影响硬膜外麻醉效果主要因素的临床观察
摘要
目的：通过硬膜外麻醉中应用相同质量不同容积和浓度的盐酸利多卡因,比较感觉阻滞平面和运动阻滞程度的变化,探讨影响硬膜外麻醉效果的主要因素。
方法：选择拟在硬膜外麻醉下择期行膝关节手术的患者40例,年龄20-60岁,其中男21例,女19例,ASAⅠ-Ⅱ级,均在腰2-3间隙穿刺行连续硬膜外阻滞麻醉,患者按随机表法随机分为两组,Ⅰ组硬膜外腔注射1%盐酸利多卡因30ml(n=20),Ⅱ组硬膜外腔注射2%盐酸利多卡因15ml(n=20)。两组均在硬膜外穿刺完成后注射盐酸利多卡因试验剂量60mg(Ⅰ组6ml,Ⅱ组3ml),5分钟后无不良反应注射剩余量。用针刺法评定感觉阻滞平面,用改良Bromage评分法(0级：无效；1级：小腿不能抬离床面；2级：膝关节不能弯曲；3级：运动完全阻滞)评定运动阻滞效果。记录患者入室、硬膜外给药后15min、30min和45min的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)和心率(HR)。记录麻醉药起效时间以及给药后15min、30min和45min的感觉阻滞平面和运动阻滞程度。记录有无应用盐酸麻黄碱。
结果：两组患者的血压和心率变化的比较差异无统计学意义(P>0.05)；麻醉药起效时间、给药后15min、30min和45min感觉阻滞平面与运动阻滞程度的比较差异均无统计学意义(P>0.05)；两组患者应用盐酸麻黄碱剂量的比较差异均无统计学意义(P>0.05)。
结论：硬膜外麻醉中应用1-2%的浓度下相同质量不同容积和浓度的盐酸利多卡因所产生的阻滞效果相同,影响硬膜外麻醉效果的主要因素是盐酸利多卡因的分子数。
Objective:To apply the same quality and the different concentration or volume dose lidocaine hydrochloride, comparing the change of sensory block and degree of motor block, discussed the major factors of effecting epidural anesthesia.
Methods:Selecting epidural anesthesia in patients undergoing elective knee joint surgery under the 40 cases, aged 20 to 60 years of age, 21 males,19 females, ASAⅠ-Ⅱ, all cases were punctured at lumbar 2-3 spinal inter space. Basisde on Random numbers table they were randomly divided into two groups:1% lidocaine hydrochloride 30ml(n=20), or 2% lidocaine hydrochloride 15ml(n=20). After epitural anaesthesia was completed, injecting lidocaine hydrochloride 60 milligram, no adverse reactions injecting the remaining amount after 5 minute. The spread of the sensory block to pinprick and the dgree of motor block(modified Bromage scale)were measured at 15,30 and 40 minute after injection. Each blood pressure (BP), mean arterial blood pressure(MAP) and heart rate (HR) were were recorded at immediately transferred to operating room, after administration 15 minute,30 minute and 45 minute. The does of ephedrine hydrochloride were recorded.
Results:There were no significant differences in the blood pressure and heart rate. There were no significant differences in the progression of analgesia and motor block were observed at any time between 1%and 2%lidocaine hydrochloride. The does of ephedrine hydrochloride were no significant difference in both groups.
Conclusions:Apply the same quality and the different concentration or volume dose lidocaine hydrochloride could emerge the same block effection, deciding the major factors of epidural anesthesia was the number of molecules.
