Wang Xiaofeng, Zhang Hui, Chen Yongzhu, Zhang Qingfu, Xie Zhenwei, Liao Junling, Jiang Wei, Zhang Junfeng
Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
Front Surg. 2022 Mar 14;9:755298. doi: 10.3389/fsurg.2022.755298. eCollection 2022.
This study was designed to investigate whether it is useful and necessary to add a T2 level thoracic paravertebral block (TPVB) based on brachial-cervical plexus block to avoid incomplete anesthesia in elderly patients undergoing deltopectoral approach proximal humeral fracture (PHF) surgery.
This study involved 80 patients scheduled for PHF surgery who were randomized to receive either IC block (combined interscalene brachial plexus with superficial cervical plexus block) or ICTP block (T2 TPVB supplemented with IC block). The primary outcome was the success rate of regional anesthesia. The patient who experienced incomplete block was administered with intravenous remifentanil for rescue, or conversion to general anesthesia (GA) if remifentanil was still ineffective. Secondary outcomes included requirements of rescue anesthesia, sensory block of the surgical region, the incidence of adverse reactions, and block procedure-related complications.
The success rate of regional anesthesia in the ICTP group was higher compared with the IC group (77.5 vs. 52.5%, = 0.019). Intravenous remifentanil was required in 32.5% of patients in the IC group and 17.5% in the ICTP group, respectively. Conversion to GA was performed in 15% of patients in the IC group and 5% in the ICTP group. Sensory block at the medial proximal upper arm was achieved in 85% of patients in the ICTP group, whereas 10% in the IC group ( < 0.001). There was no difference between the groups with respect to the incidence of intraoperative adverse reactions. No block-related complications occurred in either group.
Adding a T2 TPVB is helpful to decrease, but not absolutely avoid the occurrence of incomplete regional anesthesia during PHF surgery in elderly patients. However, considering the potential risks, it is not an ideal option while a minor dose of remifentanil can provide a satisfactory rescue effect.
ClinicalTrials.gov, identifier: NCT03919422.
本研究旨在探讨在老年患者行胸大肌三角肌入路肱骨近端骨折（PHF）手术时，在臂丛 - 颈丛阻滞基础上加用T2水平胸椎旁神经阻滞（TPVB）以避免麻醉不全是否有用且必要。
本研究纳入80例计划行PHF手术的患者，随机分为接受肌间沟阻滞（肌间沟臂丛联合颈浅丛阻滞）组或肌间沟 - T2胸椎旁神经阻滞（ICTP）组（T2 TPVB联合肌间沟阻滞）。主要结局是区域麻醉成功率。麻醉阻滞不全的患者静脉注射瑞芬太尼进行补救，若瑞芬太尼仍无效则改为全身麻醉（GA）。次要结局包括补救麻醉的需求、手术区域的感觉阻滞、不良反应发生率以及与阻滞操作相关的并发症。
ICTP组区域麻醉成功率高于IC组（77.5%对52.5%，P = 0.019）。IC组分别有32.5%的患者和ICTP组17.5%的患者需要静脉注射瑞芬太尼。IC组15%的患者和ICTP组5%的患者改为GA。ICTP组85%的患者在上臂近端内侧实现了感觉阻滞，而IC组为10%（P < 0.001）。两组术中不良反应发生率无差异。两组均未发生与阻滞相关的并发症。
加用T2 TPVB有助于降低但不能绝对避免老年患者PHF手术期间区域麻醉不全的发生。然而，考虑到潜在风险，这不是一个理想的选择，而小剂量瑞芬太尼可提供满意的补救效果。
ClinicalTrials.gov，标识符：NCT03919422。
