羅比卡因復(fù)合舒芬太尼用于腰叢聯(lián)合坐骨神經(jīng)阻滯的對照

1、羅比卡因復(fù)合舒芬太尼用于腰叢聯(lián)合坐骨神經(jīng)阻滯的對照研究唐帥 洪溪 黃宇光 任洪智 葉鐵虎 羅愛倫作者單位：100730 中國醫(yī)學(xué)科學(xué)院 中國協(xié)和醫(yī)科大學(xué) 北京協(xié)和醫(yī)院麻醉科責(zé)任作者： 洪溪 摘要 目的 評價舒芬太尼復(fù)合羅比卡因用于下肢神經(jīng)阻滯的臨床效果。 方法 40例擇期在腰叢聯(lián)合坐骨神經(jīng)阻滯下行下肢手術(shù)的病人隨機分為兩組：觀察組（n=20）用藥為含濃度為0.5ug/ml舒芬太尼的0.375%羅比卡因，對照組（n=20）用藥為0.375%羅比卡因。分別記錄兩組阻滯成功率、感覺和運動阻滯起效時間、作用時間及其它相關(guān)臨床麻醉信息。 結(jié)果 兩組間阻滯成功率、感覺和運動阻滯起效時間、作用時間無統(tǒng)計學(xué)差

2、異。 結(jié)論 0.5ug/ml的舒芬太尼對于0.375%羅比卡因用于下肢神經(jīng)阻滯的臨床效果沒有明顯影響，包括阻滯成功率、起效時間和作用時間。阿片類藥物相關(guān)的副作用則有增加的趨勢。關(guān)鍵詞 腰叢聯(lián)合坐骨神經(jīng)阻滯；羅比卡因；舒芬太尼A clinical study on combined lumbar plexus and sciatic nerve block with 0.375% ropivacaine adding 0.5ug/ml sufentanil in patients undergoing lower extremity surgery Tang Shuai , Hong Xi ,

3、Huang Yuguang ,Ren Hongzhi, Ye Tiehu, Luo Ailun, et al . Department of Anesthesiology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College ,Beijing 100730 , CHINAAbstract Objective To evaluate the clinical significance of adding 0.5ug/ml sufen

4、tanil to 0.375% ropivacaine during peripheral nerve block. Methods 40 ASA I-II patients undergoing elective lower extremity surgery under combined lumbar plexus and sciatic nerve block were randomly allocated into two groups in a double-blind fashion, group 1: 50 mL of 0.375% ropivacaine alone ( n=2

5、0), group 2: 0.375% ropivacaine plus 0.5ug/ml sufentanil (n=20). The onset time and the duration for sensory and motor block as well as anesthesia parameters were recorded. Results The mean onset time of sensory block is 12.45.9 min and 13.97.4 min respectively for lumbar plexus block, 14.27.0 min a

6、nd 14.68.6 min respectively for sciatic nerve block; The mean onset time of motor block is 10.54.2 min and 11.36.5 min respectively for lumbar plexus, 13.69.5 min and 15.47.3 min respectively for sciatic nerve block; The mean duration of sensory block is 15.24.6hr and 14.34.5hr, respectively, the me

7、an duration of motor block 16.75.3hr and 17.36.1hr. No statistical differences were found between groups. No differences regarding the incidence of oversedation, PONV, itching and haemodynamic instability were observed between two groups. Conclusion We conclude that adding sufentanil 0.5ug/ml to 0.3

8、75% ropivacaine solution did not provide clinically relevant advantages in terms of onset time, duration and quality of combined lumbar plexus and sciatic nerve block in patients undergoing elective lower extremity surgery.Key Words Peripheral nerve block; combined lumbar plexus and sciatic nerve bl

