坐骨神经阻滞的恢复时间在糖尿病人与非糖尿病人中的差异

发布时间：2018-05-12 12:29

本文选题：坐骨神经阻滞 + 糖尿病　；参考：《北京协和医学院》2015年博士论文

【摘要】：前言区域麻醉常用于肢体手术,其感觉和运动恢复时间是临床上值得关注的问题,与术后镇痛方案和术后功能康复有着密切的关系。随着糖尿病患病率的逐年上升,合并糖尿病的手术病人也越来越多。糖尿病在哪些方面影响区域麻醉已成为最近的关注点,起效时间、恢复时间、神经损伤发生率都可能受到影响。本研究拟比较糖尿病人和非糖尿病人的坐骨神经阻滞的感觉和运动阻滞恢复时间和神经损伤发生率,并筛选影响阻滞时间的因素。方法经北京协和医院伦理委员会审核并批准,连续纳入符合入选标准和排除标准的单侧下肢手术病人,按照病人是否合并糖尿病分为糖尿病组和非糖尿病组(对照组),当进行影响因素的筛选时则不分组。在术前用Semmes Weinstein monofilaments对坐骨神经支配区域(足背,足底)行单丝试验确定病人的感觉阂值,并测量空腹血糖、糖化血红蛋白水平及糖尿病视网膜病变分期。所有病例均接受超声引导(神经刺激器辅助)下的臀下入路坐骨神经阻滞,神经周围注射0.75%罗哌卡因20m1。在阻滞后的48小时内每2小时随访一次病人(不包括阻滞后的第2夜),继续以同样的方法行单丝试验检测感觉恢复进程,通过踝关节的活动(足背屈,足跖屈)来评估运动恢复进程。主要研究终点是感觉和运动阻滞恢复时间。结果本研究共纳入53例患者,全部完成实验。其中糖尿病组16例,非糖尿病组37例。除年龄和ASA分级外,其他人口统计学指标均无显著统计学差异,术前糖尿病组的空腹血糖和HbAlc明显高于对照组。糖尿病人接受坐骨神经阻滞后的感觉恢复时间与非糖尿病人无差异(16小时和16小时),但运动阻滞恢复时间明显长于非糖尿病人(21小时和16小时)。对全部病例行单因素回归分析后发现,运动阻滞恢复时间与血糖具有显著相关性,而与糖化血红蛋白的相关性不显著。与感觉阻滞恢复时间相关的因素还有性别、术前的感觉阈值、阻滞操作时间、神经被局麻药包裹的比例、ALT。与运动阻滞恢复时间相关的因素还有TBil、DBi1、Cr。结论本研究发现,在血管外科和骨科下肢手术人群中,糖尿病人接受坐骨神经阻滞后运动阻滞恢复时间明显延长,感觉恢复时间与非糖尿病人无差异。运动阻滞恢复时间与术前的空腹血糖具有显著相关性,其他与阻滞恢复时间相关的因素还有性别、术前的感觉阈值、阻滞熟练程度、局麻药扩散范围、以及肝肾功能,有待进一步验证。目的本研究拟观察乌司他丁对充气式止血带下接受双侧全膝关节置换术(TKA)的病人的围术期炎症反应、术后急性疼痛和慢性疼痛、以及膝关节功能康复速度的影响。方法选择拟在大腿止血带下接受双侧TKA的患者40例,随机分为实验组(U组)和对照组(C组),U组静脉给予乌司他丁,C组给予生理盐水。所有病人的全身麻醉方案、术后镇痛方案和功能康复方案均相同。在不同时间点采样并记录炎症细胞因子IL-6、TNF-α、IL-10的血浆浓度,观察并比较病人的静息和活动VAS疼痛评分,阿片类药消耗量,膝关节主动屈膝角度和持续被动运动角度及步行30米所需时间。结果两组患者的一般情况没有显著差异。U组的部分时间点的炎症因子水平低于C组。U组术后4小时的静息疼痛评分和舒芬太尼用量显著低于C组。术后各时间点的功能康复指标均无统计学差异。结论在双侧TKA术前和术中应用乌司他丁可以减轻围术期炎症反应,降低术后早期的静息疼痛评分,减少阿片类药物用量,但对术后膝关节功能康复指标没有显著影响。
[Abstract]:Preface regional anesthesia is commonly used in limb surgery. Its sensory and movement recovery time is a problem worthy of attention in clinical practice. It has a close relationship with postoperative analgesia and postoperative functional rehabilitation. With the increase of the prevalence of diabetes, more and more patients with diabetic surgery have been involved. In which areas diabetes affects regional anesthesia This study is to compare the sensory and motor block recovery time and the incidence of nerve injury in the sciatic nerve block of diabetics and non diabetic patients, and to screen the factors that affect the time of the block. Methods through the Peking Union Medical College Hospital ethics committee. The patients were reviewed and approved to be included in a single side of the lower extremities who were in accordance with the criteria for admission and exclusion. The patients were divided into diabetes group and non diabetic group (control group) according to whether the patients were combined with diabetes. They were not divided into groups when the influencing factors were screened. Semmes Weinstein monofilaments was used before the operation for the sciatic nerve area (foot back, A monofilament test was performed to determine the patient's sensory threshold and to measure fasting blood glucose, glycated hemoglobin levels and diabetic retinopathy. All cases received ultrasound guided (nerve stimulator assisted) hip approach to the sciatic nerve block, and 0.75% ropivacaine 20m1. was injected every 2 hours within 48 hours after the block. Follow up a patient (excluding second nights after block), continue to test the process of sensory recovery with the same method of monofilament test, and evaluate the process of recovery through the ankle joint activity (foot back flexion, foot metatarsal). The main end point is the sensory and motor block recovery time. The results of this study were included in 53 patients, all completed the experiment. There were 16 cases