摘要
目的:通过L2~3和L3~4两个不同穿刺间隙、采用0.5%等比重布比卡因7.5mg和10mg腰硬联合麻醉用于髋关节以下部位手术中的临床研究,观察不同穿刺部位腰硬联合麻醉对腰麻阻滞平面及血流动力学的影响。
方法:随机选择择期行髋关节及以下部位手术的患者80例,年龄18~64岁,ASA分级Ⅰ~Ⅱ级,分成四组。Ⅰ组是穿刺部位为L2~3、0.5%布比卡因7.5mg,Ⅱ组是穿刺部位为L2~3、0.5%布比卡因10mg,Ⅲ组是穿刺部位为L3~4、0.5%布比卡因7.5mg,Ⅳ组是穿刺部位为L3~4、0.5%布比卡因10mg,每组20例。注药速度均为0.2ml/s。观察并记录感觉阻滞起效时间、感觉阻滞平面固定时间及感觉阻滞最高平面;用改良Bromage等级评分法进行运动阻滞评级;观察脊麻用药后5min、10min、15min、20min、30min、40min、60min血压和心率的变化,并记录患者入室后的SBP、DBP、HR的基础值及术中血压和心率的最低值及出现的时间。记录术中患者低血压、心动过缓、呼吸抑制、寒战、恶心呕吐及术后头痛的发生情况及例数。
结果:各组患者感觉阻滞起效时间、平面固定时间差异无统计学意义(P>0.05)。最高感觉阻滞平面比较:同一穿刺点不同剂量Ⅰ组与Ⅱ组、Ⅲ组与Ⅳ组比较差别有统计学意义(P<0.05);不同穿刺点同一剂量Ⅰ组与Ⅲ组、Ⅱ组与Ⅳ组比较差别有统计学意义(P<0.05)。运动阻滞方面,各组患者最大Bromage分级均集中在2~3级,且分布例数差别无统计学意义(P>0.05)。蛛网膜下腔给药后四组患者SBP、DBP、HR均有不同程度下降,但术中收缩压和舒张压的最低值与基础值比较Ⅰ组与Ⅲ组、Ⅱ组与Ⅳ组差别无统计学意义(P>0.05)。四组患者麻醉后低血压发生率比较差异无统计学意义(P>0.05)。四组寒战发生率差异无统计学意义(P>0.05)。所有患者均无明显呼吸抑制、恶心呕吐及术后头痛发生。
结论:等比重布比卡因7.5mg和10mg腰硬联合麻醉用于髋部以下手术的麻醉效果好,对血流动力学影响较小。等比重液腰硬联合麻醉时腰麻阻滞平面上界水平不仅与局麻药剂量有关,而且与穿刺部位(L2~3与L3~4比较)密切相关,即相同剂量(7.5mg和10mg)L2~3间隙比L3~4间隙的阻滞平面上界高约两个节段。
Objective: To research the safety and the suitable puncture position of various surgerys combined spinal-epidral anesthesia (CSEA) by compared with the influence of blockage plane and hemodynamics when to choose the L2~3 and L3~4 puncture spots and isobaric bupivacaine of the different doses on the lower limb surgerys.
Methods: Eighty patients scheduled for the lower limb surgerys to apply combined spinal-epidral anesthesia (CSEA) are randomly selected who is 18~64 years and ASA physical stadusⅠ~Ⅱ, and divided into four groups:the L2~3 interspace and 7.5mg of isobaric bupivacaine( groupⅠ) ,the L2~3 interspace and 10mg of isobaric bupivacaine(groupⅡ),the L3~4 interspace and 7.5mg of isobaric bupivacaine(groupⅢ) and the L3~4 interspace and 10mg of isobaric bupivacaine(groupⅣ). Each group involves 20 patients. The speed of infusion anesthesic to cavitas subarachnoidealis in all patients was 0.2ml/s. The time of sensory block occur , the time of sensory block reaching to the maxlmum plane and the maxlmum plane of sensory block are Observed and recorded, the numbers of motor block reaching to maxlmum and evaluating motor block by modified bromage scale, the change of blood pressure and heart rate of 5min, 10min, 15min, 20min, 30min, 40min and 60min is observed after intrathecal local anesthetic administration, the foundation values of SBP、DBP、HR after patients entering room, the values and the occurring time of the lowest BP and HR during surgering, the incidence and numbers of hypotension, bradycardia, respiratory depression, shivering, nausea and vomit, postdural puncture headache(PDPH), et al, they are recoded.
