瑞芬太尼全身麻醉联合颈段竖脊肌平面阻滞与肌间沟臂丛神经阻滞用于关节镜下肩袖 修补术的效果比较

Comparison of the Efficacy of Remifentanil-Based General Anesthesia Combined with Cervical Erector Spinae Plane Block or Interscalene Brachial Plexus Block for Arthroscopic Rotator Cuff Repair

摘要: 目的：比较瑞芬太尼全身麻醉联合肌间沟臂丛神经阻滞(ISB)或颈段竖脊肌平面阻滞(CESPB)用于关节镜下肩袖修补术的镇痛效果及其对膈肌功能、麻醉恢复室(PACU)氧合恢复的影响。方法：将120例择期关节镜下小至中型肩袖撕裂修补术患者随机分为瑞芬太尼全身麻醉组(A组)、ISB联合全身麻醉组(B组)和CESPB联合全身麻醉组(C组)。B组和C组均于麻醉诱导前在超声引导下注射0.375%罗哌卡因20 mL。三组均接受丙泊酚和瑞芬太尼维持的全凭静脉麻醉，术后采用舒芬太尼患者自控静脉镇痛(PCIA)。观察术中瑞芬太尼和丙泊酚用量、术后24 h舒芬太尼用量、PCIA有效按压次数、补救性镇痛、术后恶心呕吐、同侧半膈肌麻痹(HDP)、PACU最低SpO₂、PACU吸氧时间及术后48 h患侧肩关节被动活动度。结果：117例患者纳入分析。与A组比较，B组和C组术中瑞芬太尼、丙泊酚及术后24 h舒芬太尼用量均减少，PCIA有效按压次数和补救性镇痛需求降低，术后48 h被动前屈和外展角度增加(均P < 0.01)；B组与C组主要镇痛结局差异无统计学意义。HDP仅见于B组，发生27例(67.5%)。B组PACU最低SpO₂低于C组(P < 0.05)，PACU吸氧时间长于C组(P < 0.01)。B组和C组术后恶心呕吐发生率低于A组。结论：ISB和CESPB联合瑞芬太尼全身麻醉均可减轻关节镜下肩袖修补术围术期镇痛负担；CESPB镇痛效果与ISB相近，且对膈肌功能影响较小，PACU氧合恢复更稳定。

Abstract: Objective: To compare the analgesic efficacy of remifentanil-based general anesthesia combined with interscalene brachial plexus block (ISB) or cervical erector spinae plane block (CESPB) for arthroscopic rotator cuff repair, and to evaluate their effects on diaphragmatic function and oxygenation recovery in the post-anesthesia care unit (PACU). Methods: A total of 120 patients scheduled for elective arthroscopic repair of small-to-medium rotator cuff tears were randomly assigned to remifentanil-based general anesthesia alone (group A), ISB combined with general anesthesia (group B), or CESPB combined with general anesthesia (group C). In groups B and C, ultrasound-guided blocks were performed before anesthesia induction with 20 mL of 0.375% ropivacaine. All patients received total intravenous anesthesia maintained with propofol and remifentanil, followed by postoperative patient-controlled intravenous analgesia (PCIA) with sufentanil. Intraoperative remifentanil and propofol consumption, 24-h postoperative sufentanil consumption, effective PCIA presses, rescue analgesia, postoperative nausea and vomiting, ipsilateral hemidiaphragmatic paresis (HDP), the lowest SpO₂ in the PACU, duration of oxygen supplementation in the PACU, and passive range of motion of the affected shoulder at 48 h after surgery were recorded. Results: A total of 117 patients were included in the final analysis. Compared with group A, groups B and C required lower intraoperative doses of remifentanil and propofol and had lower 24-h postoperative sufentanil consumption, fewer effective PCIA presses, fewer requirements for rescue analgesia, and greater passive shoulder flexion and abduction at 48 h after surgery (all P < 0.01). No statistically significant difference in the main analgesic outcomes was observed between groups B and C. HDP occurred only in group B, affecting 27 patients (67.5%). The lowest SpO₂ in the PACU was lower in group B than in group C (P < 0.05), and the duration of oxygen supplementation in the PACU was longer in group B than in group C (P < 0.01). The incidence of postoperative nausea and vomiting was lower in groups B and C than in group A. Conclusion: Both ISB and CESPB combined with remifentanil-based general anesthesia can reduce the perioperative analgesic burden in arthroscopic rotator cuff repair. CESPB provides analgesia comparable to ISB, with less effect on diaphragmatic function and more stable oxygenation recovery in the PACU.