目的 比较髂筋膜阻滞联合外侧入路坐骨神经阻滞与静脉自控镇痛对下肢骨折手术术后的镇痛效果.方法 以 2021 年 3 月-2022 年 10 月中国人民解放军联勤保障部队第九〇四医院麻醉科收治的 80 例择期全麻下行膝关节及以下骨折切开复位内固定手术的患者为研究对象,采用随机数字法分为腹股沟韧带上髂筋膜间隙阻滞联合外侧入路坐骨神经阻滞组(N 组,40 例)和静脉自控镇痛组(P组,40 例).分析比较两组术后 2、6、12、24、48、72 h静息和活动时VAS疼痛评分、曲马多镇痛补救情况、患者术后镇痛满意度评分、术后 24、48、72 h 的 QoR-15 评分、术后首次下床活动时间、不良反应发生情况.结果 与 P 组相比,N 组术后 12 h 内静息时 VAS 疼痛评分及术后 24 h内活动时VAS疼痛评分较低,使用曲马多镇痛补救例数减少,患者镇痛满意度评分及48 h内 QoR-15 评分升高,首次下床活动时间缩短,恶心呕吐和不良反应总例数减少,差异有统计学意义(P＜0.05).结论 腹股沟韧带上髂筋膜间隙阻滞联合外侧入路坐骨神经阻滞用于下肢骨折切开复位内固定术后镇痛效果好,并发症少,可促进患者早日下床活动,患者镇痛满意度及QoR-15 评分高.

目的 观察艾司氯胺酮复合丙泊酚在老年患者非插管全麻下行股骨近端防旋髓内钉(PFNA)内固定术中的应用效果.方法 选择2020年11月至2021年12月择期行PFNA内固定术老年患者57例,男33例,女24例,年龄≥65岁,BMI 18～25 kg/m2,ASAⅡ或Ⅲ级.将患者随机分为两组:插管全麻组(T组,n=28)和非插管全麻组(NT组,n=29).麻醉诱导前20 min行超声引导下患侧髂筋膜间隙阻滞(FICB),注射0.375％罗哌卡因30 ml.T组采用气管插管全麻;NT组切皮前静注艾司氯胺酮0.5 mg/kg,术中静脉泵注艾司氯胺酮0.25 mg·kg-1·h-1和丙泊酚1.5 mg·kg-1·h-1进行麻醉维持,术中保留自主呼吸.记录术中低血压、托下颌和体动例数、术后苏醒时间、PACU停留时间、术后24 h内镇痛泵有效按压次数和总按压次数.记录术后6、12、24 h静息时VAS疼痛评分.记录术前1 d和术后1 d C-反应蛋白(CRP)浓度、中性粒细胞与淋巴细胞比率(NLR).记录术后恶心呕吐、头晕、谵妄和肺部感染等并发症的发生情况.结果 与术前1 d比较,术后1 d两组CRP浓度和NLR明显升高(P<0.05).与T组比较,NT组术中低血压发生率、术后肺部感染和并发症总发生率明显降低,术后苏醒时间、PACU停留时间明显缩短,术后24 h内镇痛泵有效按压次数和总按压次数明显减少,术后12、24 h静息时VAS疼痛评分明显降低,术后1 d CRP浓度和NLR明显降低(P<0.05).两组托下颌和体动发生率、术后6 h静息时VAS疼痛评分、术前1 d CRP浓度和NLR差异均无统计学意义.结论 在老年患者PFNA内固定术中,与气管插管全麻比较,艾司氯胺酮复合丙泊酚非插管全麻可缩短术后苏醒时间,减轻术后疼痛,减少术后并发症的发生.

Objective:To investigate the effect of intravenous administration of esketamine on postoperative pain and inflammatory factors of patients with frailty undergoing total hip arthroplasty (THA).Methods:A total of 70 patients with frailty who underwent THA under general anesthesia were selected. According to the random number table method, they were divided into two groups ( n=35): an esketamine group (group K) and a control group (group C). Group K received intravenous infusion of esketamine (15 μg·kg -1·min -1) 10 min before anesthesia induction until 10 min before surgery, while group C was intravenously pumped with the same volume of normal saline, with other treatment that were the same as those in group K. Both groups were compared for their operation time, anesthesia time, intraoperative blood loss, the consumption of propofol and remifentanil during surgery, recovery time, extubation time, and the time to straight answer. Their resting Visual Analog Scale (VAS) scores 2, 6, 12 h and 24 h after surgery were recorded. Their venous blood samples were collected to measure the levels of C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) before surgery and 1 h after surgery. The time of first off-bed activity, Harris hip joint function scores on day 7 after surgery, the consumption of sufentanil within 48 h after surgery, the length of hospitalization stay, and post-operative complications were also recorded. Results:Compared with group C, the consumption of propofol and remifentanil in group K remarkably decreased ( P<0.05). There was no statistical difference in operation time, anesthesia time, intraoperative blood loss, recovery time, extubation time and the time to straight answer between the two groups ( P>0.05). The resting VAS scores in group K 2, 6 h and 12 h after surgery were lower than those in group C ( P<0.05), while no statistical difference was found in resting VAS scores 24 h after surgery ( P>0.05). The levels of CRP, TNF-α and IL-6 in the two groups 1 h after surgery were significantly higher than those before surgery ( P<0.05). Compared with group C, group K presented remarkable decreases in the levels of CRP, TNF-α, and IL-6 1 h after surgery ( P<0.05). Compared with group C, group K presented remarkable decreases in the time of first off-bed activity after surgery and the length of hospitalization stay ( P<0.05), increases in Harris hip joint function scores on day 7 after surgery and decreases in the consumption of sufentanil within 48 h after surgery ( P<0.05). The incidence of post-operative complications were lower in group K than those in group C ( P<0.05). Conclusions:Intravenous administration of esketamine can exert a better postoperative analgesic effect, reduce inflammatory factors and promote early postoperative recovery in patients with frailty after total hip replacement arthroplasty.

目的 观察氢吗啡酮复合右美托咪定硬膜外注射对老年全髋关节置换术术后镇痛的效果.方法 将78例全髋关节置换术患者随机分为研究组和对照组,每组39例.对照组术毕硬膜外注射氢吗啡酮0.3 mg,研究组依次注射右美托咪定0.5μg/kg及氢吗啡酮0.3 mg.2组术后均采用舒芬太尼静脉自控镇痛.比较2组术后1 h(T1)、4 h(T2)、12 h(T3)、24h(T4)视觉模拟评分法(VAS)评分、Ramsay镇静评分、心率(HR)、平均动脉压(MAP)及血氧饱和度(SpO2),记录舒芬太尼消耗量及不良反应的发生情况.结果 研究组静息和运动状态下T3、T4时点的VAS评分及Ramsay评分均低于对照组,差异有统计学意义(P＜0.05);研究组T4时点Ramsay评分低于T1,差异有统计学意义(P＜0.05).研究组T2～T4时点HR及T1～T3时点MAP低于对照组,差异有统计学意义(P＜0.05);研究组T2～T4时点HR低于T1时点,对照组T2 ～ T4时点MAP低于T1时点,差异有统计学意义(P＜0.05).研究组舒芬太尼消耗量少于对照组,差异有统计学意义(P＜0.05).2组不良反应比较,差异无统计学意义(P＞0.05).结论 氢吗啡酮复合右美托咪定硬膜外注射对老年全髋关节置换术后镇痛效果显著,可稳定血流动力学指标,利于术后恢复.