静脉注射地塞米松联合超声引导肌间沟臂丛神经阻滞用于肩部手术的随机对照研究
2017-08-04林雷陈春侯俊
林雷++++++陈春++++++侯俊++++++杨萍
[摘要] 目的 探讨静脉注射不同剂量地塞米松联合超声引导肌间沟臂丛神经阻滞对行肩部手术患者术后镇痛效果的影响。 方法 选择宜昌市中心人民医院2014年6月~2015年10月80例于肌间沟臂丛神经阻滞下行肩关节镜手术患者,采用电脑生成的随机数字分为四组:阻滞前分别静注生理盐水(A组,n = 20)、0.025 mg/kg地塞米松(B组,n = 20)、0.05 mg/kg地塞米松(C组,n = 20)、0.1 mg/kg地塞米松(D 组,n = 20)。主要指标:术后48 h首次需求镇痛时间;次要指标:术后24、48 h无痛或轻度疼痛及术后24 h阻滞侧上肢肌力未完全恢复患者例数,术后48 h累积镇痛药物消耗,睡眠干扰、恶心呕吐等不良事件,及患者对麻醉的满意率等。 结果 C组和D组患者术后48 h首次需求镇痛中位时间明显长于A组(P < 0.01),但C、D组间比较差异无统计学意义(P > 0.05);四组间术后24、48 h无痛或轻度疼痛,术后24 h阻滞侧上肢肌力未完全恢复,48 h内不需镇痛剂,曲马多的用量及使用哌替定患者例数等指标比较,差异均无统计学意义(P > 0.05),但D组术后48 h双氯芬酸钠栓的使用量明显低于A组(P < 0.05);C组和D组睡眠干扰患者明显少于A组(P < 0.05),且D组患者麻醉满意率高于A组(P < 0.05)。 结論 静注0.05 mg/kg或0.1 mg/kg地塞米松可延长肌间沟臂丛神经阻滞肩部手术术后镇痛时间,静注0.1 mg/kg地塞米松患者麻醉满意率更高。
[关键词] 肌间沟;臂丛神经阻滞;地塞米松
[中图分类号] R614.2 [文献标识码] A [文章编号] 1673-7210(2017)06(a)-0067-04
A randomised controlled trial of intravenous Dexamethasone combined with interscalene brachial plexus blockade guided by ultrasound in shoulder surgery
LIN Lei1 CHEN Chun1 HOU Jun2 YANG Ping2
1.Department of Anesthesia, the First College of Clinical Medical Science, Three Gorges University, Hubei Province, Yichang 443003, China; 2.Department of Anesthesia, Yichang Central People's Hospital, Hubei Province, Yichang 443003, China
[Abstract] Objective To investigate the effects of intravenous injection of different doses of Dexamethasone combined with ultrasound-guided interscalene bronchial plexus block on postoperative analgesia in patients underwent shoulder surgery. Methods 80 cases of patients underwent shoulder arthroscopy under interscalene brachial plexus blockade in Yichang Central People's Hospital from June 2014 to October 2015 were chosen and randomly divided into four groups: intravenous injection of saline (group A, n=20), 0.025 mg/kg Dexamethasone (group B, n=20), 0.05 mg/kg Dexamethasone (group C, n=20), 0.1 mg/kg Dexamethasone (group D, n=20) before blockade, respectively. Outcomes for 48 h were recorded. Primary endpoint was the time to first postoperative analgesic required. No or mild pain at 24 h and 48 h, weakness at 24 h, cumulative analgesic consumption, sleep disturbance, nausea and vomiting, and satisfaction were considered as secondary outcomes. Results The median time to first postoperative analgesic required was significantly longer in group C and group D than that in group A (P < 0.01), but there was no significant difference between group C and group D (P > 0.05). Among the four groups, no or mild pain at 24 h and 48 h, weakness at 24 h, no analgesia required, the amount of Tramadol and Dolantin required were compared, there were no significant differences (P > 0.05), but the amount of Diclofenac Sodium Suppository was lower in group D than that in group A (P < 0.05). The incidence of sleep disturbance in group C and group D was less than that in group A (P < 0.05), and patients' anesthesia satisfaction rate in group D was higher than that in group A (P < 0.05). Conclusion Intravenous injection of 0.05 mg/kg or 0.1 mg/kg Dexamethasone can extend the duration of postoperative analgesia provided by interscalene brachial plexus block, patients' satisfaction with anesthesia by using 0.1 mg/kg Dexamethasone is higher.
