超声引导下臂丛神经阻滞与全身麻醉在肘关节手术中的应用比较

武科任素敏赵丽敏闫志永姜柏林

·论著·

超声引导下臂丛神经阻滞与全身麻醉在肘关节手术中的应用比较

武科1任素敏1赵丽敏1闫志永1姜柏林2

目的对比在肘关节手术中超声引导下臂丛神经阻滞技术及全身麻醉技术的优劣。方法选取2014年10月至2017年4月涿鹿县中医院行肘关节周围骨折切开复位内固定术的患者共60例，随机分为臂丛神经阻滞组（BB组，n=30）及全身麻醉组（GA组，n=30）。BB组在超声引导下行腋路神经阻滞，GA组采用气管插管全身麻醉。对比两组患者麻醉前（T0）、手术前（T1）、手术开始1 h后（T2）及手术结束时（T3）的平均动脉压及心率；对比两组患者术中的血糖升高水平；对比两组患者术后的视觉模拟评分（visual analogue score，VAS）、对麻醉及镇痛的满意度。结果BB组患者各时间点的平均动脉压及心率的比较差异无统计学意义，GA组患者的平均动脉压及心率存在时间效应，各时间点的比较差异有统计学意义（F=9.568，P＜0.001；F=7.746，P=0.001）。两组患者术中的血糖水平均高于术前，BB组血糖的升高低于GA组[（0.6±0.4） mmol/Lvs（0.9±0.6） mmol/L，t=-2.243，P=0.030］。BB组患者术后随访时的VAS评分低于GA组[1（1，1）vs2（1，2.25），Z=2.066，P＜0.001］。BB组患者对麻醉及镇痛处理的满意度高于 GA 组[4（3，5）vs3（2.75，4），Z=1.549，P=0.016］。结论相较于全身麻醉，超声引导臂丛神经阻滞技术可以提供更好的血流动力学稳定性，更为有效的抑制手术引起的应激反应，改善患者术后疼痛评分，提高患者术后满意度。

臂丛神经阻滞； 全身麻醉； 超声； 肘关节

臂丛神经阻滞广泛应用于上肢的手术及镇痛[1］，腋窝入路因其安全性[2］及操作简单，是最常用的臂丛神经阻滞方法[3］，可为肘关节及以远水平的上肢手术提供良好的麻醉效果[4］。但臂丛阻滞依赖的解剖结构常发生变异[5］，Meta分析显示基于神经刺激仪及解剖结构的传统腋路神经阻滞方法存在近20%的失败率[6］，而需进一步实施全身麻醉以完成手术。超声定位技术的引入，使臂丛神经阻滞得到了改良[7］，可加快操作速度，降低操作风险[8］，并显著提高了成功率[3,6,9］，从而使腋路神经阻滞在肘关节手术中全面取代全身麻醉成为了可能。而目前，超声引导下腋路臂丛神经阻滞在肘关节手术中是否优于全身麻醉，尚缺乏足够的研究。本研究拟从术中血流动力学波动、应激反应、术后镇痛及患者满意度等几个方面对比两种麻醉方法的优劣，为临床中肘关节手术的麻醉方法选择提供帮助。

资料与方法

一、一般资料

选择2014年10月至2017年4月于涿鹿县中医院行肘关节周围骨折切开复位内固定术的患者共60例，随机分为臂丛神经阻滞组（BB组，n=30）及全身麻醉组（GA组，n=30）。纳入标准：（1）年龄18～80岁；（2）美国麻醉医师学会（American society of anesthesiologists，ASA）分级I ～ Ⅱ级，无合并严重的全身系统疾病；（3）骨折仅限于肘关节周围，闭合性骨折，无血管、神经损伤。排除标准：（1）病理性骨折患者；（2）多发骨折，或需同期处理其他部位损伤的患者；（3）不宜行腋路臂丛神经阻滞或全麻气管插管的患者；（4）患者拒绝。退出标准：发生严重不良事件，臂丛阻滞无法完成手术需中转全麻者。

二、麻醉方法

所有患者常规术前准备，入室后持续监测血压、心率、血氧饱和度，储氧面罩吸氧，予右美托咪定持续泵入（负荷剂量1 μg/kg输注15 min后，改为0.4 μg/kg/h持续泵注）。BB组患者在超声引导下行腋路神经阻滞：0.5%罗哌卡因30 ml中加入地塞米松5 mg，采用平面内多点注射技术，依次于桡神经、正中神经、尺神经、肌皮神经周围分别注射局麻药物7 ml，确认腋动脉实现局麻药物的完全包绕。GA组患者采用气管插管全身麻醉：丙泊酚2.0 mg/kg、舒芬太尼0.3 μg/kg、罗库溴铵0.6 mg/kg诱导，丙泊酚4～6 mg/kg/h、瑞芬太尼0.1～0.2 μg/kg/min持续泵入维持。两组患者术毕均采用静脉自控镇痛（patient controlled intravenous analgesia，PCIA）技术控制术后疼痛。

