公茂偉，孫永海，傅 強

?

“Shamrock method”超聲引導(dǎo)連續(xù)腰叢神經(jīng)阻滯用于老年患者全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛的臨床觀察

公茂偉，孫永海*，傅 強

（解放軍總醫(yī)院麻醉手術(shù)中心，北京 100853）

評價“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯與連續(xù)股神經(jīng)阻滯對全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛的臨床效果。采用開放、隨機對照的研究方法，選擇解放軍總醫(yī)院2014年6月至2014年12月?lián)衿谛袉蝹?cè)全膝關(guān)節(jié)置換術(shù)的老年患者80例，年齡65～87歲，美國麻醉醫(yī)師協(xié)會（ASA）分級Ⅱ～Ⅲ級，隨機均分為連續(xù)腰叢神經(jīng)阻滯組（L組）和連續(xù)股神經(jīng)阻滯組（F組）。L組患者采用“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下行腰叢神經(jīng)阻滯，F(xiàn)組則采用超聲引導(dǎo)聯(lián)合刺激儀定位下行股神經(jīng)阻滯，兩組穿刺成功后均注入0.2%羅哌卡因30ml并留置導(dǎo)管,術(shù)后鎮(zhèn)痛泵背景劑量為0.2%羅哌卡因5ml/h。記錄術(shù)后6，12，24，48h時靜息狀態(tài)視覺模擬評分法（VAS）評分，術(shù)后24，48h膝關(guān)節(jié)功能鍛煉時VAS評分和肌力評分；記錄術(shù)后局麻藥中毒、惡心嘔吐和神經(jīng)損傷等不良反應(yīng)的發(fā)生情況。與L組相比較，F(xiàn)組術(shù)后各時點靜息狀態(tài)和功能鍛煉VAS評分均明顯增高（＜0.05），肌力評分兩組間差異無統(tǒng)計學(xué)意義（＞0.05）。兩組均未見局麻藥中毒、神經(jīng)損傷發(fā)生，且惡心嘔吐等不良反應(yīng)發(fā)生率兩組間差異無統(tǒng)計學(xué)意義?！癝hamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯對于老年患者全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛的臨床效果優(yōu)于連續(xù)股神經(jīng)阻滯。

shamrock method；超聲；腰骶叢；自主神經(jīng)傳導(dǎo)阻滯；股神經(jīng)；老年人；關(guān)節(jié)成形術(shù)，置換，膝；術(shù)后鎮(zhèn)痛

隨著人口老齡化的日益嚴(yán)重，關(guān)節(jié)退行性疾病日益增多。人工全膝關(guān)節(jié)置換術(shù)（total knee arthoplasty，TKA）是治療膝關(guān)節(jié)嚴(yán)重疾患、重建膝關(guān)節(jié)功能的主要手段，但創(chuàng)傷較大，常常導(dǎo)致術(shù)后嚴(yán)重的疼痛[1]。超聲引導(dǎo)連續(xù)股神經(jīng)阻滯術(shù)后鎮(zhèn)痛廣泛應(yīng)用于臨床，但因閉孔神經(jīng)阻滯不全，往往難以達(dá)到滿意的鎮(zhèn)痛效果?！癝hamrock method”[2,3]是一種新式超聲引導(dǎo)下以平面內(nèi)進(jìn)針方式的腰叢神經(jīng)阻滯方法，超聲引導(dǎo)定位較神經(jīng)刺激儀定位有較為明顯的優(yōu)勢，在超聲引導(dǎo)下可直接觀察到針頭與神經(jīng)以及周圍血管組織的關(guān)系，提高了阻滯的成功率，從而減少了腎臟、神經(jīng)損傷等并發(fā)癥的發(fā)生。本研究通過比較“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯和超聲引導(dǎo)連續(xù)股神經(jīng)阻滯，觀察前者用于老年患者TKA術(shù)后鎮(zhèn)痛的可行性及臨床效果。

1 對象與方法

1.1 研究對象

選擇解放軍總醫(yī)院2014年6月至2014年12月美國麻醉醫(yī)師協(xié)會（American Society of Anesthesiologists，ASA）分級Ⅱ～Ⅲ級行TKA患者80例，年齡65～87歲，體質(zhì)量45～98kg，男36例，女44例。既往無局麻藥物過敏史和阿片類藥物成癮史，無外周神經(jīng)病變及凝血功能障礙等。采用開放、隨機對照的研究方法，隨機分為連續(xù)腰叢神經(jīng)阻滯組（L組）和連續(xù)股神經(jīng)阻滯組（F組），每組40例。

