股神经阻滞复合全身麻醉在老年患者全膝关节置换术中的临床观察

发布时间：2018-05-21 01:21

本文选题：股神经阻滞 + 老年　；参考：《中国人民解放军医学院》2014年硕士论文

【摘要】：外周神经阻滞术是一种阻滞范围局限、阻滞效果确切、镇痛作用完善，，而对全身影响相对较小的麻醉及镇痛技术，在临床应用了几十年。随着神经刺激仪和超声引导技术的发展，下肢外周神经阻滞的成功率大大提高，其在高龄患者的骨科麻醉中发挥着越来越重要的作用。股神经阻滞（Femoral NerveBlock，FNB）是迄今为止使用最广泛的下肢外周神经阻滞技术，其在下肢手术术后镇痛的研究是近年来国内外学者研究的热点，目前临床多观察的是单次股神经阻滞（single Femoral Nerve Block，sFNB）或连续股神经阻滞（continuous Femoral Nerve Block，cFNB）对单侧下肢手术的阻滞效果，而双侧下肢手术，仍旧采用全身麻醉或者椎管内麻醉等传统方法，本研究通过观察sFNB复合喉罩全身麻醉在老年患者单侧全膝关节置换术（UnilateralTotal Knee Arthroplasty，UTKA）中的临床应用与效果评价，进一步探索双侧sFNB复合全身麻醉在老年患者同期双侧全膝关节置换术（SimultaneousBilateral Total Knee Arthroplasty，SBTKA）的安全性及有效性，以期为老年患者SBTKA麻醉选择提供新的临床依据。第一部分sFNB复合喉罩全身麻醉在老年患者UTKA中的应用目的：观察sFNB复合喉罩(Laryngeal MaskAirway，LMA)全身麻醉在老年患者UTKA中的临床效果。方法：选择拟行UTKA的老年患者60例，随机分成sFNB+喉罩全身麻醉组（FLA组）、sFNB+气管插管全身麻醉组（FGA组）和气管插管全身麻醉组（GA组），观察并记录各时间点心率（Heart Rate，HR）、无创收缩压（Systolic Blood Pressure，SBP）、无创舒张压（Diastolic BloodPressure，DBP），记录三组患者手术时间及止血带应用时间，术中丙泊酚、瑞芬太尼、芬太尼用量，血管活性药物的使用及围术期不良事件发生情况；观察三组停止静脉麻醉药后苏醒时间，拔管时间。记录三组患者术后6h、24h、48h、72h静息状态的视觉模拟评分法(Visual Analogue Scale/Score，VAS)评分，术后24h、48h、72h功能训练状态的VAS评分，并记录术后镇痛泵的按压次数及不良反应。结果：60例患者均完成了本项研究。麻醉用药方面FLA组和FGA组术中丙泊酚、瑞芬太尼、芬太尼的使用量显著低于GA组（P0.01），苏醒时间及拔管时间与GA组比较明显缩短（P0.05）；血流动力学方面FLA组、FGA组在T3、T4、T5三个时间点的SBP显著低于GA组（P0.05），FLA组、FGA组T5时间点的HR显著低于GA组（P0.05）；围术期不良反应FLA组、FGA组苏醒期躁动、拔管后诉切口疼痛例数显著低于GA组（P0.01），FLA组拔管后呛咳、术后咽痛例数明显低于FGA组和GA组，差异具有显著性（P0.01）；VAS评分比较方面FLA、FGA组术后6h、24h静息状态和术后24h、48h运动状态的疼痛VAS评分均显著低于GA组同时间点（P 0.05），FLA、FGA组PCIA泵按压次数、使用总量和加用帕瑞昔布钠用量显著少于GA组(P0.05)，术后不良反应没有差异（P0.05）。结论：sFNB复合全身麻醉，特别是复合喉罩全身麻醉优于单纯全身麻醉，可以减少术中及术后用药，缩短苏醒、拔管时间，降低术后早期VAS评分，且不良反应少，可以作为老年UTKA手术的更好选择。第二部分双侧sFNB复合全身麻醉在老年患者SBTKA中的应用目的：观察双侧sFNB复合全身麻醉在老年患者SBTKA中的可行性和安全性，并评价临床效果。方法：选择本院择期行SBTKA的老年患者50例，随机分成双侧sFNB+全身麻醉组（FGA组）和全身麻醉组(GA组)各25例，观察相应时间点记录HR,有创动脉收缩压（SystolicArterial Pressure, SAP）、有创动脉舒张压（DiastolicArterial Pressure, DAP）、血氧饱和度（Surplus PulseO2, SpO2），记录两组患者手术时间及止血带应用时间，术中丙泊酚、瑞芬太尼、芬太尼用量，术中心血管事件及血管活性药物的使用，观察两组停止静脉麻醉药后苏醒时间，拔管时间。结果：45例患者完成了该研究。 