Results: It doesn't exist significant differences among four groups of the time of sensory block occurred and sensory block reaching to maxlmum plane (P>0.05). There is significant differences between groupⅠand groupⅡ, groupⅢand groupⅣof the maxlmum plane of sensory block(P<0.05). That is groupⅡ>groupⅠand groupⅣ>groupⅢ. There is significant differences between groupⅠand groupⅢ, groupⅡand groupⅣof the maxlmum plane of sensory block(P<0.05). That is groupⅠ>groupⅢand groupⅡ>groupⅣ. Bromage scale of four groups concentrated on 2~3 levels. No among groupⅠand groupⅢ, groupⅡand groupⅣin 2 and 3 level of motor block. SBP, DBP, HR of all patients decreased with different degrees In 60 minutes after SA, but no significant differences betweet Minimum value and foundation value among groupⅠand groupⅢ. So do groupⅡand groupⅣ. The incidence of hypotension groupⅡafter SA is high than groupⅠ, groupⅢand groupⅣ. That is 5%、10%、5% and 5% by turns among four groups. No significant differences among four groups of shivering were observed (P>0.05). All patients have no obvious respiratory depression, nausea , and vomit and postdural puncture headache(PDPH).
Conclusion: CSEA at different puncture spots with Isobaric bupivacaine usually has good performance to the lower limb surgerys because of good stability of hemodynamics,the minor incidence rate of untoward effect. The effect of different clearances for puncturing at L2~3 and L3~4 is not the same, choosing L2~3 always obtains at least 2 segment spinals higher planum than L3~4.
引文
1 Cook TM. Combined spinal-epidural techniques. Anaest hesia, 2000, 55 (1) : 42-64.
2 Klasen J , J unger A , Hartmann B , et al . Differing incidences of relevant hypotension with combined spinal - epidural anest hesia and spinal anest hesia. Anesth Analg, 2003, 96 (5) : 1491-1495.
3 Lee JS,Ranasinghe JS,Steadman J. Combined spinal epidural anaesthesia is better than spinal or epidural alone[J] . Rr J Anaesth, 2004, 92: 295-296.
4王忱,刘怀萍.腰麻硬膜外联合麻醉在不同手术患者的临床应用和比较[J].临床医学, 2005, 25(5): 9-11.
5 Coutes MB. Combined subarachnoid and epidural techniques. Anaesthesia, 1982, 37: 89.
6庄心良,曾因明,陈伯銮,主编.现代麻醉学,第三版.北京:人民卫生出版社, 2003. 1078.
7徐桂茹,贾方,桂晓臣等. 0.15%罗比卡因轻比重腰-硬联合麻醉用于侧位下肢骨科手术的可行性.临床麻醉学杂志, 2006, 22(7): 518-519.
8许靖,刘明基.腰麻-硬膜外联合麻醉在子宫切除术的应用.临床麻醉杂志, 2006, 22(12): 952-954.
9庄心良,曾因明,陈伯銮,主编.现代麻醉学,第三版.北京:人民卫生出版社, 2003. 1084-1085.
10 Wouff AP Hasselstraml, Kerkamp HE, et al.Extradural Propivacaine and bupivacaine in hip surgery. Br J Anaesth 1995, 74: 458-600.
11黄盛辉,主编.实用硬脊膜外腔神经阻滞学.第2版.北京:科学出版社,2001. 10212.
12刘俊杰,赵俊,主编.现代麻醉学.第二版.北京:人民卫生出版, 1996. 641.
13彭书岭,钟亮,骆厚仪等.高位硬膜外阻滞下硬膜外与静脉辅助用镇痛药对呼吸影响比较.中华麻醉学杂志, 1998, 18: 410-411.
14庄心良,曾因明,陈伯銮,主编.现代麻醉学.第3版.北京:人民卫生出版社, 2003. 1080-1081.
