布比卡因脂质体前臂远端周围神经阻滞对手外伤患者神经阻滞后反跳痛及术后康复的影响

Effect of distal forearm peripheral nerve block with liposomal bupivacaine on rebound pain after peripheral nerve block and postoperative rehabilitation in patients with hand trauma

摘要

目的: 探讨布比卡因脂质体前臂远端周围神经阻滞(DPNB)对手外伤患者神经阻滞后反跳痛(RP)及术后康复的影响。方法: 选择行手术的手外伤患者,年龄18~65岁, 身体质量指数(BMI) 18～30 kg·m^-2,ASA Ⅰ或Ⅱ级,手术区域涉及桡神经、正中神经和/或尺神经支配范围。采用随机数字表法将患者分为两组:布比卡因脂质体组(L组)和对照组(C组),每组40例。两组均先用0.375%罗哌卡因和0.5%利多卡因混合液20 mL行肌间沟臂丛神经阻滞(ISBPB)。L组在超声引导下根据手术区域涉及的神经支配选择前臂尺神经、桡神经或正中神经,每条神经周围分别注射0.665%布比卡因脂质体3 mL。C组不做任何处理。手术结束后两组患者均配备患者静脉自控镇痛(PCIA)泵。记录术后24 h内两组RP的发生情况;记录术前及术后6、12、24、48、72 h静息及运动NRS评分;记录出手术室时的静息NRS评分、改良反跳痛评分(MRPS)、术后72 h内累计阿片类药物用量;记录感觉及运动阻滞持续时间;记录术前及术后6、12、24、48、72 h肌力等级和改良Bromage评分;记录术前及术后24、48、72 h时的15项恢复质量(QoR-15)评分;记录术后有无胸闷、头晕、恶心、呕吐等不良反应。结果: 与C组相比,术后24 h内L组RP的发生率降低(P＜0.05);与C组相比,L组术后6、12 h的静息NRS评分均降低(P＜0.05);与C组相比,L组术后6、12 h的运动NRS评分降低(P＜0.05);与C组相比,L组的MRPS和术后72 h内累计阿片类药物用量均降低(P＜0.05);与C组相比,L组感觉阻滞时间显著延长(P＜0.05),而两组运动阻滞时间、术后6、12、24、48、72 h改良Bromage评分和肌力等级差异均无统计学意义(P＞0.05);与C组相比,L组术后24、48、72 h时的15项恢复质量(QoR-15)评分均增高(P＜0.05);两组术后不良反应发生情况差异无统计学意义(P＞0.05)。结论: 布比卡因脂质体前臂DPNB可有效降低手外伤患者RP发生率,提供术后12 h镇痛,促进术后康复。

Abstract

Objective: To investigate the impact of distal forearm peripheral nerve block (DPNB) with liposomal bupivacaine on rebound pain (RP) after peripheral nerve block and postoperative rehabilitation in patients with hand trauma. Methods: Patients with hand trauma, aged 18~65 years, body mass index (BMI) 18~30 kg·m^-2, and American Society of Anesthesiologists (ASA) physical status Ⅰ or Ⅱ, whose surgical area involved the innervation of the radial nerve, median nerve, and/or ulnar nerve, were selected. They were randomly divided into a liposomal bupivacaine group (group L) and a control group (group C) using a random number table, with 40 patients in each group. Both groups initially received an interscalene brachial plexus block (ISBPB) with 20 mL of a mixture of 0.375% ropivacaine and 0.5% lidocaine. In group L, the ulnar nerve, radial nerve or median nerve in the forearm were selected under ultrasound guidance according to the innervation of the surgical area, and 3 mL of 0.665% liposomal bupivacaine was injected perineurally around each selected nerve. Group C received no intervention. After surgery, all patients in both groups were equipped with patient-controlled intravenous analgesia (PCIA) pumps. The incidence of RP within 24 h postoperatively was recorded. Numerical rating scale (NRS) scores at rest and during movement were recorded before surgery, immediately upon leaving the operating room, and at 6, 12, 24, 48 and 72 h postoperatively. The resting NRS score upon leaving the operating room, the modified rebound pain score (MRPS), and the cumulative opioid consumption within 72 h postoperatively were recorded. The durations of sensory and motor blockade were recorded. Muscle strength grades and modified Bromage scores were recorded before surgery and at 6, 12, 24, 48 and 72 h postoperatively. The 15-item Quality of Recovery (QoR-15) scores were recorded before surgery and at 24, 48 and 72 h postoperatively. Adverse reactions such as chest tightness, dizziness, nausea and vomiting were recorded after surgery. Results: Compared with group C, the incidence of RP within 24 h postoperatively was lower in group L (P<0.05). Compared with group C, the resting NRS scores at 6 and 12 h postoperatively were also lower (P<0.05), and the NRS scores during movement at 6 and 12 h postoperatively were also lower (P<0.05). Compared with group C, the MRPS and the cumulative opioid consumption within 72 h postoperatively were lower in group L (P<0.05). Compared with group C, the duration of sensory block was significantly prolonged in group L (P<0.05), while the duration of motor block, and the modified Bromage scores and muscle strength grades at 6, 12, 24, 48 and 72 h postoperatively were not significantly different (all P>0.05). Compared with group C, the QoR-15 scores at 24, 48 and 72 h postoperatively were higher in group L (P<0.05). There were no statistically significant differences in the incidence of postoperative adverse reactions between the two groups (P>0.05). Conclusion: Distal forearm peripheral nerve block with liposomal bupivacaine effectively reduces the incidence of RP in hand trauma patients, provides analgesia for up to 12 h postoperatively, and promotes postoperative rehabilitation.

关键词

布比卡因脂质体 / 远端周围神经阻滞 / 反跳痛 / 手外伤 / 术后康复

Key words

liposomal bupivacaine / distal peripheral nerve block / rebound pain / hand trauma / postoperative rehabilitation

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