Xu Yang, Xie Fang, Wang Yan, Chen Jie, Liu Shenghe, Xu Tao
Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200233, China.
Department of Ultrasound Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200233, China.
J Clin Med. 2025 Sep 18;14(18):6591. doi: 10.3390/jcm14186591.
Pain-induced vasoconstriction and thrombosis cause vascular insufficiency, a major etiology of early necrosis in replanted digits. While systemic intravenous analgesia (SIVA) carries significant side effects, continuous brachial plexus block (CBPB) provides analgesia with vasodilation. Amidst uncertainties regarding distal vascular recanalization and sympathetic denervation, whether CBPB's hemodynamic effects translate into improved perfusion and outcomes in replanted digits remains unknown. This randomized controlled trial compared the effects of CBPB versus SIVA on digit perfusion, vascular insufficiency, and survival rates post-replantation. After screening 113 patients, 55 patients (71 digits) were ultimately randomized and analyzed: the CBPB group ( = 27, 36 digits) received 0.2% ropivacaine infusion at 5 mL/h; the SIVA group ( = 28, 35 digits) received intravenous parecoxib 20 mg twice daily with supplemental tramadol for visual analog scale (VAS) scores > 3. The primary outcome was digital skin temperature trajectory measured at 0, 12, 24, 36, and 48 h postoperatively. Secondary outcomes included Doppler-quantified combined volumetric flow rate of the radial and ulnar arteries (RA-UA VFR) at identical timepoints, VAS scores, vascular insufficiency incidence, and 7-day digit survival. CBPB significantly enhanced perfusion in replanted digits at all postoperative timepoints, with digital skin temperature peaking at 48 h (32 ± 1.6 °C vs. 31 ± 1.1 °C; < 0.001) and RA-UA VFR peaking at 24 h (4.0 ± 0.83 vs. 1.8 ± 0.51 mL/s; < 0.001) versus SIVA. Concurrently, CBPB provided superior analgesia (VAS 0.52 ± 0.51 vs. 1.9 ± 1.0; < 0.001) and significantly reduced 48-h vascular insufficiency incidence (8.3% vs. 29%; = 0.028). No significant difference was observed in seven-day survival rates between groups (97% vs. 91%; = 0.329). CBPB significantly enhanced perfusion in replanted digits and reduced the incidence of vascular insufficiency, despite not conferring additional survival benefits.
疼痛引起的血管收缩和血栓形成会导致血管功能不全，这是再植手指早期坏死的主要病因。虽然全身静脉镇痛（SIVA）有显著的副作用，但连续臂丛神经阻滞（CBPB）可在镇痛的同时实现血管舒张。在远端血管再通和交感神经去神经支配存在不确定性的情况下，CBPB的血流动力学效应是否能转化为再植手指灌注改善和更好的预后仍不清楚。这项随机对照试验比较了CBPB与SIVA对再植手指灌注、血管功能不全和再植后存活率的影响。在筛查了113例患者后，最终对55例患者（71根手指）进行了随机分组和分析：CBPB组（n = 27，36根手指）以5 mL/h的速度输注0.2%的罗哌卡因；SIVA组（n = 28，35根手指）每天两次静脉注射20 mg帕瑞昔布，视觉模拟量表（VAS）评分>3时补充曲马多。主要结局是术后0、12、24、36和48小时测量的手指皮肤温度变化轨迹。次要结局包括相同时间点通过多普勒量化的桡动脉和尺动脉联合容积流速（RA-UA VFR）、VAS评分、血管功能不全发生率和7天手指存活率。与SIVA相比，CBPB在所有术后时间点均显著增强了再植手指的灌注，手指皮肤温度在48小时达到峰值（32±1.6℃对31±1.1℃；P<0.001），RA-UA VFR在24小时达到峰值（4.0±0.83对1.8±0.51 mL/s；P<0.001）。同时，CBPB提供了更好的镇痛效果（VAS 0.52±0.51对1.9±1.0；P<0.001），并显著降低了48小时时血管功能不全的发生率（8.3%对29%；P = 0.028）。两组之间7天存活率无显著差异（97%对91%；P = 0.329）。尽管未带来额外的存活益处，但CBPB显著增强了再植手指的灌注并降低了血管功能不全的发生率。