9、ock; Ropivacaine; Sufentanil腰叢和坐骨神經(jīng)聯(lián)合阻滯在臨床上用于下肢的手術(shù)麻醉，常用藥為局麻藥物。局麻藥中加入阿片類藥物對于神經(jīng)阻滯效果的影響，目前文獻(xiàn)報道結(jié)論不一，尤其對于在下肢神經(jīng)阻滯方面的研究報道還很少。羅比卡因和舒芬太尼均為較新型的藥物，本研究旨在評價舒芬太尼復(fù)合羅比卡因用于下肢神經(jīng)阻滯的臨床效果。資料與方法一般資料 本研究經(jīng)北京協(xié)和醫(yī)院倫理委員會許可，每個病人均簽署知情同意書。選擇40名ASA III級、年齡1870歲、體重4070kg、擬擇期在腰叢聯(lián)合坐骨神經(jīng)阻滯下行下肢手術(shù)的病人。排除標(biāo)準(zhǔn)包括：病人拒絕、妊娠、有神經(jīng)肌肉疾病、藥物濫用史以及穿刺部位感染。

10、將病人隨機分為兩組：觀察組（n=20）用藥為含25ug舒芬太尼(0.5ug/ml)的0.375%羅比卡因 ， 對照組（n=20）用藥為0.375%羅比卡因 。手術(shù)前一天由不參與評估過程的人員利用隨機表決定用藥，并于手術(shù)當(dāng)日配藥（標(biāo)號）予操作者。方法 操作前記錄病人身高、體重，建立靜脈輸液通路，神經(jīng)阻滯過程中及術(shù)中持續(xù)監(jiān)測心電圖、無創(chuàng)血壓和脈搏氧飽和度以及呼吸頻率。穿刺前10-15分鐘靜注咪達(dá)唑侖0.04mg/kg鎮(zhèn)靜后進(jìn)行阻滯。當(dāng)認(rèn)為有必要減輕病人焦慮和不適時，分次追加咪達(dá)唑侖0.02mg/kg，禁忌給予阿片類藥物。所有外周神經(jīng)阻滯均由同一麻醉醫(yī)師完成。使用長100mm的21G絕緣刺激針（St

11、imuplex A,B.Braun;made in Japan）并連接神經(jīng)刺激器（Stimuplex-DIG, B.Braun）進(jìn)行阻滯。刺激頻率設(shè)為2Hz，刺激電流強度開始設(shè)為1.0mA，后漸減至約0.3mA并維持受刺激肌群輕微運動反應(yīng)。誘發(fā)成功后注入實驗用藥腰叢30ml，坐骨神經(jīng)20ml。神經(jīng)阻滯方法：腰叢：病人取側(cè)臥位，阻滯側(cè)下肢在上并屈髖屈膝，兩側(cè)髂嵴最高點連線與棘突交點旁開5cm為穿刺點。行局麻后，以穿刺針與皮膚呈90角進(jìn)針。按照上述方法確定位置后，緩慢注入實驗用藥30ml，每5ml回抽一次。坐骨神經(jīng)：病人取側(cè)臥位，阻滯側(cè)下肢在上并屈髖屈膝，膝關(guān)節(jié)呈90角，健側(cè)下肢伸直（Sims位）

12、。由髂后上棘與股骨大轉(zhuǎn)子作一連線，連線的中垂線與股骨大轉(zhuǎn)子和骶裂孔的連線相交，此點即為穿刺點。行局麻后，以穿刺針與皮膚呈90角進(jìn)針，按照上述方法確定位置后，緩慢注入實驗用藥20ml，每5ml回抽一次。操作結(jié)束之后，30分鐘內(nèi)每2.5分鐘、30分鐘后每30分鐘測試一次股神經(jīng)（大腿前面）、隱神經(jīng)（小腿內(nèi)側(cè)）和坐骨神經(jīng)支配皮膚區(qū)域（足背外側(cè)）的針刺痛覺是否消失，同時評價髖、膝、踝關(guān)節(jié)的運動情況。根據(jù)臨床實際工作的需要，30分鐘后無論阻滯情況如何均開始做消毒鋪巾等術(shù)前準(zhǔn)備。術(shù)后由操作者對病人進(jìn)行隨訪，記錄感覺和運動阻滯時間，并記錄所有不良事件。觀察項目 疼痛程度評估采用視覺模擬評分法VAS（010）。