15向太,王桂芳,郑述碧.等比重液腰麻的临床应用[J].四川医学, 2003, 24(4): 366.
16徐莉,郭曲练,鄢建勤.等比重与重比重局麻药在腰麻中的临床应用.中南大学学报(医学版). 2005, 30(3): 325-327.
17刘瑶,郭曲练,鄢建勤.联合腰麻硬膜外麻醉在脐以下手术中的应用[J].中国现代医学杂志, 2001, 11(10): 42-44.
18李雪萍.腰硬联合麻醉等比重液在侧卧位下肢手术中的应用.中国误诊学杂志, 2003, 3: 886-887.
19 Rawal N. Schollin J, Wwsstrom G. Epidural versus combined spinal- epidural block for cawsarean section[J]. Acta Anaesth Scan. 1998, 32(1): 61.
20 Hing JY, Lee IH.Seoul. Comparision of the Effects of Intrathecal Morphine and Pethdine on Shicering after Caesarean Delivery under Combined Spinal-Epidural Anesthesia. Anaesthesia, 2005, 60(12): 1168-1172.
21史宏伟,鲍红光,朱建明.联合腰麻-硬膜外麻醉时硬膜外注药升高阻滞平面机制的探讨.临床麻醉学杂志, 2000, 16(7): 364.
22米勒,麻醉学[M].第5版.北京:科学技术出版社, 2001: 2046-2048.
23庄心良,曾因明,陈伯銮,主编.现代麻醉学.第3版.北京:人民卫生出版社, 2003. 1080-1086.
24江楠,黄文起,肖高灿等.腰-硬联合麻醉时不同注药速度对麻醉及效果的影响[J].临床麻醉学杂志, 2000, 16(12): 623.
25杨文科,翁建东,周东贤等.腰硬联合麻醉不同注药速度对麻醉平面的影响.临床麻醉学杂志, 2003, 1(19): 49.
26郑颖梅,沈跃华,程建新等.罗哌卡因等比重液用于老年病人腰-硬联合麻醉阻滞的临床研究.临床麻醉学杂志, 2005, 2(13): 174-176.
27 Markham A, Faulds D. Ropivacaine. Areview of its pharmacology and therapeutic use in regional anaesthesia. Drugs, 1996, 52: 429- 449.
28徐启明,李文硕,主编.临床麻醉学.北京:人民卫生出版社. 2000. 120-121.
29 Reisli R, Celik J, Tuncer S, et al. Anaesthetic and haemodynam ic effects of continuous spinal versus continuous epidural anaesthesia with prilocaine. Eur J Anaesthesiol, 2003, 20: 26-30.
30 De Andres JA, Febre E, Bellver J, et al. Continuous spinal anaesthsia versus single dosing. A comparative study. Eur J Anaesthesiol, 1995, 12: 135-140.
31马平,李金生,梁向东.老年高危髋关节置换术36例麻醉报告[J].中华麻醉学杂志, 2000, 20(3): 184.
32黄绍农,曾邦雄.临床麻醉新理论和新技术[M].长沙:湖南科学技术出版社, 2003. 293.
33 Klasen J. Junger A. Hartmann B, et al. Differing incidences of relevant hypotension with eorabined spinal-epidural anesthesia and spinal anaesthesia. Anesth Analg, 2003, 96(5): 1491-1495.
34 Aredt JO, Bomer W, Krauth J, et al. Incidence and time course of cardiovascular side effects during spinal anesthesia after prophylactic administrationof intracenous fluids or vasoconstrictors[J]. Anesth Analg,1998, 87: 347-354.
35 Ramssmy M, Birnbach DJ, Stein DJ, et al. A comparison of complications which occur following combined spinal-epidural or continuous infusion epidural analgesia for labor sbstract.Socobstet Anesth Perinatol, 1995, 80(3): 104.
36宋英,罗启芳,罗江勤.蛛网膜下腔麻醉前输液对麻醉后血压的影响.护士进修杂志, 2004, 19(9): 788.
37 Casey WF, Smith CE, Katz JM, et al. Intravenous meperi dine for control of shivering during caesarean section under epidural anaesthesia Can J Aanasth. 1998, 35: 128-133.
