区域神经阻滞联合尼莫地平用于老年高血压患者膝关节置换术的临床疗效及安全性评价

Clinical efficacy and safety evaluation of regional nerve block combined with nimodipine in treating elderly patients with hypertension undergoing knee arthroplasty

摘要:

目的 探讨区域神经阻滞联合尼莫地平用于老年高血压患者膝关节置换术的临床疗效及安全性。方法 选取2021年8月—2022年7月德阳市人民医院收治的148例拟行膝关节置换术的老年高血压患者，根据随机数字表法分为对照组（给予超声引导下区域神经阻滞，74例）、联合组（给予超声引导下区域神经阻滞+尼莫地平泵注，74例）。对比两组患者手术相关指标和不同时刻血流动力学指标。对比两组患者术中血流动力学异常和药物使用情况。对比两组患者不同时刻疼痛评分、应激反应指标、神经元特异性烯醇化酶（NSE）、同型半胱氨酸（Hcy）水平。对比两组患者药物相关不良反应。结果 两组患者手术时间、睁眼时间和拔除喉罩时间比较，差异均无统计学意义（P >0.05）。联合组丙泊酚和瑞芬太尼使用量少于对照组（P <0.05）。两组患者T₀、T₁、T₂及T₃时SBP、DBP、HR、MAP比较，结果 ①不同时间点的SBP、DBP、HR、MAP比较，差异均有统计学意义（F =10.038、8.416、8.035和7.549，均P <0.05）；②两组患者SBP、DBP、HR、MAP比较，差异均有统计学意义（F =7.458、9.136、8.045和7.482，均P <0.05）；③两组患者SBP、DBP、HR、MAP变化趋势比较，差异均有统计学意义（F =6.854、7.516、8.045和10.387，均P <0.05）。联合组高血压、使用降压药占比低于对照组（P <0.05）。两组患者低血压、心动过速、心动过缓、使用升压药占比比较，差异均无统计学意义（P >0.05）。两组患者术后1、6、12、24和48 h的VAS评分比较，结果 ①不同时间点VAS评分比较，差异有统计学意义（F =8.053，P <0.05）；②两组患者VAS评分比较，差异有统计学意义（F =8.476，P <0.05），联合组低于对照组，相对镇痛效果较好；③两组患者VAS评分变化趋势比较，差异有统计学意义（F =7.154，P <0.05）。两组患者术前、术后2 h、术后12 h和术后24 h的Cor、ANP比较，结果 ①不同时间点的Cor、ANP比较，差异均有统计学意义（F =7.549和8.135，均P <0.05）；②两组患者Cor、ANP比较，差异均有统计学意义（F =6.758和7.043，均P <0.05），联合组术后Cor、ANP水平低于对照组，围手术期应激反应相对较轻；③两组患者Cor、ANP变化趋势比较，差异均有统计学意义（F =8.146和9.257，均P <0.05）。两组患者术前、术后12 h和24 h的NSE、Hcy比较，结果 ①不同时间点的NSE、Hcy比较，差异均有统计学意义（F =7.549和8.135，均P <0.05）；②两组患者NSE、Hcy比较，差异均有统计学意义（F =6.758和7.043，均P <0.05），联合组术后NSE、Hcy水平低于对照组；③两组患者NSE、Hcy变化趋势比较，差异均有统计学意义（F =8.146和9.257，均P <0.05）。两组患者不良反应总发生率比较，差异无统计学意义（P <0.05）。结论 老年高血压患者膝关节置换术中采用超声引导下区域神经阻滞联合尼莫地平泵注可减少麻醉药物使用量，稳定血流动力学指标，降低高血压发生率和降压药使用率，提高术后镇痛效果，抑制术后应激反应，降低NSE、Hcy水平，且安全性良好。

Abstract:

Objective To investigate the clinical efficacy and to evaluate the safety of regional nerve block combined with nimodipine in the treatment of elderly patients with hypertension undergoing knee arthroplasty.Methods From August 2021 to July 2022, the 148 elderly hypertensive patients admitted to Deyang People's Hospital for knee arthroplasty were selected and divided into the control group (74 patients receiving ultrasound-guided regional nerve block) and the combination group (74 patients receiving ultrasound-guided regional nerve block and nimodipine via the infusion pump). The surgical indicators and the hemodynamic parameters of the two groups of patients at different time points were compared. The intraoperative hemodynamic abnormalities and the medication use were compared between the two groups. The pain scores and levels of stress response indicators, neuron-specific enolase (NSE) and homocysteine (Hcy) at different time points were compared between the two groups.Results There was no significant difference in the operative duration, time to recovery from the surgery, or time to laryngeal mask airway removal between the two groups (P > 0.05). The amount of propofol and remifentanil used in the combination group was lower than that in the control group (P < 0.05). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and mean arterial pressure (MAP) at T₀, T₁, T₂ and T₃ in the two groups were compared via the repeated measures analysis of variance, which demonstrated that SBP, DBP, HR and MAP were different among the time points (F = 10.038, 8.416, 8.035 and 7.549, all P < 0.05) and between the two groups (F = 7.458, 9.136, 8.045 and 7.482, all P < 0.05), and that the change trends of these indicators were also different between the two groups (F = 6.854, 7.516, 8.045 and 10.387, all P < 0.05). The incidence of high blood pressure and the proportion of patients using antihypertensive drugs in combination group were lower than those in control group (P < 0.05). There was no difference in the incidence of hypotension, tachycardia and bradycardia or the proportion of patients using antihypotensive agents between the two groups (P > 0.05). The Visual Analogue Scale (VAS) scores 1 h, 6 h, 12 h, 24 h and 48 h after the surgery in the two groups were compared via the repeated measures analysis of variance, and the results showed that they were different among the time points (F = 8.053, P < 0.05) and between the two groups (F = 8.476, P < 0.05), where VAS scores in the combination group were lower than those in the control group, indicating better analgesic effects in the combination group. Besides, the change trends of the VAS scores were different between the two groups (F = 7.154, P < 0.05). The levels of cortisol (Cor) and ANP before the surgery and 2 h, 12 h and 24 h after the surgery in the two groups were compared via the repeated measures analysis of variance, which revealed that they were different among the time points (F = 7.549 and 8.135, both P < 0.05) and between the two groups (F = 6.758 and 7.043, both P < 0.05), where the levels of Cor and ANP were lower in the combination group than in the control group, suggesting that the perioperative stress response was milder in the combination group. In addition, the change trends of the levels of Cor and ANP were different between the two groups (F = 8.146 and 9.257, both P < 0.05). The levels of NSE and Hcy before the surgery and 12 h and 24 h after the surgery in the two groups were compared via the repeated measures analysis of variance, and the results exhibited that they were different among the time points (F =7.549 and 8.135, both P < 0.05) and between the two groups (F = 6.758 and 7.043, both P < 0.05), where postoperative levels of NSE and Hcy in the combination group were lower than those in the control group. The change trends of the levels of NSE and Hcy were also different between the two groups (F = 8.146 and 9.257, both P < 0.05). There was no significant difference in the overall incidence of adverse drug reactions between the two groups (P > 0.05).Conclusions In treating elderly patients with hypertension undergoing knee arthroplasty, ultrasound-guided regional nerve block combined with nimodipine via the infusion pump could reduce the use of anesthetics, stabilize hemodynamics, decrease the incidence of high blood pressure and the use of antihypertensive drugs, enhance postoperative analgesic effects, inhibit the postoperative stress response, and lower the levels of NSE and Hcy with few safety concerns.