【摘要】目的观察不同麻醉方式在终末期肾病患者动静脉内瘘腔内治疗时缓解疼痛的有效性，以期指导此类手术麻醉方式的合理选择。方法选择2019 年10月～2020 年4月在北京市海淀医院肾内科行动静脉内瘘经皮腔内球囊血管成形术(percutaneous transluminal balloon angioplasty，PTA)的190例患者，根据患者PTA 过程中针对扩张部位使用的麻醉方式分为3组：对照组(62例)，局部浸润麻醉组(72 例)，选择性神经阻滞组(56 例)。手术后使用线性直观模拟标度尺(visual analogue scale,VAS)评估患者血管扩张过程中疼痛的程度，调查患者和手术者对疼痛管理的满意度。手术后每月复查，资料随访截止至2020 年12月，以观察内瘘的通畅情况。结果选择性神经阻滞组、局部浸润麻醉组和对照组的中位疼痛评分分别为3(0～8)、3(0～10)、7(3～10)，差异具有统计学意义(F=42.656，P＜0.001)。3组在患者及手术者对疼痛管理的满意度上存在统计学差异(χ2分别为42.656, 33.859, P 均＜0.001)。选择性神经阻滞组手术后1、3、6、12 个月的初级通畅率为98.1%、81.8%、54.5%、32.7%，局部浸润麻醉组的为95.8% 、94.4% 、69.4% 、47.2% ,对照组的为98.3% 、83.3% 、56.7% 、25.0% 。各组在1个月(χ2=0.907, P=0.736)、3个月(χ2=5.603, P=0.065)、6个月(χ2= 3.594, P=0.166)的初级通畅率无统计学差异，12 个月的初级通畅率存在统计学差异(χ2=7.355, P=0.025)。结论选择性神经阻滞和局部浸润麻醉在透析患者动静脉内瘘腔内治疗时均可以提供有效安全的镇痛效果，具有较高的患者满意度，且短期初级通畅率不受影响。
【Abstract】Objective To observe the efficacy of different anesthesia approaches for relieving pain during endovascular treatment of arteriovenous fistula in patients with end-stage renal disease so as to guide the rational choice of anesthesia methods for this operation. Method A total of 190 patients undergoing percutaneous transluminal balloon angioplasty (PTA) for arteriovenous fistulas at the Renal Department of Haidian Hospital from October 2019 to April 2020 were enrolled in this study and divided into three groups: control group (n=62), local infiltration anesthesia group (n=72) and selective nerve block group (n=56). After operation, Visual Analogue Scale (VAS) was used to evaluate the degree of pain during PTA and the satisfaction in patients and surgeons. The patients were followed up until December 2020 to observe patency of the fistulas. Result The median pain scores were 3 (0～8), 3 (0～10) and 7 (3～10) in selective nerve block group, local infiltration anesthesia group and control group respectively (F=42.656, P＜0.001). The satisfaction with pain management in patients and surgeons was significant different among the three groups (c2=42.656 and 33.859 respectively, P＜0.001). The primary patency rates after operation for 1, 3, 6 and 12 months were 98.1%, 81.8%, 54.5% and 32.7% respectively in selective nerve block group, 95.8%, 94.4%, 69.4% and 47.2% respectively in local infiltration anesthesia group, and 98.3%, 83.3%, 56.7% and 25.0% respectively in control group; the primary patency rates among the three groups were similar after the operation for one month (c2=0.907, P=0.736), 3 months (c2=5.603, P=0.065) and 6 months (c2=3.594, P=0.166), but were statistically different after the operation for 12 months (c2=7.355, P= 0.025). Conclusion Selective nerve block and local infiltration anesthesia approaches can provide effective and safe analgesia during endovascular treatment of arteriovenous fistulas with better patients’satisfaction and short-term primary patency rate.
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