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超声引导下肘部连续靶神经阻滞镇痛对断指再植术后血管痉挛的影响
Effect of postoperative analgesia with Ultrasound-guided Continuous target nerve block of the wrist on vasospasm for amputated finger replantation
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DOI:
作者:
徐杨,姚军,陈勇柱,张晓丽,江伟
XU Yang
作者单位:
上海交通大学附属第六人民医院麻醉科
Department of Anesthesiology,Shanghai Sixth People's Hospital,Shanghai Jiaotong University
关键词:
超声引导;连续神经阻滞;术后镇痛;断指再植;皮温
Ultrasonic guidance; Continuous peripheral nerve block; Postoperative analgesia; Finger replantation; Skin temperature
摘要:
目的 应用超声引导下肘部桡、尺及正中神经置管连续阻滞,对断指再植术后患者进行精准的靶神经镇痛,研究该方法术后48h内镇痛效果以及对再植指皮温、存活率的影响。方法 择急诊行断指再植手术的患者60例,其中性别不限,年龄>6岁,既往均无长期服用抗凝药物,离断手指≤3根,美国麻醉医师学会分级I~II级,无严重的合并伤。将患者随机分入研究组和对照组,每组30例。研究组患者于术后根据再植指别行超声引导下肘部桡、尺及正中神经单独或联合置管,接镇痛泵行持续镇痛,镇痛配方为0.2%罗哌卡因共100mL,泵速2ml/h,术后48h拔除。对照组患者术后按需给予帕瑞昔布肌注镇痛。记录术后两组术后即刻、12h、24h、36h、48h的疼痛视觉模拟评分(VAS评分)及再植指皮温,计算两组患者再植指血管危象、二次手术探查的发生率及再植指的成活率,进行统计学分析。结果 研究组患者VAS评分维持在较低水平(1.31±1.43),术后12h、24h、36h及48hVAS评分均显著低于对照组(P值均<0.05)。研究组患者再植指在术后12h、24h、36h及48h时刻皮温均显著高于对照组(P值均<0.05),其中术后24h时两组再植指皮温差异最大。对照组发生血管危象及需二次手术的比例分别为26.67%和16.67%,显著高于研究组(P值均<0.05)。两组患者最终的再植指存活率对比无差异。结论 连续肘部靶神经阻滞可根据患者具体伤情选择阻滞桡神经、尺神经或正中神经,提供良好的镇痛,升高皮温,达到扩张血管、提高灌注的目的,减少血管危象的发生,在断指再植术后镇痛领域有着良好的应用前景。该方法能否提高断指再植存活率有待进一步研究。
Objective The present study aimed to investigate the influence of Ultrasound-guided continuous radial,ulnar and median nerve block analgesia of the wrist on skin temperature and survival following finger replantation. Methods sixty patients undergoing finger replantation,aged older than 6 years,no history of anticoagulants taken,less than four digit received replantation,American Society of Anesthesiologists(ASA)I to II,were randomized into control group and study group(n=30).Under ultrasoundguidance,continuous target nerve block analgesia of the wrist was operated for study group,followed by an infusion of 2 ml per hour for up to 2 days.Control group received parecoxibintramuscular injections when patients in need of analgesia.The skin temperature of replantationdigit and visual analog scale(VAS) were recorded at 0,12,24,36,48 hour after surgery.Inaddition,the incidence of vascular spasm,vascular embolization and the survival of reconstructive digits were observed.Results The VAS sores in study group were significantly lower at 12,24,36,48 hour after surgery than those in control group(all P<0.05). The skin temperature of on reconstructive digits in patients receiving continuous target nerve block were significantly higher at 12,24,36,48 hour after surgery than those without receiving the block(all P<0.05).The incidence of vascular spasm and vascular embolization in study group was lower than that in control group( P<0.05),but there was on significant difference in the survival rate of replanted fingers.Conclusion Ultrasound-guided continuous target nerve block of the wrist could provide more efficient postoperative analgesia. At the same time,blocking the proximal upper extremity improved tissue perfusion after replantation surgery of crushed fingers by means of preventing neurologically-mediated vasospasm.Whether postoperative continuous nerve block can improve the success rate of finger replantation is not sure,which needs further Study.
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