神经鞘膜下注药麻醉起效更快,用药量更少,术后镇痛效果更好,满意度更高,患者无神经损伤等临床症状。Objective To compare the subparaneural with extraparaneural injection of local anestheticsin ultrasound.guided popliteal sciatic nerve block for foot and ankle surgery. Methods Forty patientsundergoing unilateral foot or ankle surgery from May 2016 to April 2017 were recruited. Subjects wererandomized to subparaneural injection group （ group X, n = 20） and extraparaneural injection group（group W, n = 20）. All participates received an ultrasound.guided continuous popliteal sciatic nerveblock using a novel cannula.over.needle nerve block suite. A pipe was placed subparaneural orextraparaneural for postoperative analgesia. The time for the distal gastrocnemius muscle.s CMAPamplitude down to 0 0. 5 mv in motor nerve conduction study and the dosage of drug delivery wererecorded during the surgery. The postoperative analgesia effect, patient satisfaction and nerve injury wereobserved after the operation. Results Preoperative local anesthetics dosage [（10. 9±1. 7）mL vs （16. 1±1. 2）mL] and time of motor nerve block[（19. 9±3. 5）min vs （30. 3±2. 5）min] were significantly less ingroup X than those in group W （P〈0. 05）. The local anesthetic dosage at 6th, 24th and 48th hour ofpostoperative analgesia were significantly less in group X （P〈0. 05）. At the 6th, 24th and 48th hour aftersurgery, times of patient controlled analgesia were significantly higher in group W （P〈 0. 05）. Painscores of stationary was significantly higher in group W at the 6th hour after surgery （P〈0. 05）, whilethere was no significant difference in scores of 24th and 48th hour. Pain scores of activity wassignificantly higher in group W at the 6th, 24th and 48th hour after surgery （P〈0. 05）. group X showedsignificantly higher patient satisfaction scores （P〈0. 05）. There was no significant symptom of nerveinjury in both groups. Conclusion For patients receiving continuous popliteal sciatic nerve block in footand ankle surgery, the subparaneural injection of local anesthetics can get a faster ner

关 键 词：腘窝坐骨神经阻滞 神经鞘膜 神经传导检查 局部麻醉药 超声引导 

分 类 号：R614[医药卫生—麻醉学]