孫振中，路通俊，黃　威，劉智錦，王育明

(武警廣東省總隊(duì)醫(yī)院麻醉科，廣東　廣州　510507)

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超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯在前臂尺側(cè)手術(shù)中的應(yīng)用

孫振中，路通俊，黃威，劉智錦，王育明

(武警廣東省總隊(duì)醫(yī)院麻醉科，廣東廣州510507)

摘要：目的：評(píng)價(jià)超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯應(yīng)用于前臂尺側(cè)手術(shù)的效果和安全性。方法：選擇ASAⅠ～Ⅱ級(jí)前臂尺側(cè)手術(shù)患者60例，隨機(jī)分為超聲引導(dǎo)下肌間溝臂叢聯(lián)合腋路臂叢阻滯組(A組)和超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯組(B組)，每組各30例。配制0.5%鹽酸羅哌卡因注射液30 mL備用。A組患者先行肌間溝臂叢阻滯，超聲探頭長(zhǎng)軸與肌間溝垂直放置，調(diào)整探頭位置可顯示圓形或橢圓形低回聲的臂叢神經(jīng)上、中、下三干，在其周圍分別注射局麻藥5 mL，使局麻藥完全包繞在神經(jīng)干周圍。然后行腋路阻滯，超聲引導(dǎo)下依次在尺神經(jīng)、正中神經(jīng)和橈神經(jīng)周圍各注射局麻藥5 mL。B組患者先行肌間溝臂叢阻滯，方法同A組，顯像臂叢神經(jīng)上、中、下三干后在其周圍注射局麻藥共25 mL。然后行尺神經(jīng)阻滯，將超聲探頭垂直尺神經(jīng)溝放置于肱骨內(nèi)上髁近端，可見圓形或橢圓形的低回聲圖像即為尺神經(jīng)，在尺神經(jīng)周圍注入局麻藥5 mL。記錄麻醉操作時(shí)間和感覺阻滯起效時(shí)間；評(píng)價(jià)手術(shù)過(guò)程中的麻醉效果滿意度；記錄并發(fā)癥的發(fā)生情況。結(jié)果：兩組患者性別比例、年齡、體重、麻醉操作時(shí)間均無(wú)統(tǒng)計(jì)學(xué)意義 (P>0.05)； 兩組患者感覺阻滯起效時(shí)間比較，B組起效時(shí)間明顯短于A組 (P<0.05)；兩組患者麻醉效果滿意度的比較無(wú)統(tǒng)計(jì)學(xué)意義 (P>0.05)；兩組均無(wú)Horner綜合征、喉返神經(jīng)阻滯和尺神經(jīng)卡壓征，A組有3例發(fā)生興奮、多語(yǔ)等輕度局麻藥中毒癥狀，B組沒有任何并發(fā)癥。結(jié)論：超聲引導(dǎo)下肌間溝臂叢聯(lián)合腋路臂叢阻滯和超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯應(yīng)用于前臂尺側(cè)手術(shù)均可達(dá)到滿意的麻醉效果，但后者起效更快，安全性更高。

關(guān)鍵詞：超聲引導(dǎo)；肌間溝臂叢；尺神經(jīng)；前臂尺側(cè)

前臂尺側(cè)手術(shù)常需阻滯C5-8和T1神經(jīng)根形成臂叢的所有神經(jīng)根[1]。不同入路的選擇對(duì)麻醉效果尤為重要。肌間溝入路對(duì)尺神經(jīng)阻滯效果差，常需輔助大量靜脈藥方可完成手術(shù)，腋路阻滯對(duì)肌皮神經(jīng)和肋間臂神經(jīng)阻滯效果差，肋間臂神經(jīng)能否阻滯對(duì)成功應(yīng)用止血帶至關(guān)重要[1]。應(yīng)用超聲技術(shù)的優(yōu)勢(shì)在于能使局麻藥精確到達(dá)靶神經(jīng)周圍，達(dá)到更好的麻醉效果。為了滿足前臂尺側(cè)手術(shù)的需要，本研究選擇了超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯，觀察麻醉效果及安全性。現(xiàn)報(bào)告如下。

