不同麻醉方法对老年患者围手术期脑卒中发生高危因素的影响
摘要
目的:通过选择择期行腹部手术的老年患者,观察不同麻醉方法对围术期不同时点血栓前状态指标变化的影响,探讨不同麻醉方法是否参与围手术期脑卒中发生的可能高危因素。
方法:采用前瞻性随机对照临床研究方法。选择ASAⅠ—Ⅱ级择期行腹部手术的老年患者24例,术前患者均无心肺脑合并症,随机分为三组:全麻联合硬膜外阻滞麻醉组(A组,n=8),单纯全身麻醉组(B组,n=8),硬膜外阻滞组(C组n=8)。A组采用异丙酚全凭静脉麻醉联合硬膜外阻滞,术后行患者自控硬膜外镇痛(PCEA),硬膜外阻滞选用0.375%布比卡因;B组采用异丙酚全凭静脉麻醉,术后行患者自控静脉镇痛(PCIA);C组采用单纯硬膜外阻滞麻醉,硬膜外阻滞选用0.5%布比卡因。分别在诱导前(T_1)、全麻诱导后(T_2)(C组为手术开始即刻)、术毕即刻(T_3)、术后72h(T_4)抽取静脉血,检测反映血管内皮损伤的参数vWF因子、凝血的参数FIB、抗凝的参数TAT、纤溶的参数D—二聚体水平变化。
结果:(1) vWF:在各个时间点水平作组间比较发现:T_2时B组含量高于A,C组,T_3时B组高于C组,A,C组间无明显差异。各组组内各个时间点比较无明显差异。(2)FIB:在各个时间点水平作组间比较发现:三组各个时间点组间差异不显著;A组各个时间点的比较发现,L_4时FIB水平高于另外三个时间点,C组各个时间点的比较发现,T_4时含量高于T2,T3.(3) D—二聚体:在各个时间点水平作组间比较发现:T_2时B组D—二聚体水平高于A组,各组组内各个时间点的比较发现,A组T_4时D—二聚体水平高于另外三个时间点,B组T_2时D—二聚体水平高于另外三个时间点;(4) TAT:三组各个时间点组间差异不显著,三组每组各个时间点比较也无显著差异。
结论:相比于单纯全麻,全麻复合硬膜外麻醉和单纯硬膜外麻醉应用于行腹部手术的老年患者,能减少因手术应激引起的血管内皮损伤,减少血小板活化,降低围手术期老年患者的高凝状态,但对于纤溶状态没有明显改善。从而有利于维持患者的凝血、纤溶、抗凝系统动态平衡,降低围手术期脑卒中发生的高危因素。
Objective:To observe the change of PTS markers in old patients after abdominal operations;to compare the difference of PTS markers under different anesthesia techniques after abdominal operations in old patients,and thereby prognose its influence of perioperative stroke in old patients.
Methods:It' s a prospective randomized control study.Twenty-four ASAⅠorⅡold patients undergoing selective abdominal surgeries were divided randomly into three groups:group A(receive general anesthesia combined with continuous epidural anesthesia,n=8);group B(receive general anesthesia,n=8);group C(receive continuous epidural anesthesia,n=8).In group B,patients were finished with convention followed by patient-controlled intravenous analgesia(PCIA);while in group A and group C,patients were given 0.375%bupivacaine to maintain the block level,and were finished by patient-controlled epidural analgesia(PCEA). Blood samples were taken at pre-anesthesia(T_1)、the end of induction (T_2)(the same time as when lacerating skins for group C)、the end of operation(T_3) and postoperative 72 h(T_4) to determine activation variables of platelet(vWF)、coagulation variables(FIB)、anticoagulation variables(TAT) and fibrinolysis variables(D-Dimer).
Results:1) vWF:the level of vWF of group B was higher than group A and C at T2;group B was higher than group C at T3,while there were no significant differences between group A and C.There were no significant differences between the four time points for every group.2) FIB:the level of FIB of group A at T4 was higher than that at T1,T2 and T3;the level of FIB of group C at T4 was higher than that at T2 and T3.3) D-Dimer: the level of D-Dimer of group B at T2 was higher than group A.For group A,the level of FIB at T4 was higher than that at T1,T2,and T3.For group B,the level of FIB at T2 was higher than that at T1,T3,and T4. 4)TAT:the differences between three groups at four time points and the differences between four time points for every group were not significant. Conclusions:Compared with general anesthesia,anesthesia combined with continuous epidural anesthesia decreases the activity of platelet caused by injury of endothelium,decreases the postoperative hypercoagulation in old patients after abdominal operations;however,it is not helpful in improving th fibrinolytic function.On the whole,general anesthesia combined with continuous epidural anesthesia has benefit in the banlance of coagulation and anticoagulation,so it can prevent the perioperative stroke in old patients.
