ISB HEMDAPHRAGMATIC PARESIS

Interscalane block was performed under ultrasound guidance. Before and 30 min after the block, an independent observer evaluated ipsilateral hemidiaphragmatic movement on deep inspiration by ultrasonography using a 2-5 MHz broadband curved array transducer. Patients were examined in the semirecumbent position and scanned from a subcostal approach using the liver or spleen as an acoustic window. A < 25% reduction in Diaphragmatic Excursion (DE) was taken as mild paresis. Partial diaphragmatic palsy is diagnosed by a reduction in DE of 25-75% and complete palsy is confirmed by a more than 75% reduction in DE or paradoxical cephalad movement of the diaphragm. [11] The sensory blockade was assessed every five min for up to 30 min by the pinprick method in the C5-6 dermatome on a 3-point verbal rating scale: 0 - normal sensation, 1 - dull sensation (analgesia) and 2 - no sensation (anaesthesia). The onset time for a sensory block was defined as the time elapsed between the time of drug administration and the moment when the pinprick test yielded a score of two. Failure to reach a score of two within 30 min of interscalene block was considered to be block failure. General anaesthesia was administered to these patients. But results from these patients were also included in the final analysis based on intention to treat rather than per-protocol basis. [12, 13] The total cases of block failure were noted and the success rate for different groups was compared. The total duration of surgery was documented. At the end of the surgery, the patient was shifted to the postoperative ward. The Visual Analogue Scale (VAS) was used to assess pain and the patient was explained about the score. The patient was administered paracetamol 1g intravenously (IV) when VAS ≥ 4 and repeated after six hours only when VAS ≥ 4. If the patient has pain even after paracetamol administration, tramadol 100 mg IV was used as a rescue analgesic. The duration of postoperative analgesia was defined as the time taken from the administration of the block to the time of the first request for postoperative analgesia (VAS ≥ 4). [14] The patients were observed for any other side effects like hoarseness of voice, and Horners’ syndrome. The patients were followed up for 24 hours.本研究采用超声引导下实施肌间沟神经阻滞（interscalene block）。于阻滞前及阻滞后30分钟时，由独立观察者采用2-5 MHz宽带凸阵超声探头（broadband curved array transducer），经超声评估患者深吸气时的同侧半膈肌运动情况。患者取半卧位（semirecumbent position），以肝脏或脾脏作为透声窗，经肋下入路（subcostal approach）进行扫查。将膈肌移动度（Diaphragmatic Excursion，DE）较基线降低<25%定义为轻度膈肌麻痹；膈肌移动度降低25%~75%诊断为部分性膈肌麻痹；膈肌移动度降低>75%或膈肌出现矛盾性头向移位则确诊为完全性膈肌麻痹[11]。 每5分钟采用针刺测试法（pinprick method）评估C5~6皮节（dermatome）的感觉阻滞（sensory blockade）情况，采用3级口头评分量表：0分为感觉正常，1分为感觉迟钝（镇痛状态），2分为无感觉（麻醉状态）。感觉阻滞起效时间定义为从给药至针刺测试评分为2分的时间间隔。若肌间沟神经阻滞后30分钟内未达到评分为2分的标准，则判定为阻滞失败。部分患者接受了全身麻醉（general anaesthesia），但基于意向性治疗（intention to treat）原则而非符合方案集（per-protocol）原则，该类患者的研究数据仍被纳入最终分析[12,13]。 统计阻滞失败总例数，并比较不同组别的阻滞成功率。记录手术总时长。手术结束后，将患者转运至术后病房。采用视觉模拟评分法（Visual Analogue Scale，VAS）评估患者疼痛程度，并向其详细讲解评分规则。当VAS评分≥4分时，静脉给予对乙酰氨基酚1g（IV）；若6小时后VAS评分仍≥4分，则可重复给药。若使用对乙酰氨基酚后仍有疼痛，则给予曲马多100mg静脉推注作为补救性镇痛药物（rescue analgesic）。术后镇痛持续时间定义为从神经阻滞实施至首次因VAS评分≥4分请求镇痛的时间间隔[14]。 观察患者是否出现声音嘶哑、霍纳综合征（Horner’s syndrome）等其他不良反应，并对所有患者进行24小时随访。