方法：选择拟在硬膜外麻醉下择期行膝关节手术的患者40例,年龄20-60岁,其中男21例,女19例,ASAⅠ-Ⅱ级,均在腰2-3间隙穿刺行连续硬膜外阻滞麻醉,患者按随机表法随机分为两组,Ⅰ组硬膜外腔注射1%盐酸利多卡因30ml(n=20),Ⅱ组硬膜外腔注射2%盐酸利多卡因15ml(n=20)。两组均在硬膜外穿刺完成后注射盐酸利多卡因试验剂量60mg(Ⅰ组6ml,Ⅱ组3ml),5分钟后无不良反应注射剩余量。用针刺法评定感觉阻滞平面,用改良Bromage评分法(0级：无效；1级：小腿不能抬离床面；2级：膝关节不能弯曲；3级：运动完全阻滞)评定运动阻滞效果。记录患者入室、硬膜外给药后15min、30min和45min的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)和心率(HR)。记录麻醉药起效时间以及给药后15min、30min和45min的感觉阻滞平面和运动阻滞程度。记录有无应用盐酸麻黄碱。
结果：两组患者的血压和心率变化的比较差异无统计学意义(P>0.05)；麻醉药起效时间、给药后15min、30min和45min感觉阻滞平面与运动阻滞程度的比较差异均无统计学意义(P>0.05)；两组患者应用盐酸麻黄碱剂量的比较差异均无统计学意义(P>0.05)。
结论：硬膜外麻醉中应用1-2%的浓度下相同质量不同容积和浓度的盐酸利多卡因所产生的阻滞效果相同,影响硬膜外麻醉效果的主要因素是盐酸利多卡因的分子数。
Objective:To apply the same quality and the different concentration or volume dose lidocaine hydrochloride, comparing the change of sensory block and degree of motor block, discussed the major factors of effecting epidural anesthesia.
Methods:Selecting epidural anesthesia in patients undergoing elective knee joint surgery under the 40 cases, aged 20 to 60 years of age, 21 males,19 females, ASAⅠ-Ⅱ, all cases were punctured at lumbar 2-3 spinal inter space. Basisde on Random numbers table they were randomly divided into two groups:1% lidocaine hydrochloride 30ml(n=20), or 2% lidocaine hydrochloride 15ml(n=20). After epitural anaesthesia was completed, injecting lidocaine hydrochloride 60 milligram, no adverse reactions injecting the remaining amount after 5 minute. The spread of the sensory block to pinprick and the dgree of motor block(modified Bromage scale)were measured at 15,30 and 40 minute after injection. Each blood pressure (BP), mean arterial blood pressure(MAP) and heart rate (HR) were were recorded at immediately transferred to operating room, after administration 15 minute,30 minute and 45 minute. The does of ephedrine hydrochloride were recorded.
Results:There were no significant differences in the blood pressure and heart rate. There were no significant differences in the progression of analgesia and motor block were observed at any time between 1%and 2%lidocaine hydrochloride. The does of ephedrine hydrochloride were no significant difference in both groups.
Conclusions:Apply the same quality and the different concentration or volume dose lidocaine hydrochloride could emerge the same block effection, deciding the major factors of epidural anesthesia was the number of molecules.
引文
[1]Kamiya Y, Kikuchi T, Inagawa G, et al. Lidocaine concentration in cerebrospinal fluid after epidural administration:a comparison between epidural and combined spinal-epidural anesthesia. Anesthesiology,2009, 110(5):1127-1132.
[2]曾因明,邓小明.米勒麻醉学,第六版,北京大学医学出版社602.
[3]兰天民,苏跃.硬膜外麻醉复合咪哒唑仑术中患者的遗忘作用.中华麻醉学杂志,2003,23(10)：783.
[4]Panousis P, Heller AR, Koch T, et al. Epidural ropivacaine concentrations for intraoperative analgesia during major upper abdominal surgery:a prospective, randomized, double-blinded, placebo-controlled study. Anesth Analg,2009,108(6):1971-1976.
[5]Sakura S, Sumi M, Kushizaki H, et al. Concentration of lidocaine affects intensity of sensory block during lumbar epidural anesthesia. Anesth Analg,1999,88(1):123-127.
[6]Bromage PR. Mechanism of action of extradural local anaesthetics. Br J Anaesth,1975,47:199-211.