1資料與方法

1.1一般資料經(jīng)本院倫理委員會(huì)批準(zhǔn)，患者和家屬均簽署知情同意書。選擇ASAⅠ～Ⅱ級(jí)前臂尺側(cè)手術(shù)(包括尺骨骨折內(nèi)固定及內(nèi)固定取出術(shù)，前臂尺側(cè)清創(chuàng)縫合、神經(jīng)、肌腱、血管探查吻合術(shù))患者60例，其中男35例，女25例，年齡18～65歲，體重46～75 kg，隨機(jī)分為A、B兩組，超聲引導(dǎo)下肌間溝臂叢聯(lián)合腋路臂叢阻滯組(A組)和超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯組(B組)，每組30例。

1.2方法所有患者術(shù)前未用鎮(zhèn)靜、鎮(zhèn)痛藥物。入室后監(jiān)測(cè)BP、HR和SPO2,迅速開放外周靜脈通道。配制0.5%鹽酸羅哌卡因注射液30 mL備用。所有操作均由同一位熟練掌握超聲技術(shù)的麻醉醫(yī)生完成。A組患者先行肌間溝臂叢阻滯，患者仰臥頭偏向健側(cè)，手臂垂直緊貼身旁，常規(guī)消毒皮膚，鋪巾，超聲探頭長(zhǎng)軸與肌間溝垂直放置，調(diào)整探頭位置可顯示圓形或橢圓形低回聲的臂叢神經(jīng)上、中、下三干，利用平面內(nèi)技術(shù)，從探頭外側(cè)進(jìn)針，針頭到達(dá)神經(jīng)干周圍回抽無(wú)血時(shí)在上、中、下三干周圍各注射局麻藥5 mL，注藥時(shí)觀察局麻藥的擴(kuò)散情況，反復(fù)回抽，以確保藥液未入血，使局麻藥完全包繞在神經(jīng)干周圍。然后行腋路阻滯，患者仰臥頭偏向健側(cè)，手背貼床且靠近頭部做行軍禮狀，超聲探頭在腋窩部橫跨腋動(dòng)脈放置，圖像顯示腋動(dòng)脈、腋靜脈、尺神經(jīng)、橈神經(jīng)和正中神經(jīng)，從探頭外側(cè)進(jìn)針，采用平面內(nèi)技術(shù)依次在尺神經(jīng)、正中神經(jīng)和橈神經(jīng)周圍各注射局麻藥5 mL，注藥前反復(fù)回抽，注藥時(shí)仔細(xì)觀察藥液擴(kuò)散情況以防注入血管。B組患者先行肌間溝臂叢阻滯，方法同A組，顯像臂叢神經(jīng)上、中、下三干后在其周圍注射局麻藥共25 mL。然后行尺神經(jīng)阻滯，在肘關(guān)節(jié)尺神經(jīng)溝周圍消毒鋪巾后，將超聲探頭垂直尺神經(jīng)溝放置于肱骨內(nèi)上髁近端，可見圓形或橢圓形的低回聲圖像即為尺神經(jīng)，利用平面內(nèi)技術(shù)，在尺神經(jīng)周圍注入局麻藥5 mL。

1.3觀察指標(biāo)記錄操作時(shí)間(消毒開始至注藥完畢所需的時(shí)間，超過(guò)30 s記為1 min)和感覺阻滯起效時(shí)間(注藥完畢開始，每2 min用針刺法測(cè)一次肌皮神經(jīng)、尺神經(jīng)、正中神經(jīng)和橈神經(jīng)感覺阻滯情況，至痛覺完全消失的時(shí)間)；評(píng)價(jià)手術(shù)過(guò)程中的麻醉效果滿意度(滿意：手術(shù)過(guò)程中無(wú)痛覺，無(wú)需追加靜脈鎮(zhèn)痛藥；基本滿意：手術(shù)過(guò)程中輕微疼痛，需追加小劑量的靜脈鎮(zhèn)痛藥，但芬太尼用量不能超過(guò)0.05 mg；不滿意：切皮時(shí)疼痛明顯，追加靜脈藥后無(wú)效，改為全麻)[2]；記錄并發(fā)癥的發(fā)生情況，包括：Horner綜合征、喉返神經(jīng)阻滯、局麻藥中毒和尺神經(jīng)卡壓征。