in the middle diabetes group and 37 in the non diabetic group. Except for age and ASA classification, there was no significant difference in other demographic indicators. The fasting blood glucose and HbAlc in the pre operation diabetic group were significantly higher than those in the control group. There was no difference between the sensory recovery time of the diabetic patients after the sciatic nerve block and the non diabetic patients (16 hours and 16 hours), but there was no difference between the diabetic patients and the non diabetic patients. The recovery time of the motor block was significantly longer than that of non diabetic patients (21 hours and 16 hours). After single factor regression analysis in all cases, it was found that the recovery time of motor block was significantly correlated with blood glucose, but the correlation with glycosylated hemoglobin was not significant. The factors associated with the recovery of sensory block were gender, and the preoperative sensory threshold The factors involved in the blocking operation time, the proportion of the nerve by the local anesthetic, and the factors associated with the recovery time of the ALT. and the motor block were TBil, DBi1, Cr.. Conclusion this study found that in the group of lower extremities in the vascular surgery and Department of orthopedics, the time of the motor block recovery was significantly prolonged after the sciatic nerve block of the diabetic patients, and the time of sensory recovery and non diabetic patients were significantly prolonged. No difference. There was a significant correlation between the time of motor block recovery and the preoperative fasting blood glucose. Other factors related to the recovery time were gender, preoperative sensory threshold, block proficiency, the diffusion range of local anesthetics, and liver and kidney function. The objective of this study was to observe the effect of Ulinastatin on inflatable hemostatic band. The perioperative inflammatory response, acute pain and chronic pain after operation, and the effect of knee joint function recovery were observed in patients receiving bilateral total knee arthroplasty (TKA). Methods 40 patients receiving bilateral TKA under the thigh hemostasis were selected and randomly divided into experimental group (group U) and control group (group C), group U was given Ulinastatin, and group C was given. Normal saline. All patients' general anesthesia plan, postoperative analgesia plan and functional rehabilitation program were the same. Sampling and recording the plasma concentration of inflammatory cytokines IL-6, TNF- a, IL-10 at different time points, observing and comparing the patient's resting and active VAS pain score, opioid consumption, knee joint active knee angle and continuous being Movement angle and the time required for walking 30 meters. Results there was no significant difference in the general situation between the two groups. The level of inflammatory factors at some time points in group.U was lower than that in group C.U after 4 hours of postoperative resting pain score and sufentanil dosage significantly lower than that in group C. The preoperative and intraoperative use of ulinastatin can reduce the perioperative inflammatory response, reduce the early postoperative resting pain score, reduce the dosage of opioid drugs, but have no significant effect on the postoperative rehabilitation index of the knee joint function.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R614

【参考文献】