Analgesia of Ultrasound-guided Single-dose Adductor Canal Block with Dexmedetomidine Combined with Ropivacaine after Patella Fracture Surgery in Adults
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摘要:
目的 对比超声引导下右美托咪定复合罗哌卡因的单次收肌管阻滞与单纯罗哌卡因的连续股神经阻滞在髌骨骨折手术术后镇痛的效果。 方法 择期全麻下髌骨骨折患者31例,年龄21~69岁,BMI≤35 kg/m2,ASA 分级Ⅰ级~Ⅲ级,随机分为2组, 100 μg右美复合0.25%罗哌卡因50 mg的单次收肌管组(A组,n = 21),单纯0.25%罗哌卡因250 mg的连续股神经阻滞组(F组,n = 10)。观察比较2组患者术后6、8、12、24、36、48 h的镇痛、镇静、肌力评分,记录术后追加镇痛和不良反应的发生情况。 结果 2组患者术后各个时间点的VAS、Raymay和Lovett评分比较无统计学差异(P > 0.05)。 结论 右美托咪定作为佐剂的罗哌卡因的单次收肌管阻滞可以为髌骨骨折提供良好的术后镇痛。 Abstract:Objective To compare the analgesic effect between ultrasound-guided single-dose adductor canal block with dexmedetomidine combined with ropivacaine and continuous femoral nerve block with ropivacaine after patella fracture surgery. Methods 31 patients with patella fractures who underwent elective general anesthesia, with age ranging from 21 to 69, BMI ≤ 35 kg/m2, ASA grading Ⅰ~Ⅲ, were randomly divided into two groups. Single-dose adductor canal block group who received 100 μg dexmedetomidine combined with 0.25% ropivacaine 50 mg (A group, n = 21), and continuous femoral nerve block group who received 0.25% ropivacaine 250 mg (F group, n = 10). The scores regarding analgesia, sedation, and muscle strength at 6, 8, 12, 24, 36 and 48 h after surgery were observed and compared between the two groups and the additional postoperative analgesia and adverse reactions were recorded. Results The analgesic effect, postoperative scores based on sedation and muscle strength were not statistically different between the two groups at various points during the observation period (P > 0.05). Conclusion Single-dose adductor canal block with dexmedetomidine combined with ropivacaine can provide good analgesia after patella fracture surgery. -
Key words:
- Adductor canal nerve block /
- Dexmedetomidine /
- Ropivacaine /
- Patellar fracture /
- Analgesia /
- Ultralsound guidance
