唐群杰 葉偉標(biāo) 方建勤 黃廣用 鄭建宇

[摘要]目的 比較在肥胖患者上肢手術(shù)中應(yīng)用盲探法、神經(jīng)刺激儀引導(dǎo)法、超聲引導(dǎo)法以及超聲聯(lián)合神經(jīng)刺激儀引導(dǎo)法進(jìn)行肌間溝臂叢神經(jīng)阻滯的效果。方法 選取2017年1～12月在廣東佛山市三水區(qū)人民醫(yī)院進(jìn)行擇期上肢手術(shù)的120例肥胖患者作為研究對(duì)象，采用隨機(jī)數(shù)字表法將其分為A、B、C、D組，每組各30例。A組患者采用傳統(tǒng)的解剖定位尋找異感法（盲探法），B組患者采用神經(jīng)刺激儀引導(dǎo)法，C組患者采用超聲可視下阻滯法，D組患者采用超聲聯(lián)合神經(jīng)刺激儀行臂叢阻滯。比較四組患者的完成阻滯所需時(shí)間、感覺(jué)神經(jīng)阻滯起效時(shí)間、阻滯完善效果及并發(fā)癥總發(fā)生率。結(jié)果 B、C、D組患者完成阻滯所需時(shí)間均顯著短于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;C、D組患者完成阻滯所需時(shí)間均顯著短于B組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;D組患者完成阻滯所需時(shí)間顯著短于C組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）。B、C、D組患者的感覺(jué)神經(jīng)阻滯起效時(shí)間均顯著短于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;B、C、D組患者的感覺(jué)神經(jīng)阻滯起效時(shí)間比較，差異無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05）。B、C、D組患者的神經(jīng)阻滯完善效果均優(yōu)于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;C、D組患者的的神經(jīng)阻滯完善效果均優(yōu)于B組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;D組患者的的神經(jīng)阻滯完善效果優(yōu)于C組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）。B、C、D組患者的并發(fā)癥總發(fā)生率均顯著低于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;B、C組患者的并發(fā)癥總發(fā)生率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05）;D組患者的并發(fā)癥總發(fā)生率顯著低于B、C組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）。結(jié)論 與傳統(tǒng)盲探法比較，超聲引導(dǎo)法在肥胖患者上肢手術(shù)的肌間溝臂叢神經(jīng)阻滯中具有完成操作時(shí)間短、阻滯起效時(shí)間短、阻滯完善率高和并發(fā)癥發(fā)生率低等優(yōu)勢(shì)。超聲聯(lián)合神經(jīng)刺激儀可進(jìn)一步擴(kuò)大優(yōu)勢(shì)。

[關(guān)鍵詞]肌間溝臂叢神經(jīng)阻滯;肥胖患者;超聲引導(dǎo)法;盲探法;神經(jīng)刺激儀引導(dǎo)法

[中圖分類號(hào)] R614? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] A? ? ? ? ? [文章編號(hào)] 1674-4721（2019）2（c）-0081-05