三、观察及随访

分别记录患者麻醉前（T0）、手术前（T1）、手术开始1 h后（T2）及手术结束时（T3）的平均动脉压及心率；于手术前及手术开始1 h后抽取患者血气分析，记录患者血糖水平。手术结束12 h后访视患者，通过视觉模拟评分法（visual analogue score，VAS）记录患者的疼痛评分（0分表示无痛，10分表示难以忍受的剧烈疼痛），并通过李克特5级量表评测患者对麻醉及疼痛管理的满意程度（1分代表非常不满意，5分代表非常满意）。

四、统计学分析

采用SPSS 20.0统计软件对数据进行分析。计量资料中，正态数据以±s表示，组间比较采用t检验，采用重复测量方差分析处理组内时间效应和组间效应；非正态数据以M（P25，P75）表示，组间比较采用Kolmogorov-Smirnov Z检验，采用Spearman相关计算相关性；计数资料以例数（%）表示，组间比较采用χ2检验。以P ＜0.05作为差异具有统计学意义。

结 果

60例患者均完成了麻醉、手术及术后随访。两组患者均无严重并发症发生。BB组患者均在臂丛神经阻滞下顺利完成了手术，无需转换为全身麻醉者。两组患者的年龄、性别、美国麻醉医师协会（ASA）分级、骨折部位及手术时间的组间比较差异均无统计学意义（表1）。

观察期间内，BB组患者各时间点的平均动脉压及心率的比较差异无统计学意义（F=2.321，P=0.102；F=0.369，P=0.726）。GA组的平均动脉压及心率存在时间效应，各时间点的比较差异有统计学意义（F=9.568，P ＜0.001 ；F=7.746，P=0.001）。两组患者平均动脉压及心率的组间比较，差异无统计学意义（F=0.002，P=0.968；F=0.727，P=0.397），见图 1。

两组患者术中的血糖水平均高于术前，差异有统计学意义[（5.9±0.7）mmol/L vs（6.5±0.8）mmol/L，t=-8.098，P ＜0.001；（5.8±0.9）mmol/L vs （6.7±1.1）mmol/L，t=-7.471，P ＜0.001］。BB组血糖的升高低于GA组，差异有统计学意义[（0.6±0.4）mmol/L vs（0.9±0.6）mmol/L，t=-2.243，P=0.030］，见表 2。

BB组患者术后随访时的VAS评分低于GA组，差异有统计学意义[1（1，1）vs 2（1，2.25），Z=2.066，P ＜0.001］。BB 组 患者对麻醉及镇痛处理的满意度高于GA组，差异有统计学 意 义[4（3.00，5）vs 3（2.75，4）， Z=1.549，P=0.016］。患者的VAS评分及满意度间存在显著负相关（r=-0.549，P ＜0.001），见表 2。

图1 两组患者各观察时间点的平均动脉压及心率比较

表2 两组患者血糖、VAS评分及满意度的比较

讨 论

臂丛神经阻滞广泛应用于肘部骨科手术，安全性高[2］。因为臂丛于腋窝处位置表浅，十分适于通过超声引导穿刺。超声技术的可视化，可以使臂丛神经阻滞实现神经旁精准给药，减少了局麻药用量，降低了操作风险，并显著提高了阻滞的成功率[3,6,9］。超声下多点穿刺技术的应用可以较一点法或两点法提供更佳的麻醉效果[10］。这些技术的革新使臂丛阻滞完全替代全身麻醉成为肘关节手术的首选麻醉方法成为了可能。本研究中所有臂丛神经阻滞组的患者均顺利完成了手术，无需复合应用全身麻醉。相较于全身麻醉，臂丛神经阻滞的术中及术后管理更为简单，麻醉风险更小，对患者身体状况的要求更低[11］。同时，臂丛神经阻滞的麻醉费用更低，超声下腋路阻滞的技术难度较小，易于掌握，适于在基层医院推广应用。