[7]Sakura S, Sumi M, Yamada Y, et al. Quantitative and selective assessment of sensory block during lumbar epidural anaesthesia with 1% or 2% lidocaine. Br J Anaesth,1998,81(5):718-722.
[8]Nakayama M, Yamamoto J, Ichinose H, et al. Effects of volume and concentration of lidocaine on epidural anaesthesia in pregnant females. Eur J Anaesthesiol,2002,19(11):808-811.
[9]Liu Spencer S, Ware Paul D, Rajendran, et al. Effects of Concentration and Volume of 2-Chloroprocaine on Epidural Anesthesia in Volunteers. Anesthesiology,1997,86(6):1288-1293.
[10]傅润乔.两种浓度氯普鲁卡因用于宫产硬膜外麻醉的临床观察.北京医学,2005,27：219-221.
[11]Kopp SL, Wynd KP, Horlocker TT, Regional blockade in patients with a history of a seizure disorder. Anesth Analg,2009,109(1):272-278.
[12]Lonnqvist PA. Regional anaesthesia and analgesia in the neonate. Best Pract Res Clin Anaesthesiol,2010,24(3):309-321.
[13]何建训.硬膜外不同注射速度又打且滞平面扩徽的影响临床麻醉学杂志,1992,8(2)：71.
[14]Danelli G, Venuti FS, Zasa M, et al. Continuous lumbar epidural infusion of levobupivacaine:effects of small-or large-volume regimen of infusion. Acta Anaesthesiol Scand,2009,53(4):483-488.
[15]Galindo A,Hernandez J,Benavides O.Quality of spinal extradural anaesthesia.The influence of spinal nerve root diameter.Br J Anaesth 1975;47(1):41-7.
[16]Sindhvananda W, Leelanukrom R, Rodanant O,et al. Maternal satisfaction to epidural and spinal anesthesia for cesarean section. J Med Assoc Thai,2004,87(6):628-635.
[1]庄心良,曾因明,陈伯銮.现代麻醉学.第三版,北京,人民卫生出版社,7,1089.
[2]Duggan J, Bowler GMR, McClure JH, et al. Extradural block withbupivacaine:Influence of dose,volume,concentration and patient characteristics. Br J Anaesth,1988,61(3):324-331.
[3]Sakura S, Sumi M, Kushizaki H, et al. Concentration of lidocaine affects intensity of sensory block during lumbar epidural anesthesia. Anesth Analg,1999,88(1):123-127.
[4]徐启明.主编临床麻醉学.第2版,人民出版社,112-118.
[5]Kopp SL, Wynd KP, Horlocker TT, Regional blockade in patients with a history of a seizure disorder. AnesthAnalg,2009,109(1):272-278.
[6]Lonnqvist PA. Regional anaesthesia and analgesia in the neonate. Best Pract Res Clin Anaesthesiol,2010,24(3):309-321.
[7]曾因明,邓小明.米勒麻醉学.第六版,北京大学医学出版社,602.
[8]Brook R, McGlynn E, Cleary PD. Measuring quality of care. N Engl J Med,1996,335:966-970.
[9]Bromage PR. Mechanism of action of extradural local anaesthetics. Br J Anaesth,1975,47:199-211.
[10]Burn JM, Guyer PB, Langdon L.The spread of solutions injected into the epidural space:A study using epidurograms in patients with lumbosciatic syndrome. Br J Anaesth,1973,45(4):338-10.
[11]Bengtsson M, Malmqvist L, Edstro"m H. Spinal analgesia with glucose-free bupivacaine:effects of volume and concentration. Acta aesthesio-logica Scandinavica,1984,28(5):583-586.
[12]Sakura S, Sumi M, YamadaY, et al. Quantitative and selective assessment of sensory block during lumbar epidural anaesthesia with 1% or 2%lidocaine. Br J Anaesth,1998,81(5):718-722.