38 Horn EP. Standl T, Sessler DI, et al. Physostigmine prevents postanesthetic shivering as does meperidine or clonidine.Anesthesiology, 1998, 88(1): 108-113.
39孙大全,杭燕南主编.实用临床麻醉学[M].北京:中国医药科技出版社, 2001. 14: 381.
40 Klasen J, Junger A, Hartmann B, et al. Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia. Anesth Analg, 2003, 96(5): 1491-1495.
41 Patel M, Swami A. Combined spinal - extradural anaesthesia for caesarean section. Anaesthesia , 1992 , 47(11) : 1005.
1 Cook TM. Combined spinal - epidural techniques. Anaest hesia, 2000, 55 (1) : 42 - 64.
2 Klasen J, J unger A, Hartmann B, et al. Differing incidences of relevant hypotension with combined spinal - epidural anest hesia and spinal anest hesia. Anesth Analg, 2003, 96 (5): 1491 - 1495.
3 Lee JS,Ranasinghe JS,Steadman J. Combined spinal epidural anaesthesia is better than spinal or epidural alone[J] Rr J Anaesth, 2004, 92: 295-296.
4王忱,刘怀萍.腰麻硬膜外联合麻醉在不同手术患者的临床应用和比较[J].临床医学, 2005, 25(5): 9-11.
5黄文,罗洁,陶新发等.腰麻-硬膜外联合阻滞在前列腺汽化电切术中的应用效果观察.广西医学, 2002, 24(10): 1534-6.
6王华民,李志学,曲仁海等.腰麻硬膜外复合麻醉法10年临床分析[J].中华麻醉学杂志, 1999, 19(10): 624-625.
7 Coutes MB. Combined subarachnoid and epidural techniques. Anaesthesia, 1982, 37: 89.
8殷玉水,黄科昌,程善光等.脊麻硬膜外联合穿刺针的合理设计[J].中国医疗器械杂志, 2000, 24(1): 36-37.
9 Eldor J, Chaimsky G. Combined spinal-epidural needle (CSEN). Can J Anaesth, 1988, 35: 537.
10顾东妹,李树人.腰麻-硬膜外联合阻滞2483例临床总结[J].临床麻醉学杂志, 2001, 17(6): 3171.
11张野.复合腰麻硬膜外麻醉.国外医学麻醉学与复苏分册, 1996, 17(4): 210-212.
12庄心良,曾因明,陈伯銮主编.现代麻醉学.第3版.北京:人民卫生出版社. 2003: 1094.
13王维林,吴进凤.联合椎管内麻醉时硬膜外给药作用机制的探讨[J].中国现代医学杂志, 2002, 12(14): 71-72.
14 Miller RD. An-esthesia. 5ed.北京:中国科学出版社. 2001, 1515-1516.
15 Hong JY, Lee IH. Seoul. Comparision of the Effects of Intrathecal Morphine and Pethdine on Shivering after Caesarean Delivery under Combined Spinal-Epidural Anesthesia. Anaesthesia, 2005, 60(12): 1168-1172.
16陆萍,王秀丽,魏淑明等.椎管内联合穿刺的临床应用[J].中华麻醉学杂志, 1999, 19(10): 6291.
17.杜健儿,邓小明,徐美英.联合椎管内麻醉时硬膜外注药升高阻滞平面的机制研究[J].临床麻醉学杂志, 2000, 16(5): 233-234.
18陈传义,刘培斌,唐兴宁等.腰麻-硬膜外联合麻醉应用于剖宫产手术2134例临床观察.中国误诊学杂志, 2002, 2(12): 1847-8.
19安刚,薛富善主编.现代麻醉学技术[M].北京:科学技术文献出版社, 1999, 12-91.
20周少丽,蔡王君,马武华等.预注麻黄素预防腰麻-硬膜外联合麻醉下剖宫产术低血压.广东医学, 2002, 23(9): 32-3.
19于代华,岳云,罗颖.联合麻醉时硬膜外腔注药影响腰麻平面的机理探讨.北京医学, 2000, 22(5): 283.