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随着微创介入血管内技术的不断发展与改进,微创介入血管内手术已在全国各地广泛开展。但手术过程中导丝、导管、球囊、支架、弹簧圈等医源性材料的折断、解旋并留置于血管内的情况时有发生[1-3],这些医源性材料留置于人体血管内即成为血管内异物(Intravascular foreign bodies ),其可导致血栓形成、血管闭塞、血管穿透、心率失常等事件的发生甚至可危及患者生命[4-5]。虽然目前有血管内异物取出的术式,但因血管内异物留置部位的不同,或术者操作技术和经验积累的差异,血管内异物取出的成功率并不高。此外,血管异物取出的操作风险较高,一旦发生此类异物留置于血管内的事件,患者不仅处于较高的医疗风险下,术者也将承受巨大的心理压力,同时也增加了相关医疗纠纷发生的可能。医源性异物留置于血管内事件发生后,术者应尽可能地将异物取出,这要求术者有丰富的操作经验和合适的异物抓捕器械。因此,在现有血管内异物抓捕器械的基础上,笔者介绍一种自制异物抓捕器,该自制异物抓捕器的研制有着十分重要的临床意义和应用价值。
1. 资料与方法
1.1 研究对象
在模拟人体内血管的体外血管模型(简称模拟人)(见图1A)上构建由废弃导丝、废弃导管、废弃支架、废弃弹簧圈存留于模拟人股动脉、髂内动脉、髂总动脉、腹主动脉、胸主动脉、主动脉弓、无名动脉、颈总动脉、颈内动脉、椎动脉等不同血管部位的异物存留模型,该模型作为本试验研究对象。试验研究器械为自制抓捕器和传统异物抓捕器,后者包括临床中使用相同规格的活检钳、异物钳及血管内异物抓捕器如环状圈套抓捕器、篮网状抓捕器、三角爪型抓捕器。本自制异物抓捕器由头端抓钳、体部导管和尾部固定握把三部分组成,头端为小型金属抓钳,可直接对异物进行抓取。体部为软质塑料制成的中空导管,在对抓钳提供必要支撑力的同时可顺应血管形状到达血管内不同位置,该管状结构内腔可通过微导丝或泥鳅导丝引导头端抓钳至异物留置处,体部导管和固定握把间有一通道相通,也可将折叠导丝经固定握把处的通道置入,通过抓捕器体部导管的内腔出头端行成环状圈套对异物进行圈套,抓捕器头端抓钳和体部导管可整体通过8F导引导管。固定握把由硬质塑料制成,形态与金属活检钳握把类似(见图1B)。
1.2 实验方法
将模拟人以仰卧位置于试验操作台上,模拟全身麻醉状态下,双侧腹股沟区消毒并常规铺巾。于右侧腹股沟区行股动脉穿刺,置入8F动脉鞘,在X线动脉透视下,泥鳅导丝引导8F导引导管(Envoy,美国强生公司)沿动脉鞘置入模拟人血管内。将废弃导丝、废弃导管、废弃支架、废弃弹簧圈由近及远置于模拟人股动脉、髂内动脉、髂总动脉、腹主动脉、胸主动脉、主动脉弓、无名动脉、颈总动脉、颈内动脉、椎动脉等做成不同异物存留不同部位的异物存留模型。留置于股动脉、髂内动脉的异物以8F动脉鞘为通道,在动态透视下分别用自制抓捕器和活检钳、异物钳、血管内异物抓捕器进行异物抓取。对于留置其它动脉的异物,泥鳅导丝引导8F指引导管到达异物近端,将自制抓捕器和活检钳、异物钳、血管内异物抓捕器置入8F指引导管内,动态透视下抓取异物。活检钳、异物钳、血管内异物抓捕器根据其器械长度在其可应用范围内进行模拟人血管内异物抓取。自制抓捕器和活检钳、异物钳、血管内异物抓捕器钳住或圈套住异物后,将异物沿8F导引导管和8F动脉鞘内抓取出模拟人体外。
1.3 记录方法
将应用自制抓捕器进行模拟人血管内异物的抓取记录为自制抓捕器组,将应用活检钳、异物钳和血管内异物抓捕器进行模拟人血管内异物的抓取记录为传统抓捕器组。用自制抓捕器或活检钳、异物钳、血管内异物抓捕器钳住或圈套住异物成功后,将异物沿8F导引导管和8F动脉鞘内抓取出模拟人体外视为本次抓取成功,否则视为本次抓取失败。每组各进行80次模拟人血管内异物抓取,两组共计160次。
1.4 评估方法
(1)比较自制抓捕器组与传统抓捕器组的1次取出异物成功率;(2)比较自制抓捕器组与传统抓捕器组的3次内取出异物成功率;(3)比较自制抓捕器组与传统抓捕器组的取出异物总体成功率;(4)记录并比较自制抓捕器组与传统抓捕器组取出每例异物的平均操作时间。
1.5 统计学方法
所有数据采用SPSS 22.0统计学软件进行处理,计数资料用百分率(%)表示,计量资料用均数±标准差(
$\bar x \pm s $ )表示。各组数据间采用Pearson χ2检验或Student’ t检验,所有分析结果以P < 0.05为差异有统计学意义。2. 结果
2.1 自制抓捕器组与传统抓捕器组抓取异物的1次取出异物成功率、3次内取出异物成功率、取出异物总体成功率比较
自制抓捕器组和传统抓捕器组1次取出异物分别为58例和42例,两组有统计学差异(χ2 = 6.827,P = 0.009);自制抓捕器组3次内取出异物分别为58例、15例和4例,传统抓捕器组3次内取出异物分别为42例、14例和14例,两组有统计学差异(χ2 = 7.834,P = 0.020);自制抓捕器组和传统抓捕器组3次内取出异物分别为77例和70例,两组有统计学差异(χ2 = 4.103,P = 0.043),见表1 。
表 1 自制抓捕器组与传统抓捕器组取出异物的例数[n(%)]Table 1. The number of cases of retrieving foreign bodies between the self-made retrieval device group and the traditional retrieval device group[n(%)]组别 自制抓捕器组 传统抓捕器组 操作次数(次) 80 80 第1次取出异物 58(72.5) 42(52.5)* 第2次取出异物 15(18.8) 14(17.5)* 第3次取出异物 4(5.0) 14(17.5)* 成功取出异物 77(96.3) 70(87.5)* 与自制抓捕器组比较,*P < 0.05。 2.2 自制抓捕器组与传统抓捕器组取出每例异物的平均操作时间比较