FGA组患者术中丙泊酚、瑞芬太尼、芬太尼用量显著低于GA组（P0.01）,苏醒及拔管时间也显著短于GA组（P 0.01）；血流动力学方面FGA组T4、T5、T6、T7四个时间点的SAP显著低于GA组（P0.05），FGA组T7时间上HR显著低于GA组，差异有统计学意义（P0.05），FGA组苏醒期躁动、拔管后诉切口疼痛例数显著低于GA组（P0.05）；术后VAS评分FGA组术后6h、24h、48h静息状态VAS评分和术后48h运动状态的疼痛VAS评分均显著低于GA组同时间点（P 0.01）；术后镇痛药的使用上FGA组显著少于GA组，嗜睡、恶心呕吐不良反应发生也显著少于GA组(P0.05)；围手术期围术期应激反应没有显著性差异（P0.05）。结论：双侧sFNB复合全身麻醉是安全的、有效的，可以减少术中及术后用药，缩短苏醒、拔管时间，降低术后早期VAS评分，且不良反应少，可以作为老年SBTKA手术的选择。
[Abstract]:Peripheral nerve block is a kind of block limited, accurate block effect and perfect analgesic effect, while the anesthesia and analgesic technique which has relatively small influence on the whole body has been applied for several decades. With the development of the nerve stimulator and ultrasound guided technique, the success rate of peripheral peripheral nerve obstruction is greatly improved, and it is in the Department of orthopedics of the elderly patients. Anaesthesia plays a more and more important role. Femoral NerveBlock (FNB) is the most widely used peripheral nerve block in the lower extremities so far. Its research on postoperative analgesia after lower extremity surgery is a hot spot at home and abroad. At present, the clinical observation is the single femoral nerve block (single Femoral Nerve B). Lock, sFNB) or continuous femoral nerve block (continuous Femoral Nerve Block, cFNB) for unilateral lower extremities surgery, while bilateral lower extremity surgery still uses traditional methods such as general anesthesia or intraspinal anesthesia. This study was conducted through the observation of sFNB complex laryngeal mask body drunken in elderly patients with unilateral total knee arthroplasty (UnilateralTotal). The clinical application and effect evaluation in Knee Arthroplasty, UTKA, and further explore the safety and effectiveness of bilateral total knee replacement (SimultaneousBilateral Total Knee Arthroplasty, SBTKA) for bilateral sFNB combined general anesthesia in the elderly in order to provide a new clinical basis for the selection of SBTKA anesthesia for the elderly patients.
