等比重液腰硬联合麻醉不同穿刺部位对麻醉平面及效果的影响
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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.
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
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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.
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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.
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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.
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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.
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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.
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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.