连续腰麻对老年病人下肢手术围术期应激反应的影响

Effect of continous spinal anesthesia on stress response to surgery on lower limb of elderly patients

目的探讨连续腰麻(CSA)对老年病人下肢手术围术期应激反应的影响。方法择期行下肢骨科手术的老年病人40例,ASAⅠ～Ⅲ级,随机分为连续腰麻组(CSA组)和连续硬膜外阻滞组(CEA组,对照组),每组20例。CSA组常规行连续腰麻穿刺置管,给予0.375%布比卡因重比重液(0.75%布比卡因和10%葡萄糖注射液1∶1体积混合)0.5～1.0ml,CEA组常规行连续硬膜外穿刺置管,给予试验量2%利多卡因3ml和追加0.75%罗哌卡因8～10ml,两组病人麻醉平面均控制在T10以下。分别于手术前一天早上(T0)、手术当日麻醉前(T1)、麻醉后1h(T2)、术毕(T3)、术后24h(T4)及术后48h(T5)各时间点检测血压(BP)、心率(HR),计算心率收缩压乘积(RPP),并采静脉血检测血浆皮质醇(COR)和血糖(BS)。结果T0及T1时,患者平均动脉压(MAP)、HR、心率收缩压乘积(RPP)、COR和BS两组间比较差异均无统计学意义。CSA组MAP、HR及RPP在T1时显著升高(与T0时比较,P<0.01),而在T2时即恢复至T0水平,并持续至T(5与T0比较,P>0.05);上述各指标在麻醉后各时点(T2～T5)与T1比较,均显著降低(P<0.05或0.01);COR在T1时显著升高(与T0比较,P<0.01),麻醉后(T2～T5)降低(与T0比较,P>0.05),麻醉后各时点(T2～T5)与T1比较显著降低(P<0.05或0.01);BS在T1时升高,与T0比较P<0.05,麻醉后降低,各时点与T0比较,无统计学意义;与T1比较,T2至T5其降低则差异具有显著性(P<0.05或0.01)。上述CSA各指标围术期的变化与CEA组相似,而且各时点两组间比较差异无显著性。结论CSA用于老年病人下肢手术,能减轻病人围术期的应激反应。

[Objective] To explore the effect of continous spinal anesthesia （CSA） on stress response to surgery on the lower limbs of elderly patients. [Methods] Forty ASA Ⅰ-Ⅲ patients （21 males, 19 females） aged 65-90 years undergoing elective orthopedic procedures of lower limb were randomized to one of two groups： group CSA （continous spinal anesthesia, CSA） （n=20） and group CEA （continous epidural anesthesia, CEA, control group） （n= 20）. All the patients were premedicated with intramuscular diazepam 5 mg and scopolamine 0.3 mg. CSA was performed at L2/3 or L3/4 interspace. The patients received a 27 gauge continuous spinal catheter, which was threaded through a 22 gauge epidual needle into subarachnoid space. Hyperbaric 0.375% bupivacaine solution （0.75% bupivacaine：10% glucose solution=1：1） 0.5-1.0 mL was injected. If analgesia did not reach T10 after 5-10 minutes the same dose was repeated. In group CEA epidural catheter was placed also at L2/3 or L3/4. A test dose of 3 mL of 2% hdocaine was injected and then 0.75% ropivacaine 8-10 mL was injected into the epidural space. And analgesia should also reach T10. Lactated Ringer＇ S Solution （LR） 10 mL/kg·h and VoluvenTM （a hydroxyethylstarch 130, 000/0.4） 8-10 mL/kg·h （the ratio of volume of LR and Voluven is 3：1） were injected during operation. The parameters, including blood pressure （BP）, heart rate （HR）, blood eortisol concentration （COR）, blood glucose concentration （BS）, were detected at following time： in the morning of the day before surgery （T0）, before anesthesia induction （T1）, lh after anesthesia （T2）, at the end of surgery（T3. ）, 24 hours （T4） and 48 hours （T5） after the operation. [Results] The demographic data, duration of operation, intraoperative transfusion volume and blood loss were compared between the two groups. At TO and T1, all the parameters, including mean blood pressure （MAP）, HR, the rate pressure product （RPP）, COR and BS are compared between the two groups. In two groups, compared with those at TO, all the parameters increased significantly at T1. After anesthesia, MAP, HR, RPP, COR and BS in two groups decreased to the level at TO, and remained from T2 to T5. And there were no significant difference by comparing all the parameters at any time after anesthesia between the two groups. [Conclusion] CSA can prevent the stress response to surgery of lower limb, which is beneficial to recovery after operation.