1.2 麻醉方法

兩組入手術(shù)室后均開放靜脈通道，采用多功能監(jiān)測儀常規(guī)監(jiān)測無創(chuàng)血壓（noninvasive blood pressure，NBP）、心率（heart rate，HR）、心電圖（electrocardiogram，ECG）及脈搏血氧飽和度（pulse oxygen saturation，SPO2）。

術(shù)前30min行神經(jīng)阻滯，麻醉前均靜脈注射咪達(dá)唑侖（咪唑安定，midazolam）1～2mg、芬太尼（fentanyl）50μg。L組患者采用“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯（圖1）?；颊呷?cè)臥位，患側(cè)在上，兩下肢自然伸展略彎曲，以脊柱棘突連線為正中線，過髂嵴最高點作上述直線的垂線，自兩直線交點向阻滯側(cè)旁開4～5cm即為穿刺點[4]。確定穿刺點后，應(yīng)用超聲（美國SonoSite公司）低頻線陣探頭（頻率為2～5MHz）橫向置于腹外側(cè)腋中線，緊貼髂嵴高點，穿刺針以平面內(nèi)（in-plane）模式進(jìn)針，進(jìn)針方向垂直于皮膚或稍朝向中線。F組應(yīng)用超聲引導(dǎo)聯(lián)合刺激儀定位下行股神經(jīng)阻滯，在腹股溝韌帶下方2cm處水平放置高頻線陣探頭（頻率為7～13MHz），長軸與大腿縱軸垂直，待清晰顯示髂恥弓筋膜處由內(nèi)向外排列的股靜脈、股動脈和股神經(jīng)橫斷面超聲圖像，采用平面內(nèi)技術(shù)，由大腿外側(cè)皮膚進(jìn)針。兩組同時聯(lián)合使用神經(jīng)刺激器（Stimuplex Dig型，德國貝朗公司）輔助定位，設(shè)定刺激波寬0.1ms，頻率2Hz，電流強度為1mA，出現(xiàn)股四頭肌收縮伴髕骨跳動時，減小刺激強度，同時調(diào)整穿刺針位置，當(dāng)電流減小至0.3～0.4mA時，仍有肌群抽搐，回抽無血即可注藥1ml后肌肉顫搐即消失，調(diào)大刺激強度至1mA，無肌肉收縮可繼續(xù)注入局部麻醉藥0.2%羅哌卡因（ropivacaine）30ml，并留置導(dǎo)管，置管長度均為超出針尖后5cm。

所有患者于神經(jīng)阻滯實施后置入喉罩，靜脈靶控輸注丙泊酚（異丙酚，propofol）2.5～3.0mg/L，芬太尼50～100μg和順苯磺酸阿曲庫銨（atracurium besilate）0.1～0.2mg/kg，置入一次性Supreme喉罩（德國LMA公司）。術(shù)中吸入0.6%～1.0%七氟烷（七氟醚，sevoflurane），靜脈靶控輸注丙泊酚0.8～1.8mg/L，瑞芬太尼（remifentanil）0.1～0.2μg/（kg·h）維持麻醉，維持呼氣末二氧化碳分壓（end-tidal carbon dioxide，ETCO2）35～40mmHg（1mmHg＝0.133kPa）。術(shù)畢患者完全清醒后拔除喉罩。手術(shù)結(jié)束前兩組患者均接一次性術(shù)后鎮(zhèn)痛泵，背景劑量0.2%羅哌卡因5ml/h，保留鎮(zhèn)痛48h。任一時間點若患者的視覺模擬評分法（Visual Analogue Scale，VAS）評分＞4分，則加用帕瑞昔布鈉（parecoxib sodium）40mg靜脈注射。

1.3 觀察指標(biāo)

1.3.1 疼痛評分 疼痛強度采用VAS進(jìn)行評分，分值為0～10，0代表無痛，10代表難以忍受的疼痛。記錄術(shù)后6，12，24，48h時靜息狀態(tài)VAS評分（Rest VAS，RVAS），術(shù)后24，48h膝關(guān)節(jié)功能鍛煉時VAS評分（Functional Exercise VAS，F(xiàn)VAS）。