手术和创伤会导致免疫抑制，从而增加感染的风险[12］，疼痛反应、心血管反应和应激反应被视为躯体对手术和伤害性刺激综合反应的不同方面。通常认为，手术引起的代谢和内分泌紊乱会导致多种副反应，这些紊乱和不良的临床预后相关[13］。全身麻醉消除了对手术刺激的感知，但并没有完全消除机体对有害刺激的反应。所有的静脉及吸入全麻药物对内分泌和生理功能都没有帮助作用，而神经阻滞则可直接减少神经的传入刺激，从而改善内分泌和代谢反应，较全身麻醉更好的抑制机体的应激反应[14］。本研究中，臂丛神经阻滞组的心率和血压在各时间点均无显著性改变，而在全身麻醉组则出现了显著性波动，这提示臂丛神经阻滞可以较全身麻醉更好的抑制手术和创伤引起的心血管反应，有利于血流动力稳定。在臂丛神经阻滞组术中血糖的升高显著低于全身麻醉组，而血糖的波动反映了血浆皮质醇水平及机体应激水平的改变[13］，这提示臂丛神经阻滞可以较全身麻醉更为有效的抑制手术引起的应激反应，从而可能提供潜在的预后改善作用[12］。

表1 两组患者一般资料的比较

对于大多数患者，良好预后的关键是良好的镇痛和早期活动。臂丛神经阻滞较静脉应用止痛药物可以提供更好的术后镇痛效果[15］。通过在局麻药物中添加小剂量的地塞米松，臂丛神经的阻滞时间可以显著延迟，术后镇痛的作用时间显著增加[16-17］，减少术后阿片类药物使用，改善术后疼痛评分[18］。在肱骨近端骨折手术的研究中发现[19］，由于臂丛神经阻滞提供了术毕早期的有效镇痛，可以允许患者早期活动、加快功能锻炼，相较全身麻醉患者，臂丛神经阻滞患者在早期随访时，主被动活动范围更大，功能评分更佳。本研究中，臂丛神经阻滞组显示了更优的术后镇痛效果和对麻醉及镇痛的满意度。

本研究纳入的病例数量尚少，且对研究者未设盲，随访时间短。进一步的完善设计，扩大研究例数，延迟随访时间，尤其是增加术后早期及长期功能恢复的随访，将会提供更具意义的结果。本研究中，采用的臂丛阻滞方法为腋路阻滞，该方法相较更高位入路的阻滞方法，难以提供足够有效的止血带耐受[20］，而需复合右美托咪定等基础麻醉方法。但超声下腋路阻滞操作简单安全，更易于掌握，适于基层医院推广。

综上所述，本研究显示超声引导臂丛神经阻滞技术可以有效的替代全身麻醉应用于肘关节手术，相较于全身麻醉，臂丛神经阻滞技术可以提供更好的血流动力学稳定性，更为有效的抑制手术引起的应激反应，改善患者术后VAS评分，提高患者术后满意度。

[1]Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications [J］. Curr Opin Anaesthesiol, 2013, 26（4）: 467-474.

[2]Nowakowski P, Bieryło A. Ultrasound guided axillary brachial plexus plexus block. Part 1--basic sonoanatomy[J］.Anaesthesiol Intensive Ther, 2015, 47（4）: 409-416.

[3]Ranganath A, Srinivasan KK, Iohom G. Ultrasound guided axillary brachial plexus block [J］. Med Ultrason, 2014, 16（3）: 246-251.

[4]Mian A, Chaudhry I, Huang R, et al. Brachial plexus anesthesia:A review of the relevant anatomy, complications, and anatomical variations[J］. Clin Anat, 2014, 27（2）: 210-221.

[5]Natsis K, Totlis T, Didagelos M, et al. Scalenus minimus muscle: overestimated or not? An anatomical study[J］. Am Surg, 2013, 79（4）: 372-374.

[6]Qin Q, Yang D, Xie H, et al. Ultrasound guidance improves the success rate of axillary plexus block: a meta-analysis[J］. Rev Bras Anestesiol, 2016, 66（2）: 115-119.

[7]Nowakowski P, Bieryło A. Ultrasound guided axillary brachial plexus plexus block. Part 2-technical issues[J］.Anaesthesiol Intensive Ther, 2015, 47（4）: 417-424.

[8]Sadowski M, Tułaza B, Lysenko L. Renaissance of supraclavicular brachial plexus block[J］. Anaesthesiol Intensive Ther, 2014, 46（1）: 37-41.

[9]Choi S, Mccartney CJ. Evidence base for the use of ultrasound for upper extremity blocks: 2014 update [J］. Reg Anesth Pain Med, 2016, 41（2）: 242-250.

[10]Chin KJ, Alakkad H, Cubillos JS. Double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm[J］.Cochrane Database Syst Rev, 2013, 8（8）: CD003842.

