四种肌间沟臂丛神经阻滞方法在肥胖患者上肢手术中的应用效果比较

唐群杰 叶伟标 方建勤 黄广用 郑建宇

[摘要]目的 比較在肥胖患者上肢手术中应用盲探法、神经刺激仪引导法、超声引导法以及超声联合神经刺激仪引导法进行肌间沟臂丛神经阻滞的效果。方法 选取2017年1～12月在广东佛山市三水区人民医院进行择期上肢手术的120例肥胖患者作为研究对象，采用随机数字表法将其分为A、B、C、D组，每组各30例。A组患者采用传统的解剖定位寻找异感法（盲探法），B组患者采用神经刺激仪引导法，C组患者采用超声可视下阻滞法，D组患者采用超声联合神经刺激仪行臂丛阻滞。比较四组患者的完成阻滞所需时间、感觉神经阻滞起效时间、阻滞完善效果及并发症总发生率。结果 B、C、D组患者完成阻滞所需时间均显著短于A组，差异有统计学意义（P<0.05）;C、D组患者完成阻滞所需时间均显著短于B组，差异有统计学意义（P<0.05）;D组患者完成阻滞所需时间显著短于C组，差异有统计学意义（P<0.05）。B、C、D组患者的感觉神经阻滞起效时间均显著短于A组，差异有统计学意义（P<0.05）;B、C、D组患者的感觉神经阻滞起效时间比较，差异无统计学意义（P>0.05）。B、C、D组患者的神经阻滞完善效果均优于A组，差异有统计学意义（P<0.05）;C、D组患者的的神经阻滞完善效果均优于B组，差异有统计学意义（P<0.05）;D组患者的的神经阻滞完善效果优于C组，差异有统计学意义（P<0.05）。B、C、D组患者的并发症总发生率均显著低于A组，差异有统计学意义（P<0.05）;B、C组患者的并发症总发生率比较，差异无统计学意义（P>0.05）;D组患者的并发症总发生率显著低于B、C组，差异有统计学意义（P<0.05）。结论 与传统盲探法比较，超声引导法在肥胖患者上肢手术的肌间沟臂丛神经阻滞中具有完成操作时间短、阻滞起效时间短、阻滞完善率高和并发症发生率低等优势。超声联合神经刺激仪可进一步扩大优势。

[关键词]肌间沟臂丛神经阻滞;肥胖患者;超声引导法;盲探法;神经刺激仪引导法

[中图分类号] R614          [文献标识码] A          [文章编号] 1674-4721（2019）2（c）-0081-05

[Abstract] Objective To compare the application effect of blind probe method， nerve stimulator guidance method， ultrasonic guidance method and ultrasound combined with nerve stimulator guidance method for the intermuscular sulcus brachial plexus block in the upper limb surgery for obese patients. Methods A total of 120 obese patients who underwent elective upper extremity surgery in Foshan Sanshui District People′s Hospital of Guangdong Province from January to December 2017 were selected as sudy subjects. They were divided into A， B， C and D groups according to the random number table method， 30 cases in each group. Traditional anatomical localization to find the heterosexual method （blind probe method） was used in group A， nerve stimulator guidance method was used in group B， ultrasonic guidance method was used in group C， and ultrasound combined with nerve stimulator guidance method was used in group D. The operation completed time for nerve block， the onset time of sensory nerve block， the block improvement effect， and total incidence rate of complications were compared among the four groups. Results The operation completed time for nerve block in group B， C， and D was significantly shorter than that in group A， and the differences were statistically significant （P<0.05）. The operation completed time for nerve block in group C and D was significantly shorter than that in group B， and the differences were statistically significant （P<0.05）. The operation completed time for nerve block in group D was significantly shorter than that in group C， and the difference was statistically significant （P<0.05）. The onset time of sensory nerve block in group B， C， and D was significantly shorter than that in group A， and the differences were statistically significant （P<0.05）. There was no significant difference in the onset time of sensory nerve block among the B， C， and D groups （P>0.05）. The block improvement effect in group B， C and D was better than that that in group A， and the differences were statistically significant （P<0.05）. The block improvement effect in group C and D was significantly better than that that in group B， and the differences were statistically significant （P<0.05）. The block improvement effect in group D was better than that that in group C， and the difference was statistically significant （P<0.05）. The total incidence rate of complications in group B， C and D was significantly lower than that that in group A， and the differences were statistically significant （P<0.05）. There was no significant difference in the total incidence rate of complications between the group B and group C （P>0.05）. The total incidence rate of complications in group D was significantly lower than that in group B and C， and the differences were statistically significant （P<0.05）. Conclusion Compared with the blind probe method， the ultrasonic guidance method has the advantages of short operation time， short block effect time， high blockade improvement rate and low complication rate in the intermuscular sulcus brachial plexus block of the upper limb surgery for obese patients. The ultrasound combined with nerve stimulator guidance method can further expand the advantages.