[13]Nakayama M, Ichinose H, Yamamoto S, et al. Effects of volume and concentration of lidocaine on epidural anaesthesia in pregnant females. European Journal of Anaesthesiology,2002,19(11):808-811.
[14]Liu SS, Ware PD, Rajendram S. Effects of concentration and volume of 2-chloroprocaine on epidural anesthesia in volunteers. Anesthesiology, 1997,86(6):1288-1289.
[15]Mira Dernedde, Michaela Stadler, Francoise Bardiau, et al. Continuous epidural infusion of large concentration/small volume versus small concentration/large volume of levobupivacaine for postoperative analgesia. Anesth Analg,2003,96(3):796-801.
[16]傅润乔,岳云,薛绵荣,等.两种浓度氯普鲁卡因用于宫产硬膜外麻醉的临床观察.北京医学,2005,27：219-221.
[17]Kaneko T, Iwama H. The association between injected volume of local anesthetic and spread of epidural anesthesia:a hypothesis.Reg Anesth Pain Med,1999,24(2):153-157.
[18]Shinichi Sakura, Mariko Sumi, Hiroyuki Kushizaki,et al. Concentration of Lidocaine affects intensity of sensory block during lumbar epidural Anesthesia. Anesth Analg,1999,88(1):123-127.
[19]赵为民,米德文,李秀慧.低浓度大剂量局麻药用于低位硬膜外麻醉的观察.齐齐哈尔医学院学报,2000,21：62-63.
[20]何建训.硬膜外不同注射速度又打且滞平面扩徽的影响临床麻醉学杂志,1992,8(2)：71.
[2]曾因明,邓小明.米勒麻醉学,第六版,北京大学医学出版社602.
[3]兰天民,苏跃.硬膜外麻醉复合咪哒唑仑术中患者的遗忘作用.中华麻醉学杂志,2003,23(10)：783.
[4]Panousis P, Heller AR, Koch T, et al. Epidural ropivacaine concentrations for intraoperative analgesia during major upper abdominal surgery:a prospective, randomized, double-blinded, placebo-controlled study. Anesth Analg,2009,108(6):1971-1976.
[5]Sakura S, Sumi M, Kushizaki H, et al. Concentration of lidocaine affects intensity of sensory block during lumbar epidural anesthesia. Anesth Analg,1999,88(1):123-127.
[6]Bromage PR. Mechanism of action of extradural local anaesthetics. Br J Anaesth,1975,47:199-211.
[7]Sakura S, Sumi M, Yamada Y, et al. Quantitative and selective assessment of sensory block during lumbar epidural anaesthesia with 1% or 2% lidocaine. Br J Anaesth,1998,81(5):718-722.
[8]Nakayama M, Yamamoto J, Ichinose H, et al. Effects of volume and concentration of lidocaine on epidural anaesthesia in pregnant females. Eur J Anaesthesiol,2002,19(11):808-811.
[9]Liu Spencer S, Ware Paul D, Rajendran, et al. Effects of Concentration and Volume of 2-Chloroprocaine on Epidural Anesthesia in Volunteers. Anesthesiology,1997,86(6):1288-1293.
[10]傅润乔.两种浓度氯普鲁卡因用于宫产硬膜外麻醉的临床观察.北京医学,2005,27：219-221.
[11]Kopp SL, Wynd KP, Horlocker TT, Regional blockade in patients with a history of a seizure disorder. Anesth Analg,2009,109(1):272-278.
[12]Lonnqvist PA. Regional anaesthesia and analgesia in the neonate. Best Pract Res Clin Anaesthesiol,2010,24(3):309-321.
[13]何建训.硬膜外不同注射速度又打且滞平面扩徽的影响临床麻醉学杂志,1992,8(2)：71.
[14]Danelli G, Venuti FS, Zasa M, et al. Continuous lumbar epidural infusion of levobupivacaine:effects of small-or large-volume regimen of infusion. Acta Anaesthesiol Scand,2009,53(4):483-488.
