超声引导下窝坐骨神经联合隐神经阻滞在老年人足踝部手术中的应用

摘要

目的：观察超声引导下窝坐骨神经联合隐神经阻滞麻醉在老年人足踝部手术的麻醉效果。方法择期行足踝部手术的老年患者60例，年龄60～90岁，ASAⅠ～Ⅱ，采用数字表法随机分为两组，每组30例。A 组采用超声引导下窝坐骨神经阻滞及隐神经阻滞，分别注入0．4％盐酸罗哌卡因20 mL 和5 mL；B 组采用硬膜外麻醉，选 L3～4间隙穿刺，注入0．5％盐酸罗哌卡因8～10 mL。观察并记录两组患者麻醉前（T0）和麻醉后10 min（T1）、15 min（T2）、30 min（T3）、60 min（T4）时的收缩压、舒张压、心率和脉搏血氧饱和度，观察两组感觉运动阻滞情况及不良反应发生情况。结果A、B 两组感觉起效时间分别为（13±3）min、（14±2）min，差异无统计学意义（t ＝－1．21，P ＞0．05）；运动阻滞起效时间分别为（15±6）min、（17±5）min，差异无统计学意义（t ＝0．23，P ＞0．05）；A、B 两组感觉阻滞维持时间分别为（546±67）min、（353±68）min，运动阻滞维持时间分别为（408±40）min、（380±49）min，A 组感觉阻滞及运动阻滞维持时间均长于 B 组（t ＝－11．90、－2．23，均 P ＜0．05）。术后6 h、12 h、18 h 的 VAS 评分 A 组明显低于 B 组，而术后24 h 的 VAS 评分两组差异无统计学意义（t6h ＝－6．36，t12h ＝－11．22，t18h ＝－1．74，均 P ＜0．05，t24h ＝0．46，P ＞0．05）。A 组血流动力学稳定，而 B 组 T1、T2、T3时间点的血压波动明显[T1：SBP（116±10）mmHg、DBP（61±8）mmHg；T2：SBP（117±11）mmHg、DBP（62±8）mmHg；T3：SBP（118±8）mmHg、DBP（68±8）mmHg；T4：SBP（124±11）mmHg、DBP（67±8）mmHg]，差异均有统计学意义（tT1＝－5．08，tT2＝－4．01，tT3＝－5．39，tT4＝－2．72；DBP：tT1＝－4．59，tT2＝－3．50，tT3＝－3．19，tT4＝－2．70，均 P ＜0．05）；T2时刻 B 组心率显著增快（tT3＝－4．17，P ＜0．05）；B 组有11例尿潴留，3例恶心、呕吐，3例心动过缓，而 A 组只有1例患者发生心动过缓。结论窝坐骨神经阻滞联合隐神经阻滞用于足踝部手术麻醉效果确切，血流动力学比较稳定，且不良反应少。%Objective To observe the anesthesia efficacy of popliteal fossa sciatic and saphenous nerve block guided with ultrasound for foot and ankle surgery.Methods Sixty ASA Ⅰ -Ⅱ scheduled for foot and ankle surgery were randomly divided into two groups(n =30).In group A,the popliteal fossa sciatic saphenous nerve block guided with ultrasound with 20 mL and 5 mL of 0.4% ropivacaine.In group B,epidural anesthesia was performed with 8 -10 mL of 0.5% ropivacaine injected at epidural interspaces L3 -4.Blood pressure,heart rate and pulse oxygen saturation were monitored before anesthesia(T0 )and 10(T1 ),15(T2 ),30(T3 ),60 min(T4 )after anesthesia and 60min after operation.The sensorimotor block of anesthesia and the incidence of adverse reactions were observed in the two groups.Results The onset time of sensory block were (13 ±3)min and (14 ±2)min in the two groups,the difference was not statistically significant(t =-1.21,P >0.05).The onset time of motor block were (15 ±6)min,(17 ±5)min, the difference was not statistically significant(t =0.23,P >0.05).The sensory block duration time were (546 ±67)min and (353 ±68)min,the motor block duration time were (408 ±40)min and (380 ±49)min,the differences were statistically significant(t =-11.90,-2.23,all P <0.05).The VAS scores of group A were significantly lower than group B after operation(t6h =-6.36,t12h =-11.22,t18h =-1.74,all P <0.05).The hemodynamic of group A was more stable than group B.The value of SBP and DBP in the two groups at time points of T1 ,T2 ,T3 ,T4 were[T1 :SBP (116 ±10)mmHg,DBP(61 ±8)mmHg;T2:SBP(117 ±11)mmHg,DBP(62 ±8)mmHg;T3:SBP(118 ±8)mmHg, DBP(68 ±8)mmHg;T4:SBP(124 ±11)mmHg,DBP(67 ±8)mmHg],the differences were statistically significant (tT1 =-5.08,tT2 =-4.01,tT3 =-5.39,tT4 =-2.72;DBP:tT1 =-4.59,tT2 =-3.50,tT3 =-3.19,tT4 =-2.70,all P <0.05 ).11 cases occurred urinary retention,3 cases occurred nausea and vomiting in group B.Conclusion The popliteal fossa sciatic and saphenous nerve block is a safe and effective technique with more stable hemodynamic status and less adverse events undergoing foot and ankle surgery.