Part one application of sFNB combined laryngeal mask airway in elderly patients with UTKA
Objective: To observe the clinical effect of sFNB combined with Laryngeal MaskAirway (LMA) general anesthesia in the elderly patients with UTKA. Methods: 60 cases of elderly patients with UTKA were selected, randomly divided into sFNB+ laryngeal mask general anesthesia group (FLA group), sFNB+ tracheal intubation general anesthesia group (FGA group) and tracheal intubation general anesthesia group (GA group), observed and recorded each time. Heart Rate (HR), Systolic Blood Pressure (SBP), non invasive diastolic pressure (Diastolic BloodPressure, DBP), the time of operation and the use of tourniquet in three groups of patients, the use of propofol, Reventa Ni, fentanyl, the use of blood tube active drugs and the occurrence of adverse events in the perioperative period, and the observation of the three groups. A visual analogue scale (Visual Analogue Scale/Score, VAS) score for 6h, 24h, 48h and 72h after operation was recorded in three groups of patients after the anesthesia, and the VAS scores of the postoperative 24h, 48h, 72h functional training state were recorded, and the times and adverse reactions of the postoperative analgesia pump were recorded and the results were completed in 60 patients. The use of propofol, Reventa Ni, and fentanyl in group FLA and FGA was significantly lower than that in group GA (P0.01). The awakening time and extubation time were significantly shorter than those in the GA group (P0.05); the FLA group in the hemodynamics, FGA group at T3, T4, and T5 were significantly lower than those in the group of T3, T4, and T5. HR was significantly lower than group GA (P0.05); in group FLA, group FGA was restless in group FGA, and the number of pain cases of incision after extubation was significantly lower than that of group GA (P0.01). The number of postoperative pain in FLA group was obviously lower than that of FGA group and GA group, and the difference was significant (P0.01). The pain VAS score of 48h motor state was significantly lower than that in group GA at the same time point (P 0.05), FLA, FGA group PCIA pump press times, total use and dosage of parecoxib sodium were significantly less than GA group (P0.05), and there was no difference in postoperative adverse reaction (P0.05). Conclusion: sFNB compound general anesthesia, especially compound laryngeal mask general anesthesia, is superior to simple general anesthesia. It can reduce the use of medication during and after operation, shorten the awakening, extubation time, reduce the early VAS score after the operation, and have less adverse reactions, which can be used as a better choice for the elderly UTKA operation.
The application of second parts of bilateral sFNB combined general anesthesia in elderly patients with SBTKA
Objective: To observe the feasibility and safety of bilateral sFNB combined general anesthesia in elderly patients with SBTKA, and to evaluate the clinical effect. Methods: 50 elderly patients with SBTKA were selected and divided into 25 cases of bilateral sFNB+ general anesthesia group (group FGA) and general anesthesia group (group GA), and the corresponding time points were observed and the arterial contraction was recorded at the corresponding time point. Pressure (SystolicArterial Pressure, SAP), the arterial diastolic pressure (DiastolicArterial Pressure, DAP), blood oxygen saturation (Surplus PulseO2, SpO2), record two groups of patients' operation time and tourniquet time, operation propofol, remifentanil, fentanyl dosage, operation center vascular events and vasoactive drugs use, observe the two groups of stop Results: 45 patients completed the study. In group FGA, the dosage of propofol, Reventa Ni, fentanyl was significantly lower than that of group GA (P0.01), and the time of awakening and extubation was significantly shorter than group GA (P 0.01); the SAP of the four time points of the hemodynamic square FGA group T4, T5, T6, T7 was significantly lower than that of the GA group. .05), in group FGA, HR was significantly lower than that in group GA, and the difference was statistically significant (P0.05), group FGA was restless, and the number of pain cases of incision after extubation was significantly lower than that of GA group (P0.05). The postoperative VAS score in FGA group was significantly lower than that in the same time point (0.01). FGA group was significantly less than group GA, lethargy and nausea and vomiting were significantly less than group GA (P0.05), and there was no significant difference in perioperative stress response (P0.05) in perioperative period (P0.05). Conclusion: bilateral sFNB combined general anesthesia is safe and effective. It can reduce the use of medication during and after operation, shorten the awakening, extubation time, Reduce the early postoperative VAS score, and less adverse reactions, can be used as the choice of SBTKA surgery in the elderly.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

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