血管旁入路闭孔神经阻滞在膀胱镜下肿瘤电切术中的临床应用*

Clinical application of the obturator nerve block beside vessel in transurethral resection of bladder tumor*

摘要:

目的  比较腹股沟血管旁入路闭孔神经阻滞和经典入路闭孔神经阻滞，预防闭孔神经反射的操作可行性及效果。方法  选择经尿道膀胱肿瘤电切术（TURBT）的患者40个样本，美国麻醉医师协会分级（ASA）Ⅰ～Ⅱ级，年龄35～91岁，采用随机数字表法，将其分为血管旁入路组（V组，n =20）和经典入路组（T组，n =20）。闭孔神经阻滞前后分别测定阻滞侧大腿内收肌力量。记录每侧闭孔神经阻滞穿刺尝试次数、穿刺时间、穿刺过程中最高视觉模拟疼痛评分（VAS）、穿刺后大腿内收肌群肌力以及术中、术后并发症情况。结果  V组1次穿刺成功率明显大于T组（P <0.01）；V组闭孔神经阻滞操作时间明显少于T组（P <0.01）；T组出现2例穿刺过程误入血管，调整后注药，V组未见误穿血管病例，差异有统计学意义（P <0.01）；两组闭孔神经阻滞前后大腿内收肌力下降程度差异有统计学意义（P <0.05或P <0.01）；T组穿刺过程中最高VAS评分明显高于V组（P < 0.01）。两组患者均未出现局麻药中毒、术后闭孔神经支配区域感觉异常及闭孔神经损伤等情况。结论  与经典入路比较，超声联合神经刺激仪腹股沟血管旁入路闭孔神经阻滞定位准确，调整次数少，操作时间短，且安全、舒适、有效。

Abstract:

 Objective To compare the operational feasibility and efficacy of inguinal obturator nerve block (ONB) beside the vessel by ultrasound combined with nerve stimulation and traditional ONB guided by nerve stimulation preventing obturator nerve reflex. Methods Forty patients with American Society of Anesthesiology (ASA) Ⅰ or Ⅱ, aged 35～91 years who underwent transurethral electric excision of bladder tumor in our hospital in 2014 were randomly divided into beside vessel group (group V, n = 20) and traditional group (group T, n = 20). Adductor strength was measured before and after the block. Frequencies of obturator nerve block puncture, operation time, visual analog scale (VAS) pain score, and incidence of complications were recorded during and after ONB. Results The success rate of the first puncture was significantly higher in group V than that in group T (P < 0.01). The operation time in group V was significantly shorter than that in group T (P < 0.01). The decreased degree of adductor strength has significant difference of the two groups(P < 0.05 or P < 0.01). The VAS pain score in group T was higher than that in groups V (P < 0.01). There are two cases contract blood vessel in group T, while none in group V (P < 0.01). There was no case with the local anesthetic toxicity and paresthesia in the area of the obturator nerve and the obturator nerve injury in the two groups. Conclusion Compared with traditional ONB guided by nerve stimulation, inguinal ONB beside the vessel by ultrasound combined with nerve stimulation showed more accurate positioning, less adjustment, less puncture time, more comfortable and safe.