[Abstract] Objective To compare the application effect of blind probe method， nerve stimulator guidance method， ultrasonic guidance method and ultrasound combined with nerve stimulator guidance method for the intermuscular sulcus brachial plexus block in the upper limb surgery for obese patients. Methods A total of 120 obese patients who underwent elective upper extremity surgery in Foshan Sanshui District People′s Hospital of Guangdong Province from January to December 2017 were selected as sudy subjects. They were divided into A， B， C and D groups according to the random number table method， 30 cases in each group. Traditional anatomical localization to find the heterosexual method （blind probe method） was used in group A， nerve stimulator guidance method was used in group B， ultrasonic guidance method was used in group C， and ultrasound combined with nerve stimulator guidance method was used in group D. The operation completed time for nerve block， the onset time of sensory nerve block， the block improvement effect， and total incidence rate of complications were compared among the four groups. Results The operation completed time for nerve block in group B， C， and D was significantly shorter than that in group A， and the differences were statistically significant （P<0.05）. The operation completed time for nerve block in group C and D was significantly shorter than that in group B， and the differences were statistically significant （P<0.05）. The operation completed time for nerve block in group D was significantly shorter than that in group C， and the difference was statistically significant （P<0.05）. The onset time of sensory nerve block in group B， C， and D was significantly shorter than that in group A， and the differences were statistically significant （P<0.05）. There was no significant difference in the onset time of sensory nerve block among the B， C， and D groups （P>0.05）. The block improvement effect in group B， C and D was better than that that in group A， and the differences were statistically significant （P<0.05）. The block improvement effect in group C and D was significantly better than that that in group B， and the differences were statistically significant （P<0.05）. The block improvement effect in group D was better than that that in group C， and the difference was statistically significant （P<0.05）. The total incidence rate of complications in group B， C and D was significantly lower than that that in group A， and the differences were statistically significant （P<0.05）. There was no significant difference in the total incidence rate of complications between the group B and group C （P>0.05）. The total incidence rate of complications in group D was significantly lower than that in group B and C， and the differences were statistically significant （P<0.05）. Conclusion Compared with the blind probe method， the ultrasonic guidance method has the advantages of short operation time， short block effect time， high blockade improvement rate and low complication rate in the intermuscular sulcus brachial plexus block of the upper limb surgery for obese patients. The ultrasound combined with nerve stimulator guidance method can further expand the advantages.

[Key words] Intermuscular sulcus brachial plexus block; Obese patients; Ultrasonic guidance method; Blind probe method; Nerve stimulator guidance method

肌間溝臂叢神經(jīng)阻滯是上肢手術(shù)患者一種常用的麻醉技術(shù)[1]。肌間溝臂叢神經(jīng)阻滯的操作區(qū)域位于患者的頸部位，臨床上多數(shù)患者神經(jīng)阻滯操作區(qū)域解剖定位簡(jiǎn)單，通過(guò)尋找異感定位的“盲探法”即可快速方便實(shí)現(xiàn)肌間溝臂叢神經(jīng)阻滯操作區(qū)域的定位[2]。但部分肥胖患者的頸部肌肉和脂肪組織增多，肌間溝解剖部位不清，通過(guò)尋找異感定位臂叢神經(jīng)位置難度加大，傳統(tǒng)盲探法使用效果不佳[3]。目前臨床上實(shí)現(xiàn)肥胖患者肌間溝臂叢神經(jīng)阻滯的方法除“盲探法”外，還有神經(jīng)刺激儀引導(dǎo)法[4]、超聲引導(dǎo)法[5]以及超聲聯(lián)合神經(jīng)刺激儀引導(dǎo)法[6]等。本研究選取在廣東佛山市三水區(qū)人民醫(yī)院進(jìn)行擇期上肢手術(shù)的120例肥胖患者[30 kg/m2<體重指數(shù)（BMI）≤35 kg/m2]作為研究對(duì)象，旨在比較在肥胖患者上肢手術(shù)中應(yīng)用盲探法、神經(jīng)刺激儀引導(dǎo)法、超聲引導(dǎo)法以及超聲聯(lián)合神經(jīng)刺激儀引導(dǎo)法進(jìn)行肌間溝臂叢神經(jīng)阻滯的效果，現(xiàn)報(bào)道如下。

1資料與方法

1.1一般資料

選取2017年1～12月在廣東佛山市三水區(qū)人民醫(yī)院進(jìn)行擇期上肢手術(shù)的120例肥胖患者作為研究對(duì)象。納入標(biāo)準(zhǔn)：①30 kg/m20.05），具有可比性。本研究經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會(huì)審核批準(zhǔn)，參與研究者均簽署知情同意書。

