筋膜外与筋膜内注射行锁骨上臂丛神经阻滞对呼吸功能的影响：一项随机、对照、双盲试验。

Impact of an extrafascial versus intrafascial injection for supraclavicular brachial plexus block on respiratory function: a randomized, controlled, double-blind trial.

机构信息

Department of Anaesthesia, Valais Hospital, Sion, Switzerland.

University of Lausanne, Lausanne, Switzerland.

出版信息

Reg Anesth Pain Med. 2022 Oct;47(10):604-609. doi: 10.1136/rapm-2022-103634. Epub 2022 Jul 1.

DOI:10.1136/rapm-2022-103634

PMID:35777931

Abstract

INTRODUCTION

Hemidiaphragmatic paresis after ultrasound-guided supraclavicular brachial plexus block is reported to occur in up to 67% of patients. We tested the hypothesis that an injection outside the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with an intrafascial injection while providing similar analgesia.

METHODS

Fifty American Society of Anesthesiologists I-III patients scheduled for elective upper limb surgery received a supraclavicular brachial plexus block using 30 mL of 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%. The block procedures were randomized to position the needle tip either within the brachial plexus after piercing the sheath (intrafascial injection) or outside the brachial plexus sheath (extrafascial injection). The primary outcome was the incidence of hemidiaphragmatic paresis 30 min after the injection, measured by M-mode ultrasonography. Additional outcomes included time to surgery readiness, and resting and dynamic pain scores at 24 hours postoperatively (Numeric Rating Scale, 0-10).

RESULTS

The incidence of hemidiaphragmatic paresis 30 min after the injection was 9% (95% CI 1% to 29%) and 0% (95% CI 0% to 15%) in the intrafascial and extrafascial groups respectively (p=0.14). Extrafascial injection was associated with a longer time to surgery readiness (intrafascial: 18 min (95% CI: 16 to 21 min); extrafascial: 37 min (95% CI: 31 to 42 min); p<0.001). At 24 hours, resting and dynamic pain scores were similar between groups.

DISCUSSION

Ultrasound-guided supraclavicular brachial plexus block with an extrafascial injection does not reduce the incidence of hemidiaphragmatic paresis although it provides similar analgesia, when compared with an intrafascial injection. The longer time to surgery readiness is less compatible with contemporary operating theater efficiency requirements.

TRIAL REGISTRATION NUMBER

NCT03957772.

摘要

简介

据报道，在超声引导锁骨上臂丛阻滞后，多达 67%的患者会出现膈肌麻痹。我们假设与筋膜内注射相比，在臂丛神经鞘外注射会降低膈肌麻痹的发生率，同时提供类似的镇痛效果。

方法

50 名 ASA I-III 级择期上肢手术患者接受 30ml 1:1 混合甲哌卡因 1%和罗哌卡因 0.5%的锁骨上臂丛阻滞。将阻滞程序随机分为将针尖置于刺穿鞘后（筋膜内注射）或臂丛神经鞘外（筋膜外注射）。主要结局是注射后 30 分钟时膈肌麻痹的发生率，通过 M 型超声测量。其他结果包括手术准备时间和术后 24 小时的静息和动态疼痛评分（数字评分量表，0-10）。

结果

注射后 30 分钟时膈肌麻痹的发生率分别为 9%（95%CI，1%-29%）和 0%（95%CI，0%-15%），两组间差异无统计学意义（p=0.14）。筋膜外注射与手术准备时间较长相关（筋膜内：18 分钟（95%CI：16-21 分钟）；筋膜外：37 分钟（95%CI：31-42 分钟）；p<0.001）。在 24 小时时，两组的静息和动态疼痛评分相似。