20 Patel M, Swami A. Spinal anaesthesia for Caesarean section. Br J Anaesth , 1992, 69(6) : 662.
21史宏伟,鲍红光,朱建明.联合腰麻-硬膜外麻醉时硬膜外注药升高阻滞平面机制的探讨.临床麻醉学杂志, 2000, 16(7): 364.
22庄心良,曾因明,陈伯銮,主编.现代麻醉学,第三版.北京:人民卫生出版社, 2003. 1084-1085.
23黄文起,主译.局部麻醉学,第一版.北京:人民卫生出版社,2008. 106.
24艾肯海德.麻醉学[M],第3版.北京:科学技术出版社, 1999: 545.
25米勒.麻醉学[M],第5版.北京:科学技术出版社, 2001: 2046-204.
26 Rachel H, Foster, Anthony Markham. Levobupivacaine: A Review of its pharmachology and use as a local Anaesthetic, Drugs, 2000, 59(3): 551.
27 McClure JH. Ropivacaine. Br J Anaseth, 1996, 36: 300- 307.
28 Markham A, Faulds D. Ropivacaine. Areview of its pharmacology and therapeutic use in regional anaesthesia. Drugs, 1996, 52: 429- 449.
29俞卫峰.麻醉与复苏新论.上海:第二军医大学出版社, 2001, 6.
31郑颖梅,沈跃华,程建新等.罗哌卡因等比重液用于老年病人腰-硬联合麻醉阻滞的临床研究.临床麻醉学杂志, 2005, 21(3): 174-176.
32易杰,黄宇光,罗爱伦等.罗比卡因用于腰麻-硬膜外联合阻治的临床观察.中华麻醉学杂志, 2000, 20: 26-28.
33陆云梅,李幼琴.罗哌卡因腰-硬联合阻滞在下腹部和下肢手术中的应用.临床麻醉学杂志, 2007, 23(4): 340.
34 Gautier PE, De Kock M, Van Steenberge A, et al, Intratlecal ropivacaine for ambulatory surgery. Anesthesiology, 1999, 91 (5): 1239 -1245.
35郭艳辉,王俊科,许国忠等.罗比卡因用于蛛网膜下腔阻滞的实验研究.中华麻醉学杂志, 2002, 22: 2-45.
36徐桂茹,贾方,桂晓臣等. 0.15%罗比卡因轻比重腰-硬联合麻醉用于侧卧位下肢骨科手术的可行性.临床麻醉学杂志, 2006, 22(7): 518-519.
37刘向荣,王祖良,肖兆妍等.轻比重左旋布比卡因单侧腰-硬联合阻滞在患者下肢手术的应用.临床麻醉学杂志, 2006, 22(8): 638-639.
38许靖,刘明基.腰麻-硬膜外联合麻醉在子宫切除术的应用.临床麻醉学杂志,2006, 22(12): 952-954.
39庄心良,曾因明,陈伯銮,主编.现代麻醉学,第三版.北京:人民卫生出版社, 2003. 1078.
40贾真,朱平增,李作菊等.腰麻-硬膜外联合麻醉的缺点的改良思路与方法.国外医学麻醉学与复苏分册, 2003, 24(1): 15-17.
41 Rawal N, schollin J, Wesstrom G. Epidural versus combined spinal epidural block for cesarean section Acta Aneasthesiology Stand, 1988, 32: 61.
42 Blumgart CH, Ryall D Dennison B. et al. Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. Br J Anaesth, 1992, 69: 457.
43金宗英,罗启芳,罗江勤.蛛网膜下腔麻醉前输液对麻醉后血压的影响.护士进修杂志, 2004, 19(9): 788.
44曹国平.腰麻-硬膜外麻醉在老年患者股骨颈骨折手术中的应用.临床麻醉学杂志, 2006, 22(10): 795.
45宋修响,高秀丽.脊麻硬膜外麻醉联合麻醉穿刺针[J].中国医疗器械杂志, 1998, 6: 357.
46孙大全,杭燕南主编.实用临床麻醉学[M].北京:中国医药科技出版社, 2001.14: 381.
47 Klasen J, Junger A, Hartmann B, et al. Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia. Anesth Analg, 2003, 96(5): 1491-1495.
48吴新民. 21世纪医师丛书一麻醉科分册,北京中国协和医科大学出版社, 2000: 137.