13、在切皮前測試病人手術(shù)部位VAS評分，如大于3分，則改為異丙酚持續(xù)輸注，待術(shù)畢行針刺試驗若陰性，則定義為起效延遲；若陽性則定義為麻醉未起效。阻滯效果按以下標(biāo)準(zhǔn)評價：手術(shù)過程無痛為滿意的神經(jīng)阻滯；需改全麻的為阻滯失敗。病人對麻醉技術(shù)的滿意程度：滿意（必要時會再次選擇這種麻醉方法）；不滿意（會選擇其他不同的方法）。腰叢感覺阻滯起效時間定義為從腰叢注藥結(jié)束至大腿前部完全無針刺感；坐骨神經(jīng)感覺阻滯起效時間定義為從坐骨神經(jīng)注藥結(jié)束至足背外側(cè)完全無針刺感；腰叢運動阻滯起效時間定義為腰叢注藥結(jié)束至髖關(guān)節(jié)不能運動（大腿抬腿不能）；坐骨神經(jīng)運動阻滯起效時間定義為從坐骨神經(jīng)注藥結(jié)束至踝關(guān)節(jié)不能運動（足背伸或背屈不能

14、）。感覺阻滯時程定義為從注藥至患肢恢復(fù)知覺或麻木感消失的時間；運動阻滯時程定義為從注藥至患肢恢復(fù)運動自如的時間。統(tǒng)計分析 用SPSS for Windows Version 11.5和Microsoft Excel 97進(jìn)行統(tǒng)計學(xué)分析。計量資料以均數(shù)標(biāo)準(zhǔn)差（S）表示，應(yīng)用成組t檢驗，計數(shù)資料應(yīng)用2檢驗。P0.05為差異有顯著意義。結(jié) 果兩組病人年齡、身高、體重、性別、ASA分級、手術(shù)種類差異無顯著意義。關(guān)于神經(jīng)阻滯的麻醉效果的數(shù)據(jù)見表1，組間差異不顯著。無論是觀察組（0.375%羅比卡因加0.5ug/ml舒芬太尼）還是對照組（0.375%羅比卡因），均可以滿足大部分的神經(jīng)阻滯需要。無論是感覺或

15、是運動阻滯，腰叢阻滯起效延遲的發(fā)生均少于坐骨神經(jīng)阻滯。觀察組的坐骨神經(jīng)阻滯起效延遲的病例數(shù)多于對照組，但無統(tǒng)計學(xué)差異。對30分鐘內(nèi)起效病例進(jìn)行起效時間及維持時間的分析，可以看出，兩組在起效時間和阻滯時程方面未見統(tǒng)計學(xué)差異 （表2）。觀察組的并發(fā)癥發(fā)生例數(shù)（16人次）較對照組（6人次）高，均符合阿片類藥物的副反應(yīng)表現(xiàn)。其中：惡心觀察組2例，對照組1例，均為輕度；嘔吐觀察組2例重度，對照組1例中度；搔癢觀察組3例輕度，對照組無；困倦觀察組3例輕度、1例重度，對照組1例輕度；排尿困難觀察組1例輕度、1例重度，對照組1例重度；血流動力學(xué)不穩(wěn)定觀察組3例，對照組1例；兩組均未發(fā)生局麻藥中毒，均未發(fā)生呼吸

16、抑制。對照組一例出現(xiàn)術(shù)后小腿前面感覺障礙，經(jīng)過嚴(yán)密隨訪，術(shù)后2周時感覺障礙皮區(qū)基本穩(wěn)定于脛前區(qū)，疑與手術(shù)或麻醉過程中神經(jīng)損傷有關(guān)。表1 兩組麻醉效果組別例數(shù)部位刺激強度（mA）（S）感覺阻滯（例）運動阻滯（例）滿意度需要異丙酚（例）30內(nèi)起效起效延遲未起效30內(nèi)起效起效延遲未起效滿意不滿意觀察組20腰叢0.320.03172116131915坐骨神經(jīng)0.300.021451866對照組20腰叢0.330.04182017122003坐骨神經(jīng)0.330.0414421244*表示P0.05表2 麻醉數(shù)據(jù)（S）組別例數(shù)感覺阻滯起效時間（分鐘）運動阻滯起效時間（分鐘）感覺阻滯時程（小時）運動阻滯時程