2結(jié)果

2.1一般資料和操作時(shí)間兩組患者性別、年齡、體重、麻醉操作時(shí)間比較均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見表1。

表1　兩組患者一般資料和操作時(shí)間比較

注：與A組比較，*P>0.05。

2.2感覺阻滯起效時(shí)間B組患者感覺阻滯起效時(shí)間明顯短于A組(P<0.05)，見表2。

表2　兩組患者感覺阻滯起效時(shí)間比較

注：與A組比較，*P<0.05。

2.3麻醉效果滿意度兩組患者麻醉效果滿意度的比較無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見表3。

表3　兩組患者對(duì)麻醉效果的評(píng)價(jià)

注：與A組比較，*P>0.05。

2.4并發(fā)癥的發(fā)生情況兩組均無(wú)Horner綜合征、喉返神經(jīng)阻滯和尺神經(jīng)卡壓征，A組有3例發(fā)生興奮、多語(yǔ)等輕度局麻藥中毒癥狀，B組無(wú)任何并發(fā)癥。

3討論

前臂尺側(cè)手術(shù)麻醉重點(diǎn)不僅要阻滯手術(shù)區(qū)域的神經(jīng)，阻滯止血帶區(qū)域的神經(jīng)同樣重要。單純的肌間溝臂叢阻滯可以滿足止血帶的使用，但對(duì)尺神經(jīng)阻滯不全，單純腋路臂叢阻滯可以滿足手術(shù)區(qū)域的需求，但對(duì)肌皮神經(jīng)阻滯不全。 肌間溝聯(lián)合腋路臂叢阻滯使兩者作用互補(bǔ)，麻醉效果好，臨床上比較常用[3]。 本研究?jī)山M患者都取得很好的麻醉效果(P>0.05)，滿意率均為100%。B組選擇肌間溝臂叢聯(lián)合尺神經(jīng)阻滯，與A組相比較，幾個(gè)主要神經(jīng)感覺阻滯時(shí)間明顯縮短 (P<0.05)，與肌間溝一次注入較多劑量和容量的局麻藥有關(guān)，為血管吻合等急診手術(shù)贏得了時(shí)間。

與傳統(tǒng)技術(shù)比較，超聲引導(dǎo)技術(shù)的主要優(yōu)勢(shì)在于能夠?qū)崟r(shí)提供神經(jīng)及其周邊血管和組織影像，使得穿刺過(guò)程變得“可視”，有效克服解剖變異，提高神經(jīng)阻滯的成功率和安全性[4]。本研究?jī)山M患者均在超聲引導(dǎo)下完成操作，沒發(fā)生損傷血管和神經(jīng)的并發(fā)癥，僅A組有3例患者注藥后出現(xiàn)興奮、多語(yǔ)等輕微局麻藥中毒癥狀，給予咪達(dá)唑侖0.04 mg·kg-1靜注后癥狀消失。由于可視化操作，所有患者并未發(fā)生針尖刺破血管和局麻藥注入血管的情況，至于是否因?yàn)锳組腋路阻滯時(shí)局麻藥劑量過(guò)大、濃度過(guò)高、注藥壓力過(guò)大、速度過(guò)快導(dǎo)致局麻藥迅速大量吸收而導(dǎo)致局麻藥中毒[1]，尚需進(jìn)一步的研究論證。有報(bào)道顯示，腋路阻滯局麻藥毒性反應(yīng)發(fā)生率較其他入路高，可達(dá)1%～10%[1]。

綜上所述，超聲引導(dǎo)下肌間溝臂叢聯(lián)合腋路臂叢阻滯和超聲引導(dǎo)下肌間溝臂叢聯(lián)合尺神經(jīng)阻滯應(yīng)用于前臂尺側(cè)手術(shù)均可達(dá)到滿意的麻醉效果，但后者起效更快，安全性更高。

參考文獻(xiàn)：

[1]莊心良，曾因明,陳伯鑒.現(xiàn)代麻醉學(xué)[M].第3版.北京:人民衛(wèi)生出版社,2003：1016,1060,1054.

