入院后即刻连续腰丛神经阻滞...置换病人加速康复外科的影响_尚磊晶.pdf

安 徽 医 药 Anhui Medical and Pharmaceutical Journal 2023 Aug，27（8）入院后即刻连续腰丛神经阻滞镇痛对老年髋关节置换病人加速康复外科的影响尚磊晶1，张蜜1，范冬冬1，李苗1，李元海2作者单位：1安徽理工大学附属淮南新华医院麻醉科，安徽 淮南232052；2安徽医科大学第一附属医院麻醉科，安徽 合肥230022通信作者：李元海，男，主任医师，硕士生导师，研究方向为麻醉与疼痛，Email：基金项目：安徽理工大学校级重点项目（fsyyzd2020-05）摘要：目的 研究老年股骨颈骨折病人入院后即刻行连续腰丛阻滞预防性镇痛对住院时间、疼痛的改善程度及住院期间全身情况的影响。方法 选取2021年1月至 2022年7月安徽理工大学附属淮南新华医院骨科收治老年股骨颈骨折病人54例，按入院后即刻镇痛处理情况分为两组：连续腰丛阻滞镇痛组（N组）及常规镇痛药处理组（C组），各27例。主要观察指标为病人住院时间；次要观察指标包括术前术后视觉模拟评分（VAS）；入院后睡眠质量；血清炎性指标；术后不良反应发生率；术后髋关节外展活动度和屈曲度；术后切口引流量；首次下床活动时间。结果 N组住院时间 （6.780.80）d比（8.961.79）d、术后首次下床活动时间 （41.676.83）h比（56.8510.00）h 均短于C组（P0.05）；N组病人入院即刻阻滞后30 min静息VAS评分较阻滞前明显下降（P0.05）；N组术后的静息及运动VAS评分明显低于C 组（P0.05），差异有统计学意义；N组病人入院后术前睡眠质量优于C组 （3.590.97）分比（6.591.01）分，P0.05；N组病人术前术后血清炎性因子水平、术后切口引流量 （31.6710.00）mL比（70.0021.79）mL 及术后不良反应发生例数（5比15）明显低于C组（P0.05）。结论 入院后即刻行连续腰丛神经阻滞预防性镇痛，能有效缩短老年股骨颈骨折病人住院时间，降低疼痛程度，降低并发症发生率，促进病人早期快速康复。关键词：股骨颈骨折；麻醉和镇痛；腰骶丛；入院即刻；老年人；髋关节置换；加速康复外科Effect of continuous lumbar plexus block analgesia immediately after admission on ERAS in elderly patients undergoing hip arthroplastySHANG Leijing1,ZHANG Mi1,FAN Dongdong1,LI Miao1,LI Yuanhai2Author Affiliations:1Department of Anesthesiology,Huainan Xinhua Hospital Affiliated to Anhui University of Science and Technology,Huainan,Anhui 232052,China;2Department of Anesthesiology,The First Affiliated Hospital of Anhui Medical University,Hefei,Anhui 230022,ChinaAbstract：Objective To study the effect of continuous lumbar plexus block prophylactic analgesia on the length of hospital stay,the improvement of pain and the general condition of elderly patients with femoral neck fracture immediately after admission.Methods From January 2021 to July 2022,54 elderly patients with femoral neck fracture treated in the Department of Orthopaedics of Huainan Xinhua Hospital Affiliated to Anhui University of Technology were randomly divided into two groups according to the immediate analgesic treatment after admission:continuous lumbar plexus block analgesia group(N group,n=27)and conventional analgesics treatment group(C group,n=27).The main outcome measures were the length of stay;Secondary outcome measures included preoperative and postoperative pain score(VAS);Sleep quality after admission;Serum inflammatory index;The incidence of postoperative adverse reactions;Abduction range of motion and flexion of hip joint after operation;Postoperative incision drainage;First time out of bed activity time.Results The hospitalization time(6.780.80)d vs.