1.2方法

所有患者均采用相同濃度（0.375%）及相同劑量（30 ml）的羅哌卡因（AstraZeneca AB，國(guó)藥準(zhǔn)字H20100103，20 mg/10 ml）進(jìn)行臂叢神經(jīng)阻滯麻醉。A組患者采用傳統(tǒng)的解剖定位尋找異感法（盲探法），B組患者采用神經(jīng)刺激儀引導(dǎo)法，C組患者采用超聲可視下阻滯法，D組患者采用超聲聯(lián)合神經(jīng)刺激儀行臂叢阻滯?；颊呷胧液蟪Ｒ?guī)多參數(shù)心電監(jiān)護(hù)，開(kāi)放上肢靜脈。由經(jīng)驗(yàn)豐富及熟悉掌握超聲引導(dǎo)定位和神經(jīng)刺激儀的主治以上麻醉醫(yī)師行臂叢神經(jīng)阻滯，各組穿刺成功后，緩慢注入0.375%羅哌卡因30 ml。

1.3觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)

①記錄各組患者完成阻滯所需時(shí)間（開(kāi)始臂叢神經(jīng)阻滯操作至局麻藥注射完畢的時(shí)間）。②注藥完成后使用視覺(jué)模擬（VAS）評(píng)分法測(cè)定橈神經(jīng)、尺神經(jīng)、正中神經(jīng)、肌皮神經(jīng)及腋神經(jīng)支配區(qū)域的感覺(jué)效果，用于判定感覺(jué)神經(jīng)阻滯起效時(shí)間，具體操作如下。在紙上面劃一條10 cm的橫線，橫線的一端為0，表示無(wú)痛;另一端為10，表示劇痛;中間部分表示不同程度的疼痛。讓患者根據(jù)自我感覺(jué)在橫線上劃一記號(hào)，表示疼痛的程度，并進(jìn)行計(jì)分，以計(jì)分<3分時(shí)判定為阻滯起效時(shí)間。臂叢各神經(jīng)代表感覺(jué)區(qū)域：撓神經(jīng)代表的感覺(jué)區(qū)域?yàn)榈?、2掌骨間隙背面的“虎口區(qū)”皮膚;尺神經(jīng)代表的感覺(jué)區(qū)域?yàn)槭终?、手背?nèi)側(cè)緣;正中神經(jīng)帶包的感覺(jué)區(qū)域我拇指、食指、中指遠(yuǎn)節(jié);肌皮神經(jīng)代表的感覺(jué)區(qū)域?yàn)榍氨弁鈧?cè)皮膚;腋神經(jīng)-三角肌區(qū)皮膚。③按以下標(biāo)準(zhǔn)記錄患者的神經(jīng)阻滯效果，具體如下。Ⅰ級(jí)：阻滯范圍完善，患者無(wú)痛、安靜，肌松滿意，為手術(shù)提供良好條件;Ⅱ級(jí)：阻滯范圍欠完善，肌松效果欠滿意，患者有疼痛表情;Ⅲ級(jí)：阻滯范圍不完善，疼痛較明顯，肌松效果較差，患者出現(xiàn)呻吟、躁動(dòng)，輔助用藥后，情況有所改善，但不夠理想，勉強(qiáng)完成手術(shù);Ⅳ級(jí)：麻醉失敗，需改用其他麻醉方法后才能完成手術(shù)。④記錄患者的并發(fā)癥發(fā)生情況，包括局麻藥中毒、誤傷神經(jīng)、誤傷血管以及霍納綜合征。

1.4統(tǒng)計(jì)學(xué)方法

采用SPSS 19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析，計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差（x±s）表示，兩組間比較采用t檢驗(yàn);計(jì)數(shù)資料采用率表示，組間比較采用χ2檢驗(yàn);等級(jí)資料采用秩和檢驗(yàn)，以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2結(jié)果

2.1四組患者完成阻滯所需時(shí)間的比較

B、C、D組患者完成阻滯所需時(shí)間均顯著短于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;C、D組患者完成阻滯所需時(shí)間均顯著短于B組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;D組患者完成阻滯所需時(shí)間顯著短于C組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）（表1）。

2.2四組患者感覺(jué)神經(jīng)阻滯起效時(shí)間的比較

B、C、D組患者的感覺(jué)神經(jīng)阻滯起效時(shí)間均顯著短于A組，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）;B、C、D組患者的感覺(jué)神經(jīng)阻滯起效時(shí)間比較，差異無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05）（表2）。