王為庫(kù) 呂振江
[摘要]目的 觀(guān)察神經(jīng)刺激儀引導(dǎo)下連續(xù)股神經(jīng)阻滯用于膝關(guān)節(jié)術(shù)后鎮(zhèn)痛的效果。方法 選取2017年2~12月我院行下肢術(shù)后鎮(zhèn)痛患者100例,按照隨機(jī)數(shù)字表法分為參照組和觀(guān)察組,每組各50例。參照組實(shí)施連續(xù)靜脈給藥鎮(zhèn)痛,觀(guān)察組實(shí)施神經(jīng)刺激儀引導(dǎo)下連續(xù)股神經(jīng)阻滯鎮(zhèn)痛,比較兩組患者的各項(xiàng)臨床指標(biāo)、VAS評(píng)分、Ramsay鎮(zhèn)靜評(píng)分及不良反應(yīng)發(fā)生率。結(jié)果 兩組的HR和SpO2比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),參照組的SBP、DBP高于觀(guān)察組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);兩組治療前VAS評(píng)分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),觀(guān)察組治療6、12、36及48 h VAS評(píng)分低于參照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),觀(guān)察組治療前后VAS評(píng)分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),參照組治療后各時(shí)間段VAS評(píng)分高于治療前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);兩組治療前Ramsay鎮(zhèn)靜評(píng)分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),觀(guān)察組治療6、12、36及48 h Ramsay鎮(zhèn)靜評(píng)分低于參照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),且觀(guān)察組和參照組治療后各時(shí)間段Ramsay鎮(zhèn)靜評(píng)分高于治療前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀(guān)察組不良反應(yīng)發(fā)生率低于參照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 神經(jīng)刺激儀引導(dǎo)下連續(xù)股神經(jīng)阻滯用于膝關(guān)節(jié)術(shù)后鎮(zhèn)痛的效果較好,具有安全性和有效性,可在臨床實(shí)踐中予以廣泛推廣和應(yīng)用。
[關(guān)鍵詞]神經(jīng)刺激儀;連續(xù)外周神經(jīng)阻滯;下肢術(shù)后鎮(zhèn)痛
[中圖分類(lèi)號(hào)] R614 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-4721(2018)8(c)-0099-04
[Abstract] Objective To observe the effect of continuous femoral nerve block guided by nerve stimulators for postoperative analgesia in knee joints. Methods A total of 100 patients performed with postoperative analgesia for the lower extremities from February to December in 2017 were selected. They were equally divided into two groups by a random number table method, 50 cases in each group. In the reference group, continuous intravenous analgesia was used, while in the observation group, continuous femoral nerve block guided by nerve stimulator was adopted. The clinical indicators, visual analogue scale (VAS), Ramsay sedation score, and incidence of adverse reactions in the two groups were compared. Results There was no significant difference in heart rate (HR) or oxyhemoglobin saturation (SpO2) between the two groups (P>0.05). The systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in the reference group than in the observation group and the difference was statistically significant (P<0.05). The VAS scores before treatment in both groups were not displayed statistical significance between the two groups (P>0.05). The VAS scores 6, 12, 36 and 48 h after treatment in the observation group were all lower than those in the reference group and the difference was statistically significant (P<0.05). There was no significant difference in VAS scores before and after treatment in the observation group (P>0.05). The scores of the reference group at different timepoints after treatment were all higher compared with those before treatment and the difference was statistically significant (P<0.05). Ramsay sedation scores before treatment in both groups were not displayed statistical significance (P>0.05). The Ramsay sedation scores 6, 12, 36 and 48 h after treatment in the observation group were all lower than those in the reference group and the difference was statistically significant (P<0.05). What′s more, the Ramsay sedation scores at different timepoints after treatment in the two groups were higher compared with those before treatment and the difference was statistically significant (P<0.05). The incidence of adverse reactions in the observation group was lower than that in the reference group, and the difference was statistically significant (P<0.05). Conclusion The continuous femoral nerve block guided by nerve stimulator is effective for postoperative analgesia of knee joint. It is safe and can be widely used and promoted in clinical practice.