[Key words] Interscalene; Plexus blockade; Dexamethasone
地塞米松作為长效糖皮质激素在急慢性疼痛及区域麻醉中应用广泛。研究表明,神经周围使用地塞米松可延长多数神经阻滞时间[1-7],但可能是其经全身吸收后产生的效应,而不是本身的局部作用[8],且目前使用仍有顾虑,主要是担心地塞米松可能具有神经毒性[9-11]。近年发现,静脉注射地塞米松可延长不同人群不同手术后的镇痛时间[12-13],且静注与神经周围注射10 mg地塞米松在延长罗哌卡因肌间沟镇痛时间上无显著差异[14],在锁骨上阻滞时也有类似报道[15]。但也有研究指出,静注4 mg地塞米松与神经周围使用相比不能延长肌间沟阻滞镇痛时间,推测可能是该剂量过低,不足以延长镇痛时间[16]。本研究观察静注0.025、0.05、0.1 mg/kg地塞米松对肌间沟阻滞镇痛时间的影响,以评价其对肌间沟阻滞镇痛的效果。
1 资料与方法
1.1 一般资料
选择宜昌市中心人民医院(以下简称“我院”)2014年6月~2015年10月择期于肌间沟臂丛神经阻滞下行肩关节镜肩袖修复手术患者80例,ASAⅠ~Ⅱ级,年龄18~65岁。排除标准:年龄<18岁,地塞米松不能耐受者(包括糖尿病),孕妇,臂丛神经病变者,严重支气管疾病者,凝血功能障碍和全身使用糖皮质激素者。采用电脑生成的随机数字将其分为四组:A、B、C、D组,每组各20例。本研究经我院医学伦理委员会批准,所有研究对象均签署知情同意书。
1.2 方法
所有患者不用术前针,进入手术室后建立外周静脉通路,常规监测心电图(ECG)、脉搏氧饱和度(SpO2)、无创血压(NIBP),监测血糖。各组患者神经阻滞前由麻醉医师静脉分别给予生理盐水10 mL(A组),0.025 mg/kg地塞米松(天津金耀药业有限公司,批号:H12020514)+生理盐水共10 mL(B组),0.05 mg/kg地塞米松+生理盐水共10 mL(C组),0.1 mg/kg地塞米松+生理盐水共10 mL(D组)。患侧颈部常规消毒后,使用高频线阵探头(Ultrasound Aloka Prosound α6,日立医疗有限公司,日本)在颈5~6水平短轴寻找臂丛神经,使用22 G短斜面50 mm神经刺激针连接神经刺激器(JUNK Multistim Plex,宝雅医疗科技集团,德国),采用平面内技术由外向内进针,若刺激电流小于0.3 mA仍有明显相应肌肉收缩则调整进针位置以减少神经内注射。进针定位准确回抽无血则缓慢注射0.5%罗哌卡因30 mL(宜昌人福药业有限责任公司,批号:H20103553)。阻滞完成后以丙泊酚血浆浓度3~5 μg/mL、瑞芬太尼1.5 μg/kg、顺式苯磺酸阿曲库铵0.15 mg/kg麻醉诱导完成气管插管,接麻醉机机械通气,丙泊酚、瑞芬太尼靶控输注维持麻醉。术毕清醒拔管后送入麻醉恢复室(PACU)留观。
1.3 观察指标
主要指标:在病房内记录患者术后48 h首次需求镇痛时间。
次要指标:在PACU记录患者霍纳综合征、呼吸困难、声音嘶哑等麻醉相关并发症;在病房内记录术后24、48 h患者无痛或轻度疼痛及术后24 h阻滞侧上肢肌力未完全恢复患者例数,术后48 h累积镇痛药物消耗情况,睡眠干扰、术后恶心呕吐等不良事件及对麻醉的满意度。疼痛评估采用数字等级评分(NRS)量表,评估标准包括无痛(0分)、轻度疼痛(1~3分)、中度疼痛(4~6分)、重度疼痛(7~10分);阻滞侧的手部肌力评估:肌力丧失、较对侧肌力下降、与对侧肌力一样强。在转入及转出PACU时评估患者患肢疼痛及运动神经阻滞清况,若患者存在中度及以上疼痛或肌力与未阻滞侧一样强则判定为阻滞失败。术后镇痛方案:若存在中重度疼痛或患者要求时首选双氯芬酸钠栓50 mg塞肛,根据镇痛效果采用肌注曲马多50~100 mg或哌替定50 mg进行补充。
1.4 统计学方法