17、（小時）腰叢坐骨神經(jīng)腰叢坐骨神經(jīng)觀察組2013.97.414.68.611.36.515.47.314.34.517.36.1對照組2012.45.914.27.010.54.213.69.515.24.616.75.3討 論羅比卡因是一種新型的酰胺類局麻藥，用于神經(jīng)阻滯的麻醉和鎮(zhèn)痛，安全性好，阻滯時程長。舒芬太尼是一種脂溶性極強的阿片類藥，具有鎮(zhèn)痛效能高和作用時間長的優(yōu)點，與局麻藥物合用于椎管內(nèi)麻醉，可增強鎮(zhèn)痛效果和延長鎮(zhèn)痛時間1。但人們對將阿片類藥用于外周神經(jīng)阻滯時的臨床效果尚缺乏一致的看法。本研究的結(jié)果顯示，濃度為0.5ug/ml的舒芬太尼對0.375%羅比卡因進(jìn)行腰叢和坐骨神經(jīng)阻滯的起

18、效時間和作用時程均無顯著影響。從理論上講，當(dāng)利用局麻藥進(jìn)行外周神經(jīng)阻滯時，在神經(jīng)周圍直接應(yīng)用阿片類藥可以提供更好的鎮(zhèn)痛作用2。 許多生化和電生理研究提示在大的傳入神經(jīng)元上存在阿片受體3，并且已經(jīng)有人通過免疫組化方法,以及從功能的角度說明了該受體的存在。應(yīng)用阿片受體激動劑結(jié)合這些受體可以起到鎮(zhèn)痛作用，這可能是通過抑制動作電位的傳導(dǎo)或引起興奮性神經(jīng)遞質(zhì)釋放來達(dá)到的4； Fields用阿片類藥的向心性轉(zhuǎn)運機制來解釋其外周注射后增強鎮(zhèn)痛作用的現(xiàn)象3；阿片類藥也可能沿著神經(jīng)鞘播散到硬膜外腔或蛛網(wǎng)膜下腔與脊髓后角的阿片受體結(jié)合而起作用；此外，阿片類藥也可能被外周血管吸收入血液循環(huán)作用于中樞阿片受體。在臨床

19、研究中證明，不同的阿片類藥對局麻藥的阻滯效果有不同的影響；即便是同一種阿片類藥，其效果也隨應(yīng)用部位或局麻藥種類而變化。現(xiàn)今神經(jīng)阻滯時加入局麻藥中較常用的是阿片類藥芬太尼和舒芬太尼以及阿片受體激動拮抗劑丁丙諾啡。Nishikawa等人在臂叢神經(jīng)阻滯時在局麻藥中加入小劑量芬太尼，結(jié)果阻滯成功率增加，感覺阻滯時程延長5；而Magistris等人報道在下肢神經(jīng)阻滯時加入小劑量芬太尼后起效時間、阻滯質(zhì)量和時程均沒有變化6。 Bazin等人比較了不同阿片類藥之后發(fā)現(xiàn)，使用利多卡因和布比卡因混合液進(jìn)行臂叢神經(jīng)阻滯時，按脂溶性依次增強的順序加入嗎啡、丁丙諾啡和舒芬太尼，結(jié)果發(fā)現(xiàn)丁丙諾啡和舒芬太尼均延長了術(shù)后鎮(zhèn)

20、痛時間，舒芬太尼更明顯7；國內(nèi)亦有研究表明丁丙諾啡延長了術(shù)后鎮(zhèn)痛時間8。而Bouaziz等人在臂叢阻滯時加入舒芬太尼，起效速度、感覺運動阻滯時程沒有變化，副作用卻有增多的趨勢9。由此可見，局麻藥中加入阿片類藥后，神經(jīng)阻滯的臨床特性如何變化尚無定論。這可能與不同的神經(jīng)、不同阿片類藥的藥理學(xué)特性、阿片類藥與不同局麻藥之間的相互作用、甚至不同研究者之間的方法和觀察指標(biāo)的差異等等許多因素有關(guān)。本研究將羅比卡因的濃度降低至0.375%，意在增加局麻藥的安全性和減少其阻滯時間來突出阿片類藥的作用，并加入較大劑量舒芬太尼(0.5ug/ml)，但仍未得到陽性結(jié)果，這與Magistris等人的結(jié)果一致。外周神經(jīng)