[Key words] Nerve stimulator; Continuous peripheral nerve block; Postoperative analgesia of the lower limbs
患者術(shù)后疼痛如未及時(shí)有效的控制,極易引發(fā)出現(xiàn)其他并發(fā)癥狀,一般來(lái)說(shuō),患者需行適當(dāng)?shù)男g(shù)后鎮(zhèn)痛,術(shù)后鎮(zhèn)痛在一定程度上減輕中樞神經(jīng)的生理變化[1],有利于患者盡早恢復(fù)健康。隨著臨床醫(yī)療技術(shù)的不斷發(fā)展和進(jìn)步,術(shù)后疼痛的管理和控制也隨之發(fā)展,臨床中較為常見(jiàn)的兩種術(shù)后鎮(zhèn)痛方式為連續(xù)靜脈給藥鎮(zhèn)痛或神經(jīng)刺激儀引導(dǎo)下連續(xù)外周神經(jīng)阻滯鎮(zhèn)痛[2],且神經(jīng)刺激儀能明顯獲取目標(biāo)肌肉運(yùn)動(dòng)反應(yīng)情況,對(duì)深度鎮(zhèn)靜或全身麻醉實(shí)施的連續(xù)股神經(jīng)阻滯來(lái)說(shuō)效果顯著,外周神經(jīng)導(dǎo)管位置的準(zhǔn)確性得以保證。本研究對(duì)神經(jīng)刺激儀引導(dǎo)下連續(xù)外股神經(jīng)阻滯用于膝關(guān)節(jié)后鎮(zhèn)痛的效果進(jìn)行觀(guān)察,現(xiàn)報(bào)道如下。
1資料與方法
1.1一般資料
選取我院2017年2~12月收治的膝關(guān)節(jié)術(shù)后鎮(zhèn)痛患者100例,按照隨機(jī)數(shù)字表法分為參照組和觀(guān)察組,每組各50例。納入標(biāo)準(zhǔn):均符合臨床診斷標(biāo)準(zhǔn)并實(shí)施膝關(guān)節(jié)置換術(shù),經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會(huì)認(rèn)證并簽署知情同意書(shū)。排除標(biāo)準(zhǔn):合并高血壓、糖尿病等全身性疾病患者,肝腎功能障礙患者,藥物過(guò)敏患者,凝血功能障礙患者。觀(guān)察組男27例,女23例;年齡24~64歲;體重51~84 kg,平均(62.38±5.74)kg;ASA分級(jí):1級(jí)12例,2級(jí)25例,3級(jí)13例。參照組男26例,女24例;年齡22~63歲;體重52~86 kg,平均(61.47±5.63)kg;ASA分級(jí):1級(jí)11例,2級(jí)27例,3級(jí)12例。兩組的一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2方法
兩組均行吸氧治療并開(kāi)放靜脈通道。參照組術(shù)后實(shí)施連續(xù)靜脈給藥鎮(zhèn)痛,將1 μg/ml舒芬太尼(宜昌人福藥業(yè)有限責(zé)任公司,國(guó)藥準(zhǔn)字H20054256)溶液予以輸注200 ml,輸注速度為4 ml/h,每次使用劑量不得超過(guò)1.5 ml。觀(guān)察組于麻醉前選擇股神經(jīng)在神經(jīng)刺激儀引導(dǎo)下進(jìn)行定位和穿刺,神經(jīng)刺激儀型號(hào)為Ssimu-plexHNS12,然后留置導(dǎo)管,隨后行麻醉誘導(dǎo)和維持,誘導(dǎo)依次靜注咪達(dá)唑侖0.05 mg/kg(江蘇恩華藥業(yè)股份有限公司,國(guó)藥準(zhǔn)字H10980025),芬太尼4 μg/kg(宜昌人福藥業(yè)有限責(zé)任公司,國(guó)藥準(zhǔn)字H42022076),丙泊酚1.5 mg/kg(Fresenius Kabi AB,國(guó)藥準(zhǔn)字J20080023),順阿曲庫(kù)銨0.07 mg/(kg·h)(江蘇恒瑞醫(yī)藥股份有限公司,國(guó)藥準(zhǔn)字H20060869)。麻醉維持為靜脈泵注瑞芬太尼9 μg/(kg·h)(宜昌人福藥業(yè)有限責(zé)任公司,國(guó)藥準(zhǔn)字H20030197)、丙泊酚2 mg/(kg·h)、順阿曲庫(kù)銨0.07 mg/(kg·h)(江蘇恒瑞醫(yī)藥股份有限公司,國(guó)藥準(zhǔn)字H20060869)。
1.3觀(guān)察指標(biāo)
①觀(guān)察并記錄兩組舒張壓(SBP)、收縮壓(DBP)、心率(HR)、血氧飽和度(SpO2)[3]。②視覺(jué)模擬評(píng)分(VAS):0分表示無(wú)痛,10分表示劇烈疼痛且難以忍受,分?jǐn)?shù)越高表明疼痛程度越嚴(yán)重[4]。③Ramsay鎮(zhèn)靜評(píng)分:1分表示患者不安靜、不合作,2分表示患者安靜且合作,3分表示患者嗜睡但配合指令,4分表示患者處于睡眠狀態(tài),但可喚醒,5分表示患者反應(yīng)遲鈍,6分表示患者處于深度睡眠狀態(tài)且不可喚醒[5]。④不良反應(yīng):觀(guān)察并記錄兩組發(fā)生惡心、頭暈和尿潴留等不良反應(yīng)發(fā)生例數(shù),不良反應(yīng)發(fā)生率=不良反應(yīng)發(fā)生例數(shù)/總例數(shù)×100%。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS 17.0統(tǒng)計(jì)學(xué)軟件處理,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,采用t檢驗(yàn);計(jì)數(shù)資料以率表示,采用χ2檢驗(yàn),以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1兩組患者麻醉12 h后各項(xiàng)臨床指標(biāo)的比較