1.3.2 肌力評分 記錄各時間點患肢股四頭肌肌力，0分為完全癱瘓，1分為可收縮，2分為不能抗重力，3分為抗重力不抗阻力，4分為可抗弱阻力，5分為正常。

1.3.3 不良反應(yīng) 包括術(shù)后局部麻醉藥中毒癥狀、惡心嘔吐、神經(jīng)損傷等情況。

圖1 腰叢“Shamrock method”入路

Figure 1 Shamrock method ultrasound-guided lumbar plexus blocks

ESM: erector spinae muscles; LP: lumbar plexus; PM: psoas major muscle; QLM: quadratus lumborum muscle; SP: spinous process; TP: transverse process; VB: vertebral body. A: diagrammatic drawing, white arrow is puncture needle; B: ultrasound images

1.4 統(tǒng)計學(xué)處理

2 結(jié) 果

兩組患者性別、年齡、體質(zhì)量一般情況差異無統(tǒng)計學(xué)意義（＞0.05；表1）。術(shù)后6，12，24，48h RVAS評分（表2）和術(shù)后24h、48h FVAS評分（表3）L組明顯低于F組（＜0.05）；術(shù)后24和48h肌力評分L組分別為（2.6±0.5）分和（4.2±0.3）分，F(xiàn)組分別為（2.7±0.4）分和（4.3±0.4）分，兩組間差異無統(tǒng)計學(xué)意義（＞0.05）。術(shù)后24h功能鍛煉時，兩組均有加用帕瑞昔布鈉病例（L組2例，F(xiàn)組5例）。兩組均無局部麻醉藥中毒、神經(jīng)損傷發(fā)生，且惡心嘔吐等不良反應(yīng)發(fā)生率兩組間差異無統(tǒng)計學(xué)意義。

3 討 論

TKA常伴隨骨質(zhì)、骨膜等組織的損傷以及術(shù)中止血帶的使用造成血管的缺血再灌注損傷，因此術(shù)后患者早期會經(jīng)歷劇烈疼痛[5,6]。TKA術(shù)后完善的鎮(zhèn)痛利于患者早期行康復(fù)訓(xùn)練，從而防止術(shù)后黏連、縮短術(shù)后恢復(fù)時間、減少心血管及肺部并發(fā)癥發(fā)生[7]。本研究應(yīng)用“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢阻滯用于老年患者TKA術(shù)后，取得滿意的鎮(zhèn)痛效果?！癝hamrock method”[2]在超聲引導(dǎo)下可以直接觀察到針頭與神經(jīng)以及周圍血管組織的關(guān)系，并且可以看到注射藥物后局部擴(kuò)散的整個動態(tài)過程，不僅縮短了操作時間、加快了神經(jīng)阻滯，而且增加了阻滯的成功率。聯(lián)合應(yīng)用超聲和刺激器進(jìn)行神經(jīng)穿刺使操作更簡便、有效和安全[8]，使得穿刺定位更精確，確保藥液準(zhǔn)確注射在其周圍。從而減少了腎臟、神經(jīng)的損傷等并發(fā)癥的發(fā)生。

表1 兩組患者基本情況比較

L group: continuous lumbar plexus nerve blocks group; F group: continuous femoral nerve blocks group

表2 兩組患者靜息時術(shù)后不同時間點VAS評分

L group: continuous lumbar plexus nerve blocks group; F group: continuous femoral nerve blocks group; RVAS: Rest Visual Analogue scale; TKA: total knee arthoplasty. Compared with L group,*＜0.05

表3 兩組患者功能鍛煉時術(shù)后不同時間點VAS評分

L group: continuous lumbar plexus nerve blocks group; F group: continuous femoral nerve blocks group; FVAS: Functional Exercise Visual Analogue Scale; TKA: total knee arthoplasty. Compared with L group,*＜0.05

靜脈鎮(zhèn)痛操作簡便、不影響肌力、適用范圍廣，但阿片類藥物有較嚴(yán)重的呼吸抑制、惡心嘔吐、尿潴留和瘙癢等不良反應(yīng)。硬膜外術(shù)后鎮(zhèn)痛效果較為滿意，但關(guān)節(jié)置換術(shù)后常使用的低分子肝素等抗凝劑預(yù)防術(shù)后深靜脈血栓，有形成椎管內(nèi)血腫的風(fēng)險，限制了其臨床使用[9]。