[15]Galindo A,Hernandez J,Benavides O.Quality of spinal extradural anaesthesia.The influence of spinal nerve root diameter.Br J Anaesth 1975;47(1):41-7.
[16]Sindhvananda W, Leelanukrom R, Rodanant O,et al. Maternal satisfaction to epidural and spinal anesthesia for cesarean section. J Med Assoc Thai,2004,87(6):628-635.
[1]庄心良,曾因明,陈伯銮.现代麻醉学.第三版,北京,人民卫生出版社,7,1089.
[2]Duggan J, Bowler GMR, McClure JH, et al. Extradural block withbupivacaine:Influence of dose,volume,concentration and patient characteristics. Br J Anaesth,1988,61(3):324-331.
[3]Sakura S, Sumi M, Kushizaki H, et al. Concentration of lidocaine affects intensity of sensory block during lumbar epidural anesthesia. Anesth Analg,1999,88(1):123-127.
[4]徐启明.主编临床麻醉学.第2版,人民出版社,112-118.
[5]Kopp SL, Wynd KP, Horlocker TT, Regional blockade in patients with a history of a seizure disorder. AnesthAnalg,2009,109(1):272-278.
[6]Lonnqvist PA. Regional anaesthesia and analgesia in the neonate. Best Pract Res Clin Anaesthesiol,2010,24(3):309-321.
[7]曾因明,邓小明.米勒麻醉学.第六版,北京大学医学出版社,602.
[8]Brook R, McGlynn E, Cleary PD. Measuring quality of care. N Engl J Med,1996,335:966-970.
[9]Bromage PR. Mechanism of action of extradural local anaesthetics. Br J Anaesth,1975,47:199-211.
[10]Burn JM, Guyer PB, Langdon L.The spread of solutions injected into the epidural space:A study using epidurograms in patients with lumbosciatic syndrome. Br J Anaesth,1973,45(4):338-10.
[11]Bengtsson M, Malmqvist L, Edstro"m H. Spinal analgesia with glucose-free bupivacaine:effects of volume and concentration. Acta aesthesio-logica Scandinavica,1984,28(5):583-586.
[12]Sakura S, Sumi M, YamadaY, et al. Quantitative and selective assessment of sensory block during lumbar epidural anaesthesia with 1% or 2%lidocaine. Br J Anaesth,1998,81(5):718-722.
[13]Nakayama M, Ichinose H, Yamamoto S, et al. Effects of volume and concentration of lidocaine on epidural anaesthesia in pregnant females. European Journal of Anaesthesiology,2002,19(11):808-811.
[14]Liu SS, Ware PD, Rajendram S. Effects of concentration and volume of 2-chloroprocaine on epidural anesthesia in volunteers. Anesthesiology, 1997,86(6):1288-1289.
[15]Mira Dernedde, Michaela Stadler, Francoise Bardiau, et al. Continuous epidural infusion of large concentration/small volume versus small concentration/large volume of levobupivacaine for postoperative analgesia. Anesth Analg,2003,96(3):796-801.
[16]傅润乔,岳云,薛绵荣,等.两种浓度氯普鲁卡因用于宫产硬膜外麻醉的临床观察.北京医学,2005,27：219-221.
[17]Kaneko T, Iwama H. The association between injected volume of local anesthetic and spread of epidural anesthesia:a hypothesis.Reg Anesth Pain Med,1999,24(2):153-157.
[18]Shinichi Sakura, Mariko Sumi, Hiroyuki Kushizaki,et al. Concentration of Lidocaine affects intensity of sensory block during lumbar epidural Anesthesia. Anesth Analg,1999,88(1):123-127.
[19]赵为民,米德文,李秀慧.低浓度大剂量局麻药用于低位硬膜外麻醉的观察.齐齐哈尔医学院学报,2000,21：62-63.
[20]何建训.硬膜外不同注射速度又打且滞平面扩徽的影响临床麻醉学杂志,1992,8(2)：71.