21、阻滯和椎管內(nèi)麻醉有區(qū)別，椎管內(nèi)給藥時阿片類藥更容易擴散入中樞神經(jīng)系統(tǒng)阻滯其中的阿片受體，而外周神經(jīng)給藥時阿片類藥被包裹于局部，不易擴散入中樞神經(jīng)系統(tǒng)。這可以用來解釋為什么硬膜外應(yīng)用阿片類藥會明顯延長鎮(zhèn)痛時間而外周神經(jīng)應(yīng)用卻并不明顯。 如此大劑量的舒芬太尼若直接入血，必然會產(chǎn)生鎮(zhèn)靜、呼吸抑制等阿片類藥入血的征象，但外周神經(jīng)給藥后，藥物被包裹并緩慢吸收，血藥濃度持續(xù)在較低水平，故神經(jīng)周圍注射此劑量的舒芬太尼是安全的。樣本量可能對研究結(jié)果有影響，但因為至今尚無下肢神經(jīng)阻滯加入阿片類藥的陽性結(jié)果，故無法計算所需樣本量，因此我們選擇了國內(nèi)外文獻(xiàn)常用的樣本量。本研究結(jié)果顯示，0.5ug/ml的舒芬太尼對于

22、0.375%羅比卡因用于下肢神經(jīng)阻滯的臨床效果沒有明顯影響，包括阻滯成功率、起效時間和作用時間。阿片類藥物相關(guān)的副作用則有增加的趨勢。阿片類藥對外周神經(jīng)的作用機制仍不明確，在臨床中的應(yīng)用尚需要進(jìn)一步研究，這可能還需要做一些動物試驗或離體試驗。參考文獻(xiàn)1 Polley, Linda S. MD; Columb, Malachy O. FRCA; Wagner, Deborah S. PharmD; Naughton, Norah N. MD. Dose-dependent Reduction of the Minimum Local Analgesic Concentration of Bupi

23、vacaine by Sufentanil for Epidural Analgesia in Labor. Anesthesiology,1998,89:626-632.2 Stein C.The control of pain in peripheral tissue by opioids.New Engl J Med,1995,332:1685-1690.3 Fields HL,Emcen PC,Leigh BK et al.Multiple opiate receptor sites on primary afferent fibres. Nature,1980,284:351-353

24、.4 Stein C.Peripheral mechanisms of opioid analgesia.Anesth Analg,1993,76:182-191.5 Nishikawa K, Kanaya N,et al. Fentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism. Anesth Analg,2000,91(2):384-387.6 Magistris L, Casati A,et al. Combined sciat

25、ic-femoral nerve block with 0.75% ropivacaine: effects of adding a systemically inactive dose of fentanyl. Eur J Anaesthesiol,2000,17(6):348-353.7 Bazin JE, Massoni C, Bruelle P,et al. The addition of opioids to local anaesthetics in brachial plexus block: the comparative effects of morphine, bupren

26、orphine and sufentanil. Anaesthesia. 1997,52(9):858-862.8 徐文慶,等.丁丙諾啡加入局麻藥用于臂叢神經(jīng)阻滯的術(shù)后鎮(zhèn)痛作用.臨床麻醉學(xué)雜志,2005,21:753-754.9 Bouaziz H, Kinirons BP, et al. Sufentanil does not prolong the duration of analgesia in a mepivacaine brachial plexus block: a dose response study. Anesth Analg,2000,90(2):383-387.Sufen

27、tanil does not enhance the efficacy of ropivacaine in combined lumbar plexus and sciatic block: A controlled, randomized clinical trialShuai Tang, M.D; Xi Hong, M.D; Yuguang Huang, M.D; Hongzhi Ren, M.D; Tiehu Ye, M.D; Ailun Luo,M.D;Summary To date, the efficacy of the combination of opioids and loc

28、al anesthetics in peripheral nerve block is not conclusive yet. In this study, the onset time, duration as well as quality of lumbar plexus and sciatic nerve blockade were evaluated using sufentanil and ropivacaine combination compared with plain ropivacaine. 40 patients scheduled for lower extremit