[11]Kim JJ, Dhaliwal G, Kim GY, et al. General anesthesia is not necessary for hemodialysis access surgery[J］. Am Surg,2015, 81（10）: 932-935.

[12]Wolf AR. Effects of regional analgesia on stress responses to pediatric surgery[J］. Paediatr Anaesth, 2012, 22（1）: 19-24.

[13]Milosavljevic SB, Pavlovic AP, Trpkovic SV, et al. Influence of spinal and general anesthesia on the metabolic, hormonal, andhemodynamic response in elective surgical patients[J］. Med Sci Monit, 2014, 20 : 1833-1840.

[14]Junuzovic D, Celic-Spuzic E, Hasanbegovic M. The correlation between type of anesthesia and the hormones levels during and after transvesical prostatectomy[J］. Acta Inform Med, 2011,19（4）: 216-219.

[15]Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery[J］. Cochrane Database Syst Rev, 2014, 4（2）: CD007080.

[16]Choi S, Rodseth R, Mccartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials[J］.Br J Anaesth, 2014, 112（3）: 427-439.

[17]Leurcharusmee P, Aliste J, Van Zundert TC, et al. A multicenter randomized comparison between intravenous and perineural dexamethasone for Ultrasound-Guided infraclavicular block[J］. Reg Anesth Pain Med, 2016, 41（3）: 328-333.

[18]Knezevic NN, Anantamongkol U, Candido KD. Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery[J］. Pain Physician, 2015, 18（1）: 1-14.

[19]Egol KA, Forman J, Ong C, et al. Regional anesthesia improves outcome in patients undergoing proximal humerus fracture repair[J］. Bull Hosp Jt Dis （2013）, 2014, 72（3）: 231-236.

[20]Chin KJ, Singh M, Velayutham V, et al. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm[J］.Cochrane Database Syst Rev, 2010, 28（2）: CD005487.

Comparison between ultrasound-guided brachial plexus block and general anesthesia for surgery of elbow joint

Wu Ke1, Ren Sumin1, Zhao Limin1, Yan Zhiyong1, Jiang Bailin2.1Department of Anesthesiology, Zhuolu County Hospital of Traditional Chinese Medicine, Zhangjiakou 075699,China;2Department of Anesthesiology, Peking University People's Hospital, Beijing 100044, China

Jiang Bailin, Email: jiangbailin@139. com

BackgroundBrachial plexus block is commonly used for surgery and analgesia of the upper extremity. Due to the simplicity of operation and the safety of approaches to brachial plexus block, the axillary brachial plexus block, which provides effective anesthesia distal to the elbow, is the most widely performed approach. Being decisional for traditional method, the anatomical structures however, express variations sometimes. A meta-analysis demonstrated that the failure rate of axillary brachial plexus block using anatomical-based traditional approach or nerve stimulation was nearly 20%. Consequently, further general anesthesia is required for the completion of surgery. The development of precise nerve localization modalities using ultrasound shortens the performance time, reduces the incidence of vascular puncture, and improves block success, which makes it possible for axillary brachial plexus block to take the place of general anesthesia for the surgery of elbow joint completely. Currently, there is still few evidence of the superiority of ultrasound guidance axillary brachial plexus block compared to general anesthesia in anesthesia and analgesia for the surgery of elbow joint. The goal of this study was to determine whether ultrasound guidance axillary brachial plexus block is more effective thangeneral anesthesia in the suppression of hemodynamic and stress response to the elbow joint surgery.Methord（1）General data. Sixty patients who