[Key words] Intermuscular sulcus brachial plexus block; Obese patients; Ultrasonic guidance method; Blind probe method; Nerve stimulator guidance method

肌间沟臂丛神经阻滞是上肢手术患者一种常用的麻醉技术[1]。肌间沟臂丛神经阻滞的操作区域位于患者的颈部位，临床上多数患者神经阻滞操作区域解剖定位简单，通过寻找异感定位的“盲探法”即可快速方便实现肌间沟臂丛神经阻滞操作区域的定位[2]。但部分肥胖患者的颈部肌肉和脂肪组织增多，肌间沟解剖部位不清，通过寻找异感定位臂丛神经位置难度加大，传统盲探法使用效果不佳[3]。目前临床上实现肥胖患者肌间沟臂丛神经阻滞的方法除“盲探法”外，还有神经刺激仪引导法[4]、超声引导法[5]以及超声联合神经刺激仪引导法[6]等。本研究选取在广东佛山市三水区人民医院进行择期上肢手术的120例肥胖患者[30 kg/m2<体重指数（BMI）≤35 kg/m2]作为研究对象，旨在比较在肥胖患者上肢手术中应用盲探法、神经刺激仪引导法、超声引导法以及超声联合神经刺激仪引导法进行肌间沟臂丛神经阻滞的效果，现报道如下。

1资料与方法

1.1一般资料

选取2017年1～12月在广东佛山市三水区人民医院进行择期上肢手术的120例肥胖患者作为研究对象。纳入标准：①30 kg/m20.05），具有可比性。本研究经医院医学伦理委员会审核批准，参与研究者均签署知情同意書。

1.2方法

所有患者均采用相同浓度（0.375%）及相同剂量（30 ml）的罗哌卡因（AstraZeneca AB，国药准字H20100103，20 mg/10 ml）进行臂丛神经阻滞麻醉。A组患者采用传统的解剖定位寻找异感法（盲探法），B组患者采用神经刺激仪引导法，C组患者采用超声可视下阻滞法，D组患者采用超声联合神经刺激仪行臂丛阻滞。患者入室后常规多参数心电监护，开放上肢静脉。由经验丰富及熟悉掌握超声引导定位和神经刺激仪的主治以上麻醉医师行臂丛神经阻滞，各组穿刺成功后，缓慢注入0.375%罗哌卡因30 ml。

1.3观察指标及评价标准

①记录各组患者完成阻滞所需时间（开始臂丛神经阻滞操作至局麻药注射完毕的时间）。②注药完成后使用视觉模拟（VAS）评分法测定桡神经、尺神经、正中神经、肌皮神经及腋神经支配区域的感觉效果，用于判定感觉神经阻滞起效时间，具体操作如下。在纸上面划一条10 cm的横线，横线的一端为0，表示无痛;另一端为10，表示剧痛;中间部分表示不同程度的疼痛。让患者根据自我感觉在横线上划一记号，表示疼痛的程度，并进行计分，以计分<3分时判定为阻滞起效时间。臂丛各神经代表感觉区域：挠神经代表的感觉区域为第1、2掌骨间隙背面的“虎口区”皮肤;尺神经代表的感觉区域为手掌、手背内侧缘;正中神经带包的感觉区域我拇指、食指、中指远节;肌皮神经代表的感觉区域为前臂外侧皮肤;腋神经-三角肌区皮肤。③按以下标准记录患者的神经阻滞效果，具体如下。Ⅰ级：阻滞范围完善，患者无痛、安静，肌松满意，为手术提供良好条件;Ⅱ级：阻滞范围欠完善，肌松效果欠满意，患者有疼痛表情;Ⅲ级：阻滞范围不完善，疼痛较明显，肌松效果较差，患者出现呻吟、躁动，辅助用药后，情况有所改善，但不够理想，勉强完成手术;Ⅳ级：麻醉失败，需改用其他麻醉方法后才能完成手术。④记录患者的并发症发生情况，包括局麻药中毒、误伤神经、误伤血管以及霍纳综合征。

1.4统计学方法

采用SPSS 19.0统计学软件进行数据分析，计量资料用均数±标准差（x±s）表示，两组间比较采用t检验;计数资料采用率表示，组间比较采用χ2检验;等级资料采用秩和检验，以P<0.05为差异有统计学意义。

2结果

2.1四组患者完成阻滞所需时间的比较

B、C、D组患者完成阻滞所需时间均显著短于A组，差异有统计学意义（P<0.05）;C、D组患者完成阻滞所需时间均显著短于B组，差异有统计学意义（P<0.05）;D组患者完成阻滞所需时间显著短于C组，差异有统计学意义（P<0.05）（表1）。

2.2四组患者感觉神经阻滞起效时间的比较

B、C、D组患者的感觉神经阻滞起效时间均显著短于A组，差异有统计学意义（P<0.05）;B、C、D组患者的感觉神经阻滞起效时间比较，差异无统计学意义（P>0.05）（表2）。