自制抓捕器组取出异物77例的每例异物的平均操作时间为(7.42±1.68)min,显著短于传统抓捕器组70例的(13.21±5.25)min,两组有统计学差异(t = 9.192,P = 0.000),见表2。
表 2 自制抓捕器组与传统抓捕器组取出每例异物的平均操作时间[($\bar x\pm s $ ),min]Table 2. The average time for retrieving each foreign body between the self-made retrieval device group and the traditional retrieval device group[($\bar x\pm s $ ),min]组别 自制抓捕器组 传统抓捕器组 操作次数(次) 80 80 取出每例异物平均时间 7.42 ± 1.68 13.21 ± 5.25* 与自制抓捕器组比较,*P < 0.05。 3. 讨论
在微创介入血管内手术中,虽然医源性器械异物脱落后留置于患者血管内的事件并不常见,但该类事件一旦发生却是手术中非常严重的并发症[4],常由于器械本身质量不佳或术者手术操作失误而引起[1,6],且一定程度上属于医疗事故,血管内异物留置可存在于动脉或静脉内,文献报道[7]约80%的血管内异物存留于动脉,约80% 的患者有缺血症状,约20%异物存留于静脉,约30%患者有呼吸困难、咯血、胸痛等症状。留置于血管内的异物可造成血栓形成从而闭塞血管。异物随血流漂浮可栓塞动脉,导致脑梗死、肺梗死、心肌梗死、肾梗死、脾梗死等。部分异物可随血流搏动将周围的血管壁刺破造成出血。异物留置于血管内还可形成有菌性炎症或无菌性炎症,严重情况下导致菌血症甚至可危及患者生命[1]。因此对于医源性脱落于血管内的器械异物,若其能在X线下显影,以及在血管内异物抓捕器械使用范围内及术者操作能力允许,术者均应尽可能取出[2,6]。反之则应密切观察患者术后各项生命体征及神经功能,及时给予对症处理,并定期复查血管内异物的情况。
血管内医源性脱落异物取出的手术方式包括外科血管切开异物取出术与微创介入血管内异物取出术两种。以往对血管内异物的处理方法是行外科手术血管切开异物取出[6],但这种术式属于开放性手术,对患者创伤较大,且需直接切开血管,大量出血及感染等风险较高。医源性血管内异物一般为断裂导丝、断裂导管、释放支架、解旋弹簧圈等,这些异物可随心跳搏动和呼吸运动而在血管内漂流移动,存在术前定位后异物再移位的问题[2,8],进一步增加异物取出的难度甚至或可因异物再移位而导致手术失败。目前临床应用较多的是微创介入的术式行血管内异物取出,其显著优势在于对患者的创伤极小,安全性较以往的外科血管切开异物取出术明显提高。此外,在动态X线透视下,可实现对血管内异物位置的实时监测,大大提高异物定位的准确性和异物取出成功率[9-12],因此在临床中作为首选的血管异物取出的术式,外科血管切开异物取出术仅在血管内术式取出失败[2,6]以及必须行异物取出时才考虑运用。
临床上常用的异物抓取器械多为活检钳或异物钳,如硬质活检钳、软质活检钳、内镜内活检钳等,其头端有多种形状以用于不同部位,常应用于呼吸道、消化道和腹腔内等肉眼能够直视或借助内窥镜等手段观察到的部位[13-14]。活检钳和异物钳的固定握把形态能良好契合人体手指、手掌活动功能,使术者在手术中的操作较为方便灵活,但因其钳体常较短且坚硬,极少运用于血管内的异物取出,仅在紧急情况下可尝试使用[15]。血管内环状圈套抓捕器、篮网状抓捕器、三角爪型抓捕器为目前临床上常用的血管内异物抓捕器械[1,4,16],但因其头端圈套装置设计单一,对异物的抓持力较弱,抓取能力有限。对一些嵌顿较为稳固或留置位置不易到达的异物取出较为困难,且部分抓捕器本身材质偏硬,头端尖锐,易损伤血管内膜或穿破血管。大部分血管内异物抓捕器通过旋转抓捕器近端的扭控器来实现对抓捕器头端圈套的控制从而抓捕异物,但缺点在于通过扭控器传导的旋转或推拉力量仅部分能传达至抓捕器头端,因此术者难以高效掌控抓捕器对异物的抓取。此外,术者对扭控器的操作相比较于较活检钳或异物钳固定握把的操作更为不便,无形中增加了血管内异物取出的时间。因此,在结合活检钳或异物钳和血管内抓捕器两者原基础上对其结构和材料进行改造,设计出一种包含抓钳和圈套形头端的自制异物抓捕器,使其能在血管内安全、有效、操作便捷地使用,旨在高效地取出血管异物,降低手术风险。
本自制抓捕器头端为抓钳与圈套双重设计,抓钳能对异物的抓取提供强大的抓持力,易于将嵌顿较为牢固的血管内异物如断裂导丝、断裂导管、释放支架、解旋弹簧圈等异物取出,头端的圈套也可以辅助抓钳进行圈套异物,进一步提高异物的取出效率。抓钳头端可通过旋转抓捕器的固定把手自由旋转,方便用于抓取留置于血管内不同位置、不同角度的异物,可将操作时间明显缩短。该自制抓捕器中间段为导管状结构,管体质地较为柔软顺滑,可轻松通过抓钳外层的导引导管通路,在血管内也能够较少对血管的造成损伤。本自制抓捕器在传统活检钳、异物钳的基础上进行了延长设计,经股动脉穿刺沿导引导管置入后可到达右侧颈内动脉高度,扩大了异物取出的范围。且抓捕器固定握把与活检钳或异物钳相类似,较传统血管内异物抓捕器更便于术者的操作使用。