麻醉前,兩組HR和SpO2比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),麻醉12 h后觀(guān)察組SBP、DBP低于參照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)(表1)。
2.2兩組患者各時(shí)間段VAS評(píng)分的比較
治療前,兩組VAS評(píng)分的比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),觀(guān)察組在治療6、12、36及48 h的VAS評(píng)分均低于參照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);另外,治療前后觀(guān)察組的VAS評(píng)分的比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),但參照組治療后VAS評(píng)分與治療前比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。
2.3兩組患者各時(shí)間段Ramsay鎮(zhèn)靜評(píng)分的比較
兩組治療前Ramsay鎮(zhèn)靜評(píng)分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),觀(guān)察組在治療6、12、36及48 h的Ramsay鎮(zhèn)靜評(píng)分均低于參照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),且兩組在不同時(shí)間段的Ramsay鎮(zhèn)靜評(píng)分均低于治療前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表3)。
2.4兩組患者的不良反應(yīng)總發(fā)生率的比較
觀(guān)察組患者的不良反應(yīng)發(fā)生率低于參照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表4)。
3討論
術(shù)后疼痛在臨床中十分常見(jiàn),如未進(jìn)行及時(shí)有效的控制,患者易出現(xiàn)諸多不良反應(yīng)和持續(xù)性傷害,進(jìn)展至慢性疼痛后,不僅危害患者健康,也降低患者的生活質(zhì)量,因此,術(shù)后有效鎮(zhèn)痛逐漸成為臨床關(guān)注的重點(diǎn)[6]。一般來(lái)說(shuō),下肢術(shù)后鎮(zhèn)痛多使用阿片類(lèi)藥物[7],受耐藥性影響,藥物不良反應(yīng)相對(duì)較多,嘔吐、瘙癢、惡心等不良反應(yīng)發(fā)生率極高,不利于患者的預(yù)后效果,總體來(lái)說(shuō)效果并不是十分理想。外周神經(jīng)阻滯的應(yīng)用改善了以往治療現(xiàn)狀,盡管鎮(zhèn)痛時(shí)間相對(duì)較長(zhǎng),但不良反應(yīng)相對(duì)較少,安全性較高,且外周神經(jīng)阻滯下患者的血流動(dòng)力學(xué)更加趨于穩(wěn)定,對(duì)患者身體機(jī)能的干擾相對(duì)較小,降低患者病理生理反應(yīng)的發(fā)生率,利于患者更快康復(fù)[8]。但是,由于外周神經(jīng)阻滯需在浸潤(rùn)阻滯、異感等方式進(jìn)行定位[9],手術(shù)成功率相對(duì)較低,因此,準(zhǔn)確定位是提高外周神經(jīng)阻滯成功率的關(guān)鍵。隨著醫(yī)療技術(shù)的發(fā)展和進(jìn)步,神經(jīng)刺激儀的應(yīng)用為連續(xù)外周神經(jīng)阻滯下肢術(shù)后鎮(zhèn)痛帶來(lái)新方向,極大的提高了手術(shù)成功率。眾所周知,神經(jīng)刺激儀引導(dǎo)下連續(xù)外周神經(jīng)阻滯操作相對(duì)簡(jiǎn)單、安全性較高、患者鎮(zhèn)痛和鎮(zhèn)靜效果明顯,對(duì)患者早期活動(dòng)和抗凝治療的影響較小[10],且不良反應(yīng)相對(duì)更少,在有效改善患者預(yù)后的同時(shí),利于患者盡快恢復(fù)健康,縮短住院時(shí)間,效果顯著。本研究結(jié)果顯示,兩組患者的HR和SpO2比較,差異無(wú)統(tǒng)計(jì)學(xué)意義,觀(guān)察組患者的SBP、DBP均高于參照組,提示應(yīng)用神經(jīng)刺激儀引導(dǎo)下連續(xù)外周神經(jīng)阻滯下肢術(shù)后鎮(zhèn)痛對(duì)患者心率和血氧飽和度影響不大,但對(duì)收縮壓和舒張壓影響較大。觀(guān)察組在治療6、12、36及48 h的VAS評(píng)分和Ramsay鎮(zhèn)靜評(píng)分均低于參照組,且觀(guān)察組不良反應(yīng)發(fā)生率明顯低于參照組,提示實(shí)施神經(jīng)刺激儀引導(dǎo)下連續(xù)外周神經(jīng)阻滯下肢術(shù)后鎮(zhèn)痛能明顯改善患者疼痛和鎮(zhèn)靜效果,且患者不良反應(yīng)發(fā)生率相對(duì)較低,安全性較高。但仍需注意的是,本研究選取病例有限,對(duì)神經(jīng)損傷與鎮(zhèn)痛效果的關(guān)聯(lián)性仍需進(jìn)一步探討。
綜上所述,下肢術(shù)后鎮(zhèn)痛在神經(jīng)刺激儀引導(dǎo)下連續(xù)外周神經(jīng)阻滯能明顯改善患者鎮(zhèn)靜效果和疼痛,改善患者血壓指標(biāo),具有安全性和有效性,具有極佳的臨床應(yīng)用價(jià)值。
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