方法:采用前瞻性随机对照临床研究方法。选择ASAⅠ—Ⅱ级择期行腹部手术的老年患者24例,术前患者均无心肺脑合并症,随机分为三组:全麻联合硬膜外阻滞麻醉组(A组,n=8),单纯全身麻醉组(B组,n=8),硬膜外阻滞组(C组n=8)。A组采用异丙酚全凭静脉麻醉联合硬膜外阻滞,术后行患者自控硬膜外镇痛(PCEA),硬膜外阻滞选用0.375%布比卡因;B组采用异丙酚全凭静脉麻醉,术后行患者自控静脉镇痛(PCIA);C组采用单纯硬膜外阻滞麻醉,硬膜外阻滞选用0.5%布比卡因。分别在诱导前(T_1)、全麻诱导后(T_2)(C组为手术开始即刻)、术毕即刻(T_3)、术后72h(T_4)抽取静脉血,检测反映血管内皮损伤的参数vWF因子、凝血的参数FIB、抗凝的参数TAT、纤溶的参数D—二聚体水平变化。
结果:(1) vWF:在各个时间点水平作组间比较发现:T_2时B组含量高于A,C组,T_3时B组高于C组,A,C组间无明显差异。各组组内各个时间点比较无明显差异。(2)FIB:在各个时间点水平作组间比较发现:三组各个时间点组间差异不显著;A组各个时间点的比较发现,L_4时FIB水平高于另外三个时间点,C组各个时间点的比较发现,T_4时含量高于T2,T3.(3) D—二聚体:在各个时间点水平作组间比较发现:T_2时B组D—二聚体水平高于A组,各组组内各个时间点的比较发现,A组T_4时D—二聚体水平高于另外三个时间点,B组T_2时D—二聚体水平高于另外三个时间点;(4) TAT:三组各个时间点组间差异不显著,三组每组各个时间点比较也无显著差异。
结论:相比于单纯全麻,全麻复合硬膜外麻醉和单纯硬膜外麻醉应用于行腹部手术的老年患者,能减少因手术应激引起的血管内皮损伤,减少血小板活化,降低围手术期老年患者的高凝状态,但对于纤溶状态没有明显改善。从而有利于维持患者的凝血、纤溶、抗凝系统动态平衡,降低围手术期脑卒中发生的高危因素。
Objective:To observe the change of PTS markers in old patients after abdominal operations;to compare the difference of PTS markers under different anesthesia techniques after abdominal operations in old patients,and thereby prognose its influence of perioperative stroke in old patients.
Methods:It' s a prospective randomized control study.Twenty-four ASAⅠorⅡold patients undergoing selective abdominal surgeries were divided randomly into three groups:group A(receive general anesthesia combined with continuous epidural anesthesia,n=8);group B(receive general anesthesia,n=8);group C(receive continuous epidural anesthesia,n=8).In group B,patients were finished with convention followed by patient-controlled intravenous analgesia(PCIA);while in group A and group C,patients were given 0.375%bupivacaine to maintain the block level,and were finished by patient-controlled epidural analgesia(PCEA). Blood samples were taken at pre-anesthesia(T_1)、the end of induction (T_2)(the same time as when lacerating skins for group C)、the end of operation(T_3) and postoperative 72 h(T_4) to determine activation variables of platelet(vWF)、coagulation variables(FIB)、anticoagulation variables(TAT) and fibrinolysis variables(D-Dimer).
Results:1) vWF:the level of vWF of group B was higher than group A and C at T2;group B was higher than group C at T3,while there were no significant differences between group A and C.There were no significant differences between the four time points for every group.2) FIB:the level of FIB of group A at T4 was higher than that at T1,T2 and T3;the level of FIB of group C at T4 was higher than that at T2 and T3.3) D-Dimer: the level of D-Dimer of group B at T2 was higher than group A.For group A,the level of FIB at T4 was higher than that at T1,T2,and T3.For group B,the level of FIB at T2 was higher than that at T1,T3,and T4. 4)TAT:the differences between three groups at four time points and the differences between four time points for every group were not significant. Conclusions:Compared with general anesthesia,anesthesia combined with continuous epidural anesthesia decreases the activity of platelet caused by injury of endothelium,decreases the postoperative hypercoagulation in old patients after abdominal operations;however,it is not helpful in improving th fibrinolytic function.On the whole,general anesthesia combined with continuous epidural anesthesia has benefit in the banlance of coagulation and anticoagulation,so it can prevent the perioperative stroke in old patients.
引文
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