本试验研究采用自制异物抓捕器与传统异物抓捕器在模拟人血管内各进行80次异物抓取并比较两组抓取异物的效果。结果显示自制抓捕器组较传统抓捕器组有更高的1次取出异物成功率、3次内取出异物成功率、取出异物总体成功率和更短的取出每例异物平均操作时间,差异均有统计学意义(P < 0.05)。这说明本自制异物抓捕器较传统异物抓捕器能更有效地实施血管内异物取出。其有效性在本次试验中已得到初步验证。但该试验总共抓取次数仅为160次,为小样本量试验,仍需进一步完善更大样本量的试验。综上所述,在模拟人血管内操作,本自制异物抓捕器较传统异物抓捕器能更有效地抓取模拟人血管内异物,成功率更高,操作时间更短。
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表 1 2 组患者一般情况的比较(
$\bar x \pm s $ )Table 1. Comparison of general conditions between two groups of patients (
$\bar x \pm s $ )组别 n 男/女(n) 年龄(岁) ASAⅠ/Ⅱ/Ⅲ(n) BMI(kg/m2) A 21 10/11 41.9 ± 18.75 8/10/3 37.38 ± 5.54 F 10 5/5 46.6 ± 19.68 3/5/2 40.7 ± 4.52 t/卡方值 −0.64 0.47 −1.63 P 1.000 0.53 1.00 0.11 表 2 2组患者不同时间点VAS评分的比较 [ (
$ \bar x \pm s $ ),分]Table 2. Comparison of VAS scores between two groups at different time points [(
$ \bar x \pm s $ ),分]指标 组别 T1 T2 T3 VAS A 1.57 ± 2.27 1.38 ± 1.88 1.86 ± 2.31 F 0.7 ± 1.55 0.7 ± 1.55 1.00 ± 2.10 T4 T5 T6 A 2.24 ± 2.49 2.00 ± 1.95 2.00 ± 2.14 F 2.80 ± 2.89 2.20 ± 1.72 1.80 ± 1.08 表 3 2组患者不同时间点镇静、肌力评分的比较[(
$ \bar x \pm s $ ),分]Table 3. Comparison of sedation, muscle strength scores between two groups at different time points [(
$ \bar x \pm s $ ),分]指标 组别 T1 T2 T3 Ramsay A 1.81 ± 0.40 1.90 ± 0.30 1.90 ± 0.30 F 1.90 ± 0.30 1.90 ± 0.30 1.80 ± 0.40 T4 T5 T6 A 1.95 ± 0.38 1.95 ± 0.22 2.00 ± 0.00 F 1.70 ± 0.46 2.00 ± 0.00 1.90 ± 0.30 T1 T2 T3 lovett A 1.81 ± 1.21 1.95 ± 1.20 2.00 ± 1.14 F 2.00 ± 0.63 2.10 ± 0.54 2.10 ± 0.54 T4 T5 T6 A 2.33 ± 1.02 2.24 ± 1.04 2.33 ± 1.11 F 2.20 ± 0.75 2.40 ± 0.66 2.40 ± 0.66 表 4 2组患者术后各时间点的其他情况[n(%)]
Table 4. Other conditions of the two groups at each postoperative time points [n(%)]
事件 组别 n T1 T2 T3 T4 T5 T6 追加镇痛药 A 21 2(9.52) 0 2(9.52) 3(14.28) 0 0 F 10 2(20.00) 1(10.00) 2(20.00) 3(30.00) 2(20.00) 1(10.00) 恶心、呕吐 A 21 0 1(4.76) 1(4.76) 1(4.76) 2(9.52) 0 F 10 1(10.0) 1(10.00) 0 0 0 0 肢体异感 A 21 3(14.29) 3(14.29) 3(14.29) 4(19.05) 4(19.05) 4(19.05) F 10 0 0 0 0 0 0 头痛 A 21 1(4.76) 1(4.76) 1(4.76) 0 0 0 F 10 0 0 0 0 0 0 其他 A 21 无 无 无 无 无 无 F 10 无 无 无 脱管2例 无 无 -
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