(8.961.79)d and the first postoperative ambulation time(41.676.83)h vs.(56.8510.00)h in group N were shorter than those in group C(P0.05);In group N,the resting VAS score at 30 min after immediate block was significantly lower than that before block(P0.05);The VAS scores of rest and exercise in group N were significantly lower than those in group C(P0.05);The preoperative sleep quality of patients in group N was better than that of patients in group C(3.590.97)vs.(6.591.01),P0.05;The levels of serum inflammatory factors,postoperative incision drainage volume(31.6710.00)mL vs.(70.0021.79)mL and the incidence of postoperative adverse reactions(5 vs.15)in group N were significantly lower than those in group C(P0.05).Conclusion Prophylactic analgesia with continuous lumbar plexus nerve block immediately after admission can effectively shorten the length of hospital stay,reduce the degree of pain,reduce the incidence of complications,and promote early and rapid recovery of elderly patients with femoral neck fracture.Key words：Femoral neck fractures;Anesthesia and analgesia;Lumbosacral plexus;Immediately after admission;Elderly patients;Hip replacement;Enhanced recovery after surgery临床医学引用本文：尚磊晶，张蜜，范冬冬，等.入院后即刻连续腰丛神经阻滞镇痛对老年髋关节置换病人加速康复外科的影响 J.安徽医药，2023，27（8）：1646-1650.DOI：10.3969/j.issn.1009-6469.2023.08.034.1646网络首发时间：2023-07-06 14:58:24网络首发地址：https:/ 徽 医 药 Anhui Medical and Pharmaceutical Journal 2023 Aug，27（8）加速康复外科（enhanced recovery after surgery，ERAS）以服务病人为中心的诊疗理念为核心，减少围手术期应激反应及术后并发症，缩短住院时间，促进病人康复。围术期疼痛管理是ERAS的重要环节之一。髋部骨折是老年人常见的严重损伤，患者会经历中到重度疼痛，机体产生应激反应，对凝血、免疫、内分泌系统产生一系列影响。髋部骨折术后常采用多模式镇痛技术，可有效降低患者术后疼痛程度、提高患者术后康复运动配合度、改善预后，但对患者办理入院至手术前，疼痛处理往往缺乏重视。骨折初期急性疼痛如不及时有效的得到控制，将对患者整体病情造成不良影响，不利于患者的快速康复及总体预后1。目前老年髋关节骨折病人在住院后和手术日之间常规使用口服、肌内注射及静脉注射药物进行镇痛，但会产生头晕、恶心、呕吐、镇静等副作用。有研究显示连续腰丛阻滞用于老年全髋关节置换术后镇痛效果良好，并可减少术后镇痛导致的并发症2，是一种对全身呼吸和循环影响极小的镇痛方式。但这种方法用于术前镇痛的效果少有报道。本文研究了老年股骨颈骨折病人入院后即行连续腰丛阻滞镇痛对病人住院时间、疼痛程度、睡眠质量、康复指标、炎症反应等指标的影响，为这类病人快速康复提供新的思路和方法。1资料与方法1.1一般资料选择2021年1月至2022年7月安徽理工大学附属淮南新华医院骨科就诊的54例老年股骨颈骨折病人。所有病人入院后使用简易智能精神状态检查量表（mini-mental state examination，MMSE）评估病人基础认知功能状态（文盲17分，小学20分，初中23分，高中及以上 26分3）。纳入标准：年龄65 岁；预计于 48 h 内行手术治疗者；急诊评估视觉模拟评分（visual analogue scale，VAS）4。排除标准：任何原因（严重的视、听觉或语言交流障碍）不能配合实验或对实验方法不理解或拒绝试验的病人；对任何一种药物成分过敏者；术前24 h内应用过疼痛治疗药物者；存在神经阻滞或NSAIDs类、阿片类药物禁忌证者；合并中枢神经系统或精神类疾病；严重肝肾功能异常或其他系统性病变；严重脊柱畸形；长期酗酒或有精神药物依赖史；有严重脏器功能障碍者。剔除标准：术中发生大量出血超过800 mL需要输血，手术时间超过2，发生严重药物过敏事件以及其他未预计的严重不良事件，任何原因导致不愿合作退出。本研究通过安徽理工大学附属淮南新华医院伦理委员会批准（批号EC-20190724-1061），病人或其近亲属对研究方案签署知情同意书。1.2研究方法与麻醉管理病人到达骨科病房后，麻醉医生进行老年疾病及 ASA