open reduction and internal fixation surgeries for fractures around elbow joints in zhuolu county hospital of traditional Chinese medicine from October 2014 to April 2017 were enrolled in this study. Inclusion criteria: ①age ranges from 18-80 years old; ②class I-II based on American Society of Anesthesiologists （ASA）scale without severe systematic diseases;③closed fractures of elbow joint without neurovascular injuries. Exclusive criteria: ① pathologic fractures; ② multiple fractures or injuries of other parts required to be treated at the same time;③patients who do not undergo axillary brachial plexus block or general anesthesia and endotracheal intubation;④patient rejection. Exclusion criteria: serious adverse effects occurred; the operation could not be conducted under brachial plexus block and should be transferred to general anesthesia. All patients were randomly assigned into 2 groups：the brachial plexus block group （group BB,n=30） and the general anesthesia group （group GA,n=30）.（2）Anesthetic management. All patients underwent routine preoperative preparation.The blood pressure, heart rate and blood oxygen saturation were monitored continuously after arrival.Supplemental oxygen and pulse oximetry were applied throughout the procedure. All patients were premeditated with dexmedetomidine （1 μg/kg of loading dose for 15 min of infusion and later transferred to 0.4 μg/kg/h for continuous infusion） prior to anesthesia. In group BB, 0.5 % bupivacaine 30 ml with dexamethasone 5 mg was prepared as local anesthetics. Through in-plane multiple-injection technique, 7 ml of local anesthetics were incrementally injected around radial nerve, median nerve, ulnar nerve and musculocutaneous nerve,. The axillary nerve was confirmed to be wrapped in the local anesthetic drug. In group GA, the anesthesia was induced with propofol （2.0 mg/kg）, sufentanil （0.3 μg/kg） and rocuronium （0.6 mg/kg） via endotracheal intubation. The anesthesia was maintained with propofol（4-6 mg·kg-1·h-1） and remifentanil （0.1-0.2 μg·kg-1·min-1）. Patient controlled intravenous analgesia （PCIA） was used for post-operation analgesia in both groups.（3）Observation and follow-ups. The mean arterial pressure and the heart rate were recorded before the anesthesia（T0）, before the surgery （T1）, 1 h after the surgical incision （T2）, at the end of surgery （T3）.2 blood samples were collected at T1 and T2 to measure the blood glucose level. The pain scales were assessed via the visual analogue score （0 point presented as no pain and 10 points presented as unbearable pain） 12 h after the operation, and the satisfactions of anesthesia and analgesia were assessed according to the Likert scale （1 point presented as extremely dissatisfied and 5 points presented as very satisfied）.（4）Statistical analysis . The SPSS 20.0 statistical software was used to analyze the data. In the measurement data, normal data presented asx-±swere compared byttest. The intra group time effect and inter group effect were processed by repeated measurement of variance analysis; non-normal data presented as M （P25，P75） were compared by Kolmogorov-SmirnovZtest and the correlation was calculated by Spearman rank relational coefficient; the enumeration data was presented as case number （%）, and χ2test was used in the comparison between groups.P＜0.05 was considered as statistically significant as the difference.ResultsAnesthesia, surgical operation and postsurgical follow-up were completed in all patients. There was no severe complication during and after surgery in either group. With successful brachial plexus block and analgesics, no patient in BB group underwent general anesthesia. There was no significant difference in demographic data, surgical performance times and locations of fracture between the 2 groups. There was no significant difference in mean arterial pressures and heart rates at different time points of measurement for BB group. Changes in the mean arterial pressure and the heart rate were statistically significant for GA group （F=9.568,P＜0.001;F=7.746,P=0.001）.The values of mean arterial pressure and heart rate did not differ significantly between groups. The concentrations of plasma glucose （mmol/L） 1 h after the surgical incision were significantly higher than those before the surgery in both groups （5.9±0.7 vs 6.5±0.8,t=-8.098,P＜0.001; 5.8±0.9vs6.7±1.1,t=-7.471,P＜0.001）, and the increment in BB group was significantly lower than that in GA group （0.6±0.4vs0.9±0.6,t=-2.243,P=0.030）. The VAS score in BB group wassignificantly lower than that in GA group 12 h postoperatively [1（1, 1）vs2（1, 2.25）,Z=2.066,P＜0.001］. The satisfaction for anesthesia and analgesia was significantly higher in BB group [4（3,5）vs3（2.75, 4）,Z=1.549,P=0.016］. The negative correlation between the VAS score and the satisfaction for anesthesia was statistically significant （r=-0.549,P＜0.001）.ConclusionThe ultrasound guidance axillary brachial plexus block can take place of general anesthesia in anesthesia and analgesia for surgery of elbow joint. Compared to general anesthesia, ultrasound guidance brachial plexus block is more effective in suppressing hemodynamic fluctuation and stress response to surgery and improving post-operational pain rating and patients' satisfaction for anesthesia and analgesia.

Brachial plexus block； General anesthesia； Ultrasound； Elbow joint

2017-04-10）

（本文编辑：胡桂英；英文编辑：陈建海、张晓萌、张立佳）

10.3877/cma.j.issn.2095-5790.2017.02.008

北京大学人民医院研究与发展基金（RDC2014-09）

075699 张家口，涿鹿县中医院麻醉科1; 100044 北京大学人民医院麻醉科2

姜柏林, Email: jiangbailin@139.com

武科, 任素敏,赵丽敏,等. 超声引导下臂丛神经阻滞与全身麻醉在肘关节手术中的应用比较[J/CD].中华肩肘外科电子杂志 ,2017,5（2）：119-124.