文章摘要
超声引导下腹股沟韧带上髂筋膜阻滞对老年患者股骨转子间骨折闭合复位预后的影响
Effect of ultrasound-guided iliofemoral ligament block on the prognosis of intertrochanteric femoral fracture in the elderly
  
DOI：10.12089/jca.2020.10.007
中文关键词: 髂筋膜阻滞  老年  超声  股骨骨折  预后
英文关键词: Iliac fascial block  Elderly  Ultrasound  Femoral fracture  Prognosis
基金项目:
作者单位E-mail
王丽 110016,沈阳市,北部战区总医院麻醉科  
袁梦琦 110016,沈阳市,北部战区总医院麻醉科  
西志梦 110016,沈阳市,北部战区总医院麻醉科  
张铁铮 110016,沈阳市,北部战区总医院麻醉科  
刁玉刚 110016,沈阳市,北部战区总医院麻醉科 diao72@163.com 
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中文摘要:
      
目的 评价超声引导下腹股沟韧带上髂筋膜阻滞对老年股骨转子间骨折闭合复位预后的影响。
方法 选取2018年1月至2020年1月择期行股骨转子间骨折闭合复位手术患者50例，男42例，女8例，年龄78～91岁，BMI 18～25 kg/m2，ASA Ⅱ或Ⅲ级，采用随机数字表法分为两组：全身麻醉联合髂筋膜阻滞组（T组）和全身麻醉组（G组），每组25例。T组患者在实施全身麻醉前20 min行超声引导下髂筋膜阻滞，于患侧腹股沟韧带上确定好髂筋膜位置，采用平面内操作技术于髂筋膜下给予0.25%罗哌卡因+0.67%利多卡因共30 ml，10～15 min后测定阻滞平面。G组仅接受全身麻醉。术后两组均行PCIA，配方：舒芬太尼150 μg+昂丹司琼24 mg+生理盐水稀释至100 ml，背景剂量2 ml/h，单次剂量0.5 ml，锁定时间15 min。采用VAS评分法评估疼痛程度，VAS疼痛评分≥4分时静脉注射羟考酮0.05 mg/kg行补救镇痛。记录麻醉诱导前（T0）、髓内针固定时（T1）、手术结束即刻（T2）、术后6 h（T3）动脉血乳酸（Lac）和血糖（Glu）浓度。记录手术时间、术中丙泊酚、瑞芬太尼用量、晶体液输入量、胶体液输入量、输液总量、出血量、尿量和去甲肾上腺素使用例数。记录术后6、8、12、24 h静息和运动时VAS疼痛评分，术后24 h内舒芬太尼用量及羟考酮使用例数。记录PACU停留时间、术后住院时间以及恶心呕吐、皮肤瘙痒、肺部炎症、阻滞部位感染等并发症情况。
结果 与G组比较，T1—T3时T组动脉血Lac、Glu浓度明显降低（P<0.05）；T组术中去甲肾上腺素使用率明显降低，术中瑞芬太尼用量、术后24 h内舒芬太尼用量明显减少，羟考酮使用率明显降低（P<0.05）；术后6、8、12 h T组静息及运动时VAS疼痛评分明显降低（P<0.05）；T组PACU停留时间、术后住院时间明显缩短，术后恶心呕吐发生率明显降低（P＜0.05）。两组术中丙泊酚用量、晶体液输入量、胶体液输入量、输液总量、出血量和尿量差异无统计学意义。两组术后皮肤瘙痒、肺部炎症、穿刺部位感染情况差异无统计学意义。
结论 与单独全身麻醉比较，联合超声引导下腹股沟韧带上髂筋膜阻滞降低应激水平，镇痛效果好，减少术后并发症，有助于促进患者术后康复，缩短住院时间。
英文摘要:
      
Ojective To evaluate the effect of ultrasound-guided superior iliac fascia block on the prognosis of elderly patients with intertrochanteric fracture.
Methods From January 2018 to January 2020, 50 patients, 42 males and 8 females, aged 78-91 years, with a BMI 18-25 kg/m2, falling into ASA physical status Ⅱ or Ⅲ, were randomly divided into two groups: general anesthesia combined with iliac fascia block group (group T) and general anesthesia group (group G), 25 cases in each group. In group T, ultrasound-guided iliac fascia block was performed 20 min before general anesthesia, and the position of iliac fascia was determined on the affected side of inguinal ligament. A total of 30 ml of 0.25% ropivacaine+0.67% lidocaine was given under the iliac fascia with in plane operation technology. The block plane was measured after 10-15 minutes. Group G was injected with 30 ml normal saline. Sufentanil was used for PCIA in both groups. The formula was sufentanil 150 μg + ondansetron 24 mg and normal saline diluted to 100 ml, background dose 2 ml/h, single dose 0.5 ml, locking time 15 min. VAS score was used to evaluate the pain degree. When VAS score was ≥ 4 points, oxycodone 0.05 mg/kg was injected intravenously for rescue analgesia. The concentrations of lactic acid (Lac) and glucose (Glu) were recorded before anesthesia induction (T0), at the time of intramedullary nailing (T1), at the end of operation (T2), and 6 h after operation (T3). The operation time, the dosage of propofol and remifentanil, the amount of crystalloid fluid, colloidal fluid, total infusion volume, blood loss, urine volume and norepinephrine utilization rate were recorded. The VAS pain scores at rest and exercise 6, 8, 12, and 24 h after operation, the total dosage of sufentanil, and the number of cases of auxiliary analgesic drugs used within 24 h after operation, the postoperative PACU stay time, hospitalization time, nausea and vomiting, skin itching, pulmonary inflammation, infection of block site, and other complications were recorded.
Results Compared with group G, the concentrations of Lac and Glu in group T were significantly decreased at T1-T3(P < 0.05). Compared with group G, the use rate of norepinephrine in group T was significantly reduced (P < 0.05). Compared with group G, the use of remifentanil, total sufentanil dosage within 24 h after operation and the usage rate of adjuvant analgesics in group T were significantly reduced (P < 0.05). There was no significant difference in the dosage of propofol between the two groups. The VAS pain scores at rest and exercise (deep breathing or cough) 6, 8, 12 h after operation were lower in group T than those in group G (P < 0.05). There was no significant difference between the two groups in the amount of crystalloid fluid input, colloidal fluid input, total infusion volume, blood loss and urine volume between the two groups. The postoperative PACU stay time and hospitalization time in group T were significantly shorter than those in group G (P < 0.05), and the incidence of postoperative nausea and vomiting in group T was significantly less than that in group G (P < 0.05). There was no significant difference in pulmonary inflammation, skin itching and puncture site infection between the two groups.
Conclusion ultrasound-guided iliofemoral ligament block is beneficial to improving the prognosis, reducing the level of stress and postoperative complications, meanwhile, it also helps to promote postoperative rehabilitation and shorten the length of stay.
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