Clinical Study Of Ultrasound-guided Femoral Nerve Block Combined With BIS Feedback Target-controlled Infusion In The Operation Of Patella Fractures

ObjectiveTo investigate the clinical application of ultrasound-guided femoral nerve block combined bispectral index by feedback target controlled infusion in the surgery of patellar fracture,and to observe its safety and feasibility during perioperative period.Method60 patients scheduled for open reduction and internal fixation of elective single patellar fracture for the first time,32 to 82 years,ASA physical status???,were selected and divided into 2 groups randomly using random number table,30 cases/group.Group A:Gneral anesthesia with LMA,Group B:Ultrasound-guided femoral nerve block combined with bispectral index by feedback target controlled infusion anesthesia.All patients were fasted and drinking forbidden routinely,and no premedicate.After the patients entered into the operating theatre,give nasal catheter oxygen inhalation(2L/min)and open forearm peripheral vein access,the multifunctional anesthesia monitor was used to monitor and record the patients'HR?BP?RR?ECG?SPO2?BIS and other vital signs continuously.Group A:The induction of general anesthesia:Propofol infusion with intravenous minipump 1.5?2.5mg/kg,intravenous injected fentanyl 1?3ug/kg and atracurium besylate 0.15mg/kg,laryngeal mask airway insertion for control breathing after the patients' autonomous respiration and consciousness vanished.The maintenance of general anesthesia:Propofol and remifentanil infusion with intravenous minipump.During perioperative period,according to hemodynamic fluctuation adjust general anestheticsInfusion velocity or use vasoactive agent when necessary to maintain its stability.After surgery,when recovery muscle strength the patients were given neostigmine 0.07mg/kg and atropine 0.5mg to antagonize residual muscle relaxant.Performing extubation when patients had clinical extubation indicationsGroup B:Ultrasound-guided femoral nerve block:the patients were maintained at dorsal position,spread both lower limbs slightly,and the diseased side external rotation slightly.The skin was disinfected routinely and sterile manipulation strictly during puncture.High frequency linear probe was put on the femoral artery pulse,firstly grab the femoral artery image,then the probe was move outwards 0.5?1cm,we can see the slightly high echo femoral nerve section that was similar to fusiformis,and adjust ultrasonic probe scan depth and probe position for slightly high-definition and high echo femoral nerve section images,with the imagine was in the center of the ultrasonic screen.Inserting a 50mm puncture needle from the lateral end of the probe,make the needle show in the ultrasonic screen clearly,reach to femoral nerve of iliopsoas through sartorius,inject with 2ml normal saline after pumpback without blood,then observe the diffusion of femoral nerve,if the normal saline spread around femoral nerve of the deep surface of fascia iliaca,think the puncture position was correct,then proceed to inject 0.5%ropivacaine 20ml.Start to evaluated the block effect of the disease side postinjection in 3?5 minutes,evaluated the block effect by adopting improved scoring method of Bromage postinjection in 10?15minutes,finally the patients of grade 2?3 proceed to the next experiment.Confirm the femoral nerve block effects was perfect,start the feedback target-controlled infusion loop immediately,adjust the infusion concentration of propofol on the basis of BIS,and keep the BIS at 65?80,stop propofol target-controlled infusion after surgery.During perioperative period,according to hemodynamic fluctuation use vasoactive agent to maintain its stability.SBP?DBP?MAP and HR were recorded at the time of after the patient entered into the operating theatre(D0)?on tourniquet(D1)?skin incision(D2)?left the operating theatre(D3);the use dosage of propofol and fentanyl were observed and recorded;the wake-up time and recovery time of orientation were observed and recorded.VAS at the time of 2h(T0)?6h(Ti)?12h(T2)?24h(T3)?48h(T4)after surgery were recorded;After the surgery follow the patient,the incidence of drowsiness?nausea?vomiting and respiratory depression within 24 hours were recorded,use the Likert scale aimed at the patient satisfaction evaluation of anesthesia.Results1.General informationThere is no statistical difference of age?height,?weight and operation time were observed between group A and group B(P>0.05).Changes of SBP?DBP?MAP?HR2.1 Group comparison2.1.1 SBP was significantly higher at D0 in group A and group B compared with Di?D2?D3,with significant difference(P<0.05).2.1.2 DBP was significantly higher at D0 in group A and group B compared with D1?D2?D3,with significant difference(P<0.05).2.1.3 At Do MAP was significantly higher in group A and group B compared with D1?D2?D3,with significant difference(P<0.05).2.1.4 At D0 HR was significantly higher at in group A compared withD1?D2?D3,with significant difference(P<0.05);At D1 HR was significantly higher in group A compared with D2(P<0.05);At D2HR was significantly higher in group A compared with D3,with significant difference(P<0.05).In group B HR was not statistically significant different at Do?D1?D2?D3(P>0.05).2.2 Group comparison2.2.1 At D0 there is no significant difference of SBP between group A and group B(P>0.05);SBP was significantly higher at D1?D2?D3 in group B compared with group A(P<0.05).2.2.2 At D0?D3 there is no significant difference of DBP between group A and group B(P>0.05);SBP was significantly higher at D1?D2 in group B compared with group A(P<0.05).2.2.3 At D0?D1?D2?D3 there is no significant difference of MAP between group A and group B(P>0.05).2.2.4 At Do there is no significant difference of HR between group A and group B(P>0.05);Compared with group A,HR in group B was significantly higher at D1?D2?D3(P<0.05).3.The use dosage of propofol and fentanyl in group B was significantly less than in group A(P<0.05).4.The wake-up time and recovery time of orientation in group B was significantly earlier than in group A(P<0.05).5.Compared with group A,VAS in group B was lower at T0?Ti?T2?T3(P<0.05);At T4 there is no significant difference of VAS between group A and group B(P>0.05).6.The incidence of drowsiness?delirium?nausea and vomiting within 24 hours after surgery in group B was much lower than in group A(P<0.05),all the patients in group A and group B did not happen respiratory depression within 24 hours after surgery.7.The patient satisfaction evaluation of anesthesia(Likert Scale)was significantly higher in group B compared with group A(P<0.05).ConclusionUltrasound-guided femoral nerve block combined bispectral index by feedback target-controlled infusion anesthesia in the operation of patellar fracture can meet the need during surgery,and has better analgesic effect after surgery,and the hemodynamics was more stability during surgery,and the incidence rate of adverse effect was lower after the surgery,the satisfaction evaluation of anesthesia was higher after surgery.