29、y surgery under combined lumbar plexus and sciatic nerve block were randomly allocated into two groups. 50ml of 0.375% ropivacaine with 0.5ug/ml sufentanil (trial group) and 0.375% plain ropivacaine (control group) were administered when the location of lumbar plexus and sciatic nerve were confirmed

30、 by a nerve stimulator. Onset and duration of sensory and motor block were investigated. Opioid-related side effects were recorded. Quality of anesthesia in terms of success rate of block, patients satisfaction were reviewed after surgery. The addition of sufentanil to ropivacaine did not facilitate

31、 the onset of the block, nor the duration of analgesia. For lumbar plexus block, the mean onset time of sensory block was 13.97.4 min (trial group) vs. 12.45.9 min (contral group) respectively, 11.36.5 min vs.10.54.2 min respectively for motor block. For sciatic nerve block, the onset time of sensor

32、y block was 14.68.6 min vs. 14.27.0 min respectively, 15.47.3 min vs. 13.69.5 min respectively for motor block. The mean duration of sensory block is 14.34.5hr(trial group) vs 15.24.6hr(contral group) respectively, the mean duration of motor block 17.36.1hr vs. 16.75.3hr respectively. Opioid-related

33、 side effects were similar between groups, as well as the success rate of the block and patients satisfaction. We concluded that, during combined lumbar plexus and sciatic nerve block, adding sufentanil 0.5ug/ml to 0.375% ropivacaine solution did not provide clinically relevant advantages in terms o

34、f onset time, duration and quality of anesthesia for patients undergoing elective lower extremity surgery.Key words: lumbar plexus and sciatic nerve block; sufentanil; ropivacaine; 1. Introduction The perineural use of opioids develops rapidly. Most investigations are focusing on the effect of opioi

35、ds in epidural anesthesia. It seems that sufentanil has been proved to be effective in promoting the anesthesia and analgesia effect of local anesthetics in epidural anesthesia1. But the results of opioids in peripheral nerve block are quite different. Some biochemical and electrophysiological studi

36、es have shown the presence of opioid receptors in major afferent neurons2,3, which was confirmed via immunohistochemical technique as well as from the point of function. Opioid agonist might take analgesia action by binding with these receptors, that was probably achieved because of inhibition of ac

37、tion potential or the release of excitatory neurotransmitters4; Fields et al2 attributed this potentiation of analgesia after injection of opioids to mechanism of concentric transportation; in addition, opioids might also propagate along the neural sheath to epidural or subarachnoid cavity, then bin

38、d with the opioid receptors located in dorsal horn of spinal cord; finally, opioids could be absorbed into peripheral blood vessels and transported through circulation to the central opioid receptors. Consequently, the adding of opioids to local anesthetic solution for peripheral nerve block should

39、present better analgesic effect theoretically5,6. Nishikawa et al7 reported greater success rate of brachial plexus block when adding fentanyl to lidocaine, with longer duration of block. Bazin et al 8 compared different opioids combined with lidocaine and bupivacaine in peripheral nerve block, and

40、found that the more lipophilic the opioid is, the longer the duration of pain reliefs after the operation.However, there are still quite a few clinical studies showing no difference considering the onset time and duration when adding opioids to local anesthetics, with increasing tendency of side eff

41、ects9. Magistris et al10 reported no change in terms of onset time, duration and quality of peripheral block on lower extremities adding small dosage of opioids. Their negative result might partly be explained with different pharmacokinetics between long-acting ropivacaine and short-acting fentanyl.