[2]傅志海，吳雅松 王小虎，等.超聲引導(dǎo)鎖骨手術(shù)患者C5和頸淺叢聯(lián)合阻滯的效果[J].中華麻醉學(xué)雜志,2013,11(33):11.

[3]文四成,陳潛沛,鄧蕊，等.超聲可視下肌間溝聯(lián)合腋路臂叢神經(jīng)阻滯效果[J].廣東醫(yī)學(xué),2014,35(3):400.

[4]Kapral S,Greher M，Hober G,et al.Ultrasonically guidance improves the success rale of interasealence brachial plexus blockade[J].Beg Anesth Pain Mde,2008,33(3):253-258.

Application of Interscalene Brachial Plexus Combined with Ulnar Nerve Block to Operation of Dorsoulnar Forearm Guided by Ultrasound

SUNZhen-zhong,LUTong-jun,HUANGWei,LIUZhi-jin,WANGYu-ming

(Dept.ofAnesthesia,ArmedPoliceCorpsHospitalinGuangdongProvince,Guangzhou,Guangdong510507)

Abstract:Objective: to evaluate the effects and safety of the application of interscalene brachial plexus combined with ulnar nerve block to operation of dorsoulnar forearm guided by ultrasound. Methods: 60 patients had dorsoulnar forearm operation at ASA Ⅰ～Ⅱ level were chosenand randomly divided into two groups A and B, ultrasound guided interscalene and road axillary brachial plexus block (group A) and interscalene combined with ulnar nerve block of brachial plexus (group B), 30 cases in each group. 30 ml 0.5% ropivacaine hydrochloride injection was made. Group A had interscalene brachial plexus block first, the long axis of ultrasound probe was placed perpendicular to the interscalene; probe location was adjusted to show round or oval hypoechoic upper, middle and lower trunk of brachial plexus; 5 mL local anesthetic was injected respectively around the three trunks of brachial plexus to make local anesthetics completely around the nerve trunk.Then the axillary road blocks was performed, in turn guided by ultrasound 5 mL of local anesthetic was injected to the ulnar nerve, median nerve and radial nerves.Group B had interscalene brachial plexus block first just as group A. After the imaging of the upper, middle and lower trunk of brachial plexus 25 mL injection of local anesthetic was injected around the nerve trunk. Then the ulnar nerve block was made, the long axis of ultrasound probe was placed vertically, proximal to the medial epicondyle of the humerus, round or oval hypoechoic image was the ulnar nerve, 5 mL injection of local anesthetic was injected around the ulnar nerve.The operation time and sensory block onset time of anesthesia were recorded; the satisfaction of anaesthesia effect during surgical proccess was evaluated; the occurrence of complications was recorded.Results: There had no statistical significance between the sex ratio, age, weight, anesthesia operation time of the two groups (P>0.05); The sensory block onset time of the two groups was compared; it was found that Goup B was significantly shorter than Group A (P<0.05); The comparison of the satisfaction of Anesthetic effect between the two groups had no statistically significance (P>0.05); Two groups had no Horner Syndrome, recurrent laryngeal nerve block and ulnar nerve entrapment. Three cases of group A had mild local anesthetics poisoning ymptom such as excitement, logomania. Group B did not have any complications. Conclusion: The application of ultrasound-guided interscalene brachial plexus block combined with axillary brachial plexus block and with ulnar nerve block to dorsoulnar forearm surgery can achieve the satisfactory anaesthesia effect, but the latter works faster and safer.

Key words:guided by ultrasound; interscalene brachial plexus; Ulnar nerve; dorsoulnar forearm

中圖分類號(hào)：R614.4

文獻(xiàn)標(biāo)志碼：A

文章編號(hào)：1001-5779(2016)02-0218-03

DOI:10.3969/j.issn.1001-5779.2016.02.016

(收稿日期：2015-05-02)(責(zé)任編輯：敖慧斌)