采用SPSS 13.0统计软件进行数据分析,正态分布的计量资料以均数±标准差(x±s)表示,非正态分布的计量资料以中位数(四分位间距)表示,组间比较采用单因素方差分析;计数资料用率表示,组间比较采用χ2检验,部分资料采用Fisher确切概率法;术后首次需求镇痛时间比较采用Kaplan-Meier生存分析;以P < 0.05为差异有统计学意义。
2 结果
2.1 四组一般资料比较
四组患者年龄、体重指数、性别、ASA分级、阻滞失败例数比较,差异均无统计学意义(P > 0.05)。
2.2 四组术后48 h首次需求镇痛时间比较
A、B、C、D组术后48 h首次需求镇痛时间为12(4.25)、14(5.25)、16.5(7.5)和20(6.75)h,Kaplan-Meier生存分析显示,C组和D组术后48 h首次需求镇痛时间显著长于A组,差异有高度统计学意义(P < 0.01),但C、D组间比较差异无统计学意义(P > 0.05);B组术后首次需求镇痛中位时间与A组比较,差异亦无统计学意义(P > 0.05)。
2.3 四组术后48 h累积消耗镇痛药物比较
D组术后48 h双氯芬酸钠栓的使用总量明显低于A组,差异有统计学意义(P < 0.05)。术后48 h内不需镇痛剂患者例数、曲马多的用量及使用哌替定患者例数各组间差异无统计学意义(P > 0.05)。
2.4 四组不良事件及满意度比较
术后24、48 h无痛或轻度疼痛及24 h肌力未完全恢复、霍纳综合征、呼吸困难、声音嘶哑患者例数在各组间比较差异无统计学意义(P > 0.05)。D组恶心呕吐发生率明显低于A组(P < 0.05),C、D组睡眠干扰发生率低于A组(P < 0.05),D组患者麻醉满意率高于A组,差异有统计学意义(P < 0.05),见表3。各组患者的血糖水平术后48 h均在正常范围。
3 讨论
如何有效延长神经阻滞作用时间一直是区域麻醉中的热点问题,连续神经阻滞能延长神经阻滞的镇痛时间,但管道容易移位且有感染风险[17-21]。地塞米松、可乐定、曲马多、丁丙诺啡等药物曾被加入到局麻药中,但其安全性仍有待证实[22]。因此,笔者认为应该确立静脉注射地塞米松在外周神经阻滞镇痛中的重要作用。本研究发现,静注0.05 mg/kg(C组)或0.1 mg/kg(D组)地塞米松能使罗哌卡因肌间沟阻滞的镇痛时间分别延长4.5 h及8 h,但两者之间差异无统计学意义,但D组患者满意率更高。本研究中术后24、48 h无痛或轻度疼痛患者在各组间比较差异无统计学意义,可能与术后使用镇痛剂有关。
目前静注地塞米松的镇痛量效反应关系尚未完全确定,荟萃分析显示小于0.1 mg/kg地塞米松不能降低疼痛评分及镇痛剂的用量,而大于0.1 mg/kg时未表现出量效反应关系[12]。本研究结果显示,0.05 mg/kg地塞米松有延长镇痛时间的作用,可能与该研究用药时机有关,术前给予地塞米松比术中更有效[12]。有研究发现,静注8 mg与40 mg地塞米松在减轻肩关节镜手术术后疼痛等方面无显著差异,提示地塞米松有封顶效应[23]。
本研究四组患者24 h肌力未完全恢复、声音嘶哑等不良事件的发生率无统计学差异,可能与采用超声联合神经刺激仪引导有关。本研究中有1例患者出现呼吸困难,可能是阻滞了同侧膈神经。D组恶心呕吐的发生率明显低于A组,可能与地塞米松本身具有的协同止吐作用有关。理论上静脉使用地塞米松可能会引起血糖升高,但本研究中各组的血糖均在正常范围。
综上所述,静脉注射0.05 mg/kg或0.1 mg/kg地塞米松可延长肌间沟臂丛神经阻滞肩部手术术后镇痛时间,且两者效果无明显差异,但后者患者麻醉满意率更高,低于0.05 mg/kg地塞米松的作用有待进一步明确。
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(收稿日期:2017-02-22 本文编辑:程 铭)
(本栏目主编:王 庚)