Singelyn等[10]報道有效的外周神經(jīng)阻滯能緩解疼痛、減少嗎啡類藥物的應(yīng)用。并且外周神經(jīng)阻滯還具有對患者血流動力學(xué)影響小的特點，尤其適用于老年合并心血管疾病的患者[11]。國內(nèi)TKA術(shù)后多采用連續(xù)股神經(jīng)阻滯鎮(zhèn)痛，股神經(jīng)阻滯基本只能抑制膝關(guān)節(jié)前方的傷害性刺激傳導(dǎo)，對TKA術(shù)后靜息狀態(tài)和功能鍛煉引起的疼痛均不能完全阻斷[12]。Macalou等[13]的研究表明，股神經(jīng)阻滯聯(lián)合閉孔神經(jīng)阻滯的鎮(zhèn)痛效果較單純股神經(jīng)阻滯顯著提高，說明閉孔神經(jīng)阻滯不全是導(dǎo)致術(shù)后疼痛的主要原因之一，大腿下1/3段內(nèi)側(cè)區(qū)被認(rèn)為是閉孔神經(jīng)支配區(qū)域。本研究應(yīng)用“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯用于老年患者TKA，結(jié)果為L組術(shù)后各時點RVAS和FVAS均明顯低于F組（＜0.05），表明腰叢神經(jīng)阻滯對閉孔神經(jīng)作用相對完善，從而明顯提高了鎮(zhèn)痛效果。

完善的腰叢神經(jīng)阻滯需要局麻藥量較大，局麻藥通過周圍及中樞兩條途徑預(yù)防和減少疼痛，緩解由股四頭肌痙攣所致的功能障礙。羅哌卡因是一種新的酰胺類局部麻醉藥，其作用強度和藥代動力學(xué)與布比卡因類似，但它的心臟毒性較低，使用低濃度、小劑量時幾乎只阻滯感覺神經(jīng)[14]，相關(guān)研究證實0.2%羅哌卡因用于連續(xù)神經(jīng)阻滯能有效減輕痛覺而不抑制運動纖維[15]，可達(dá)到最佳的鎮(zhèn)痛和最小的運動阻滯平衡[16]。本觀察中應(yīng)用0.2%羅哌卡因取得較滿意的鎮(zhèn)痛效果。

綜上所述，本研究認(rèn)為“Shamrock method”超聲引導(dǎo)聯(lián)合刺激儀定位下連續(xù)腰叢神經(jīng)阻滯用于老年患者TKA術(shù)后鎮(zhèn)痛，效果優(yōu)于連續(xù)股神經(jīng)阻滯，并且增加了阻滯的成功率及安全性，此種方法應(yīng)用于臨床具有可行性。

[1] Jia DL, Li SQ, Han Bin,. Analgesic efficacy of stimulating catheter for continuously postoperative femoral nerve block[J]. J Clin Anesthesiol, 2011, 27(3): 257?260. [賈東林, 李水清, 韓 彬, 等. 刺激型導(dǎo)管連續(xù)股神經(jīng)阻滯術(shù)后鎮(zhèn)痛效果觀察[J]. 臨床麻醉學(xué)雜志, 2011, 27(3): 257?260.]

[2] Lin JA, Lee YJ, Lu HT. Finding the bulging edge: a modified shamrock lumbar plexus block in average-weight patients[J]. Br J Anaesth, 2014, 113(4): 718?720.

[3] Lin JA, Lu HT. Solution to the challenging part of the shamrock method during lumbar plexus block[J]. Br J Anaesth, 2014, 113(3): 516?517.

[4] Grant SA, Breslin DS, Macleod DB,. Variability in determination of point of needle insertion in peripheral nerve blocks: a comparison of experienced and inexperienced anaesthetists [J]. Anaethesia, 2003, 58(7): 688?692.

[5] Dorr LD, Chao L. The emotional state of the patient after total hip and knee arthroplasty[J]. Clin Orthop Relat Res, 2007, 463: 7?12.

[6] Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve blockcontinuous femoral nerve block after total knee arthroplasty on hospital length of stay and longterm functional recovery within an established clinical pathway [J]. Anesth Analg, 2006, 102(4): 1234?1239.

[7] Wang XD, Lin HH. Analgesic effect of continuous femoral nerve block in postoperative analgesia undergoing total knee arthroplasty[J]. Shandong Med J, 2007, 47(21): 91?92. [王曉東, 林惠華. 連續(xù)股神經(jīng)阻滯用于全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛效果觀察[J]. 山東醫(yī)藥, 2007, 47(21): 91?92.]

[8] Abrahams MS, Aziz MF, Fu RF,. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials[J]. Br J Anaesth, 2009, 102(3): 408?417.

