锁骨上臂丛神经阻滞中“角落口袋”技术减少膈神经麻痹：单中心、观察者盲法、随机对照试验。
Reduced Hemidiaphragmatic Paresis With a "Corner Pocket" Technique for Supraclavicular Brachial Plexus Block: Single-Center, Observer-Blinded, Randomized Controlled Trial.
机构信息
Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
出版信息
Reg Anesth Pain Med. 2018 Oct;43(7):720-724. doi: 10.1097/AAP.0000000000000795.
BACKGROUND AND OBJECTIVE
Hemidiaphragmatic paresis is common after supraclavicular brachial plexus block (SCBPB). In this randomized trial, we compared the incidence of hemidiaphragmatic paresis in patients who had local anesthetic injected primarily in the corner pocket (defined as the intersection of the first rib and subclavian artery) during SCBPB with that of patients who underwent injection primarily inside the neural cluster.
METHODS
Thirty-six patients scheduled for right elbow, forearm, wrist, or hand surgery under SCBPB (using 12.5 mL of 0.75% ropivacaine and 12.5 mL of 2% lidocaine with 1:200,000 epinephrine) were randomly assigned to 1 of 2 groups. In group CP, local anesthetic was injected primarily in the corner pocket (20 mL) and secondarily inside the neural cluster (5 mL). In group NC, local anesthetic was deposited primarily inside the neural cluster (20 mL) and secondarily in the corner pocket (5 mL). The primary outcome was the incidence of hemidiaphragmatic paresis, as measured by M-mode ultrasonography 30 minutes after SCBPB.
RESULTS
The incidence of hemidiaphragmatic paresis was significantly lower in group CP than in group NC (27.8% vs 66.7%, P = 0.019). The median decreases in forced expiratory volume at 1 second (7.5% [interquartile range, 3.3%-17.1%] vs 24.4% [interquartile range, 10.2%-31.2%]; P = 0.010) and forced vital capacity (6.4% [interquartile range, 3.3%-11.1%] vs 19.3% [interquartile range, 13.7%-33.2%]; P = 0.001) were also lower in group CP than in group NC.
CONCLUSIONS
The incidence of hemidiaphragmatic paresis was effectively reduced when local anesthetic was injected primarily in the corner pocket during right-sided SCBPB. However, the 28% incidence of hemidiaphragmatic paresis associated with the corner pocket technique may still represent a prohibitive risk for patients with preexisting pulmonary compromise.
CLINICAL TRIAL REGISTRATION
This study was registered at Clinical Trial Registry of Korea, identifier KCT0001769.
背景与目的
锁骨上臂丛阻滞（SCBPB）后膈神经麻痹很常见。在这项随机试验中，我们比较了将局部麻醉剂主要注入角袋（定义为第一肋和锁骨下动脉的交点）时行 SCBPB 的患者与主要在神经丛内注射时的患者膈神经麻痹的发生率。
方法
36 例行 SCBPB（使用 12.5 mL 0.75%罗哌卡因和 12.5 mL 2%利多卡因加 1:200,000 肾上腺素）的右肘、前臂、手腕或手部手术患者被随机分为 2 组。在 CP 组中，局部麻醉剂主要注入角袋（20 mL），其次是神经丛内（5 mL）。在 NC 组中，局部麻醉剂主要注入神经丛内（20 mL），其次是角袋（5 mL）。主要结局是 30 分钟后行 SCBPB 时通过 M 模式超声测量膈神经麻痹的发生率。
结果
CP 组膈神经麻痹的发生率明显低于 NC 组（27.8%比 66.7%，P = 0.019）。第 1 秒用力呼气量（FEV1）的中位数下降（7.5%[四分位距，3.3%-17.1%]比 24.4%[四分位距，10.2%-31.2%]；P = 0.010）和用力肺活量（FVC）（6.4%[四分位距，3.3%-11.1%]比 19.3%[四分位距，13.7%-33.2%]；P = 0.001）也低于 NC 组。
结论
在右侧 SCBPB 时将局部麻醉剂主要注入角袋可有效降低膈神经麻痹的发生率。然而，角袋技术相关的 28%膈神经麻痹发生率对于存在肺部合并症的患者可能仍然是一个不可接受的风险。
临床试验注册
本研究在韩国临床试验注册中心注册，标识符为 KCT0001769。
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