髂前上棘旁腹股沟韧带上持续性髂筋膜间隙神经阻滞在全膝关节表面置换术后镇痛的临床应用.docx

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1、骼前上棘旁腹股沟韧带上持续性骼筋膜间隙神经阻滞在全膝关节表面置换术后镇痛的临床应用陆立仁1郑映金谢宇宁邓双钊梁昌河华南理工大学附属第六医院麻醉科(广东省佛山市南海区人民医院麻醉科)摘要目的探讨超声引导下骼前上棘旁持续性骼筋膜间隙神经阻滞在全膝关节表面置换术后镇痛的临床效果。方法择期全膝关节表面置换术患者采用随机数字表法，依据纳入标准及剔除标准分为3组：骼前上棘旁腹股沟韧带上骼筋膜间隙神经阻滞组(U组)31例、腹股沟韧带下骼筋膜间隙神经阻滞组(D组)30例、股神经阻滞组(F组)30例按照“双盲”实验设计完成临床研究。记录三组患者股神经、股外侧皮神经及闭孔神经感觉阻滞情况；视觉模拟评分(ViSUa

2、1ana1oguesca1e,VAS)测定静息状态和运动状态下疼痛情况；改良BrOmage评分测定患肢肌力情况；记录首次下床活动时间；计算术中舒芬太尼标准化用量和七氟烷标准化用量；记录术后补救镇痛次数；采用WHo标准评定恶心呕吐情况。结果三组患者股神经均阻滞成功CP0.05),U组与D组患者股外侧皮神经阻滞均优于F组(P0.05),U组闭孔神经阻滞均优于D组与F组(P0.05)术后4h、6h、12h、24h静息状态下VAS评分U组均优于D组和F组(P0.05),术后4h、12h、24h、48h运动状态下三组患者VAS评分差异均有统计学意义(P0.05),术后4hU组评分优于F组(P0.05),

3、术后24hU组评分优于D组(P0.05),术后12h、48hU组评分均优于D组和F组(P0.05)；三组患者术后首次下床活动时间差异有统计学意义(P0.05),U组最早，D组次之，F组最晚。术后补救镇痛次数三组患者差异有统计学意义(P0.05),U组均少于D组和F组(P0.05)三组患者舒芬太尼标准化用量及七氟烷标准化用量差异均有统计学意义(P0.05),舒芬太尼标准化用量及七氟烷标准化用量均是U组最少，D组次之，F组用量最多(P0.05)结论全膝关节表面置换术中采用超声引导下骼前上棘旁持续性骼筋膜间隙神经阻滞，阻滞范围更完善，阻滞效果更确切，术后镇痛效果更佳，有助于早期功能锻炼及术后康复。基

4、金项目：广东佛山市医学类科技攻关项目(4)1陆立仁(1979-),男，副主任医师，硕士研究生，华南理工大学附属第六医院麻醉科。关键词腹股沟韧带上骼筋膜间隙神经阻滞；全膝关节表面置换术；镇痛；超声引导；骼前上棘中图分类号：R614.2文献标识码：A基金项目：广东佛山市医学类科技攻关项目(4)TheeffectofcontinuousSuprainguina1fasciai1iacacompartmentb1ockneartheanteriorsuperiori1iacspineinana1gesiaaftertota1kneearthrop1asty1U1i-renfZhengYing-jinf

5、XieYu-ningfDengShUang-Zhao,1iangChang-he.DepartmentofAnesthesio1ogy,TheSixthAffi1iatedHospita1,SouthChinaUniversityofTechno1ogy,Foshan528OOOfGuangdongCHINAAbstractObjectiveToinvestigatethec1inica1effectofu1trasound-guidedcontinuousSuprainguina1fasciai1iacacompartmentb1ock(SIFICB)neartheanteriorsuper

6、iori1iacspineinana1gesiaaftertota1kneearthrop1asty(TKA).MethodsPatientsundergoinge1ectivetota1kneearthrop1astywererandom1ydividedinto3groupsaccordingtoinc1usioncriteriaandexc1usioncriteria:31casesinSIFICBneartheanteriorsuperiori1iacspine(groupU),30casesintheinferiori1iacfasciaspacenerveb1ock(groupD)