[9] Guan ZP, Lyu HS, Wu C,. Early diagnosis and treatment of pulmonary embolism after total joint replacement: report of five cases [J]. Chin J Surg, 2003, 41(1): 37?40. [關(guān)振鵬, 呂厚山, 吳 淳, 等. 人工關(guān)節(jié)置換術(shù)后肺栓塞的早期診斷和處理[J]. 中華外科雜志, 2003, 41(1): 37?40.]

[10] Singelyn FJ, Deyaert M, Joris D,. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty[J]. Anesth Analg, 1998, 87(1): 88?92.

[11] Murray JM, Derbyshire S, Shields MO. Lower limb blocks[J]. Anaesthesia, 2010, 65(Suppl 1): 57?66.

[12] Capdevila X, Macaire P, Dadure C,. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evalution[J]. Anesth Analg, 2002, 94(6): 1606?1613.

[13] Macalou D, Trueck S, Meuret P,. Postoperative analgesia after total knee replacement: the effect of an obturator nerve block added to the femoral 3-in-1 nerve block[J]. Anesth Analg, 2004, 99(1): 251?254.

[14] Wu ZD. Surgery[M]. Beijing: People’s Medical Publishing House, 2008: 85?86. [吳在德. 外科學(xué)[M]. 北京: 人民衛(wèi)生出版社, 2008: 85?86.]

[15] Brodner G, Buerkle H, Van Aken H,. Postoperative analgesia after knee surgery: a comparison of three different concentrations of ropivacaine for centrations of ropivacaine for continuous femoral nerve blockade[J]. Anesth Analg, 2007, 105(1): 256?262.

[16] Smet I, Vlaminck E, Vercauteren M. Randomized controlled trial of patient-controlled epidural analgesia after orthopaedic surgery with sufentanil and ropivacaine 0.165% or levobupivacaine 0.125%[J]. Br J Anaesth, 2008, 100(1): 99?103.

（編輯: 周宇紅）

Efficiency of ultrasound-guided “Shamrock” continuous lumbar plexus block for postoperative analgesia in the elderly after total knee arthroplasty

GONG Mao-Wei, SUN Yong-Hai*, FU Qiang

(Anesthesia and Operation Center, Chinese PLA General Hospital, Beijing 100853, China)

To evaluate the efficacy of the “Shamrock method”, ultrasound combined with stimulator guided continuous lumbar plexus nerve block for postoperative analgesia in the elderly after total knee arthroplasty by compared with continuous femoral nerve block.An open, randomized, controlled trial was conducted on 80 ASA Ⅱ or Ⅲ patients (65 to 87 years old) undergoing total knee arthroplasty in our hospital from June to December 2014. The patients were randomly assigned to continuous lumbar plexus nerve block group (L group) and continuous femoral nerve block group (F group). The patients of the former group received continuous lumbar plexus nerve block by ultrasound guided “shamrock” and electronic nerve stimulator, and those of the latter group received continuous femoral nerve block by ultrasound guiding combined with stimulator. After the nerve block catheters were inserted and 30ml 0.2% ropivacaine was given, all patients received patient-controlled analgesia (PCA) after the surgery with 0.2% ropivacaine 5ml/h as the background dose. Visual Analogue Scale (VAS) was employed to evaluate the pain level at 6, 12, 24 and 48h, postoperatively. VAS pain scores were recorded at 24 and 48h, postoperatively, during functional excise and muscle strength. The toxic reaction, nausea and vomiting, and nerve damage were recorded after surgery.The VAS scores during rest and functional excise were significantly higher in F group than in L group (＜0.05), but there was no difference in the muscle strength between the 2 groups (＞0.05). No local anesthetic toxicityor nerve damage was founded in the both groups, and there was no statistical difference in the incidence of side effect such as nausea and vomiting during postoperative analgesia.The ultrasound-guided “shamrock” combined with stimulator for continuous lumbar plexus nerve block is superior to continuous femoral nerve block in analgesia for postoperative analgesia in the elderly after total knee arthroplasty.

shamrock method; ultrasound; lumbosacral plexus; autonomic nerve blocks; femoral nerve; aged; arthroplasty, replacement, knee; postoperative analgesia

R592; R614.4

A

10.11915/j.issn.1671-5403.2015.06.095

2015?03?20;

2015?05?10

孫永海，E-mail:sunyonghai68@aliyun.com