42、 Acturally this is a dilemma, it is difficult to have any inclination. So we carried out this randomized, controlled trial to compare the efficacy of plain ropivacaine with ropivacaine plus sufentanil in combined lumbar plexus and sciatic nerve block for patients undergoing elective lower extremity

43、operations.2. MethodsAfter institutional ethics approval and written informed consent, 40 patients of ASA III scheduled for elective lower extremity surgery under combined lumbar plexus and sciatic block were enrolled in this study. Patients with following conditions were excluded: patient refusal,

44、pregnancy, neuromuscular disease, drug abuse, coagulopathy and infection of local injection site. Patients were randomly allocated into two groups, the group 1(trial group, n=20) received 0.375% ropivacaine HCL(0.75%NAROPIN manufactured by Astrazeneca, Sweden) with 0.5ug/ml sufentanil citrate(Manufa

45、ctured by Impfstoffwerk Dessau-Tornau GmbH, Germany) in the solution; group 2(control group, n=20) received 0.375% plain ropivacaine HCL(0.75%NAROPIN manufactured by Astrazeneca, Sweden). The solvent is 0.9%NaCl. Allocation of patients and preparation of drug solutions were done before surgery by a

46、staff who did not participate in either anesthesia nor evaluation process. The patients height, body weight were recorded and IV route was established before anesthesia. ECG, non-invasive blood pressure and SpO2 were monitored during anesthesia and operation. Patients were sedated with midazolam 0.0

47、4mg/kg 10-15min before the block was started, and repeat dose of 0.02mg/kg each time if necessary. Systemic use of opioid was prohibited.All lumbar plexus and sciatic block were performed by the same staff anesthetist who was blind to the patients group or the drug used. A 100mm 21-gauge insulated n

48、eedle was connected with a peripheral nerve stimulator (Stimuplex-DIG, Braun; Melsugen, Germany), which was used to identify the lumbar plexus and sciatic nerve. The stimulation frequency was 2Hz, the stimulation current was initially set at 1.0mA, then was decreased gradually to less than 0.5mA whe

49、n slight muscle twitch was still present, which was identified as appropriate position of the needle. The amount of study solution applied into lumbar plexus and sciatic block was 30ml and 20ml respectively.2.1. techniquesLumbar plexus: patients were put in lateral position with block side up, hip a

50、nd knee bent. Draw a line along the spinal process and another line along the bilateral highest point of iliac crests, the block site was made 4-5cm lateral to the intersection point of the two lines. After local skin infiltration with local anesthesia, the needle connected with stimulator using 1.0

51、mA was inserted perpendicular to the skin and redirected until the twitch of quadriceps muscle of thigh was elicited. The current was turned down slowly to approximately 0.5mA and keep the twitch still present, then drug solution was injected slowly and negative aspiration was made every 5ml for blo

52、od. Patients with evidence of epidural spread, demonstrated by contralateral hip-flexor weakness before or after surgery, were recorded.Sciatic nerve: after lumbar plexus injection, patients were still in lateral position, but the lower leg was straightened and upper knee joint was bent in 90angle (

53、Sims position). sciatic nerve blocks were performed according to the classic Labat approach: a line was drawn from the posterior superior iliac spine to the midpoint of the great trochanter. A perpendicular line was drawn bisecting this line which extended 5cm caudally, and a second line was drawn f

54、rom the great trochanter to the sacral hiatus. The intersection of this latter line with the perpendicular one indicated the point of needle entry. The stimulating needle was inserted and redirected eliciting flexion or extension of the foot. The current was turned down from 1.0mA to 0.5mA with the

55、muscle twitch still present, and the solution was injected slowly and aspirated every 5ml to avoid misplacing to the blood vessel.Sensory and motor blocks on the operated limb were evaluated every 2.5min within first 30min, and every 30min later. Pinprick test were made at anterior part of the thigh

56、 for lumbar plexus, lateral part of dorsal foot for sciatic nerve, respectively. While motor block was evaluated by asking the patient to flex the leg at the hip(represents the motor function of lumbar plexus) and to plantar flex or dorsiflex the foot(represents the motor funtion of sciatic nerve)11

57、 . Patients were followed up after the operation regarding the duration of the block and all adverse events. 2.2. Outcome measuresVisual Analogue Scale (VAS, 0-10) was applied to describe pain intensity by patients. If VAS was more than 3 during surgical area before incision, propofol infusion was t

58、hen offered. By the end of operation, pinprick test was done when patients woke up, it was described as delayed onset of the block if patients felt no pain, failed if pain persisted by that time. Quality of the block was described as: satisfactory (surgical procedure without pain) ; failed (general anesthesia was needed). Patients were asked to give their comment after operation: satisfactory (would choose the same