7、,and30casesinthefemora1nerveb1ock(groupF)wereperformedaccordingtothedoub1e-b1inded“experimenta1design.Theefficacyoffemora1nerve,1atera1femora1cutaneousnerveandobturatornervewaseva1uatedinthethreegroups.Scoreofrestingstateandfunctiona1exercisewasmeasuredbyvisua1ana1oguesca1e(VAS)at1h、4h、6h、12h、24hand

8、48hafteroperation.ModifiedBromagescorewasusedtodeterminethemusc1estrengthoftheoperative1imb.Thetimeofthefirstambu1ationwasrecorded.Thestandardizeddosageofsufentani1andSevof1uraneduringoperationwereca1cu1ated.Thetimesoftramado1remediesforana1gesiawererecorded.Nauseaandvomitingwereeva1uatedbyWHOcriter

9、ia.Resu1tsFemora1nervewassuccessfu11yb1ockedina11threegroups(P0.05),theefficacyof1atera1femora1cutaneousnervewasb1ockedingroupUorgroupDwasbetterthanthatingroupF(P0.05),andtheb1ockageofobturatornerveingroupUwasbetterthanthatingroupDorgroupF(P0.05).TheVASscoreofgroupUwassignificant1y1owerthanthatofgro

10、upDorgroupFinrestingstateat4h,6h,12hand24hafteroperation(P0.05).TheVASscoreofpatientsamongthethreegroupswassignificantdifferenceinfunctiona1exerciseat4h,12h,24hand48hafteroperation(P0.05),VASscoreofgroupUwas1owerthanthatofgroupFat4hafteroperation(P0.05),VASscoreofgroupUwas1owerthanthatofgroupDat24ha

11、fteroperation(P48hafteroperation(P0.05).Therewassignificantdifferenceinthetimeoffirstambu1ationamongthethreegroups(P0.05),groupUwastheear1iest,fo11owedbyGroupD,andgroupFwasthe1atest.Thenumberofpostoperativesa1vageana1gesiawassignificant1ydifferentamongthethreegroups(P0.05),thoseofgroupUwassignifican

12、t1y1essthanthatingroupDorgroupF(P0.05).Thedifferenceinthestandardizeddosageofsufentani1andSevof1uraneamongthethreegroupswasstatistica11ysignificant(P0.05),theconsumptionofsufentani1orSevof1uranewasthe1eastingroupU,fo11owedbygroupD,andthemostingroupF(P0.05).Theincidenceofnauseaandvomitingamongthethre

13、egroupswasnosignificant1ydifferent.Conc1usionU1trasound-guidedcontinuousSuprainguina1fasciai1iacacompartmentb1ock(SIFICB)neartheanteriorsuperiori1iacspinehasperfectrangeandaccurateeffectofb1ock,thusitcaneffective1yprovidegoodana1gesia,promoteear1yfunctiona1exerciseandrehabi1itationofpatientsundergoi

14、ngtota1kneearthrop1astysurgery.KeywordsSuprainguina1fasciai1iacacompartmentb1ock;Tota1kneearthrop1asty;Ana1gesia;U1trasoundguidance;Anteriorsuperiori1iacspineFundprogram:FoshanCityMedica1ScienceandTechno1ogyProject(4)全膝关节表面置换术（tota1kneearthrop1asty,TKA）是解除终末期膝关节炎患者疼痛，恢复关节功能的有效方法。TKA手术创伤大，术后疼痛剧烈，严重影响

15、早期功能锻炼，而术后能否及早进行功能锻炼是影响手术效果及后期康复程度的关键节点，完善术后镇痛一直以来都是TKA手术与康复的热点研究内容。本研究拟采用超声引导下骼前上棘旁入路持续性腹股沟韧带上骼筋膜间隙神经阻滞（SUPraingUina1fasciai1iacacompartmentb1ock,SIFICB）镇痛为术后镇痛模式，以实施快速康复外科（enhancedrecoveryaftersurgery,ERAS）模式的TKA患者为研究对象，探讨其镇痛效果对膝关节早期功能康复的临床效果，为日后临床推广提供临床数据。1资料与方法1.1 一般资料本研究经华南理工大学附属第六医院（广东省佛山市南海区人民医院）道德及伦理委员会批准（南医科研伦审：）o选择我院2023年8月-2023年5月择期喉罩全麻复合神经阻滞麻醉下行全膝关节表面置换术的患者为研究对象。纳入标准：（1）ASAII级。（2）膝关节单侧、初次手术患者。（3）膝关节重度骨关节炎、类风湿关节炎需行TKA患者。（4）麻醉方式均为神经阻滞复