腰麻在高龄病人髋关节置换手术中的应用

Application of spinal anesthesia in aged patients undergoing hip replacement

目的比较研究小剂量左旋布比卡因或布比卡因复合芬太尼腰麻在高龄病人髋关节置换手术中的麻醉效果和血液动力学改变。方法40例髋关节置换手术病人,年龄80～97岁,ASAⅡ～Ⅲ级,按随机化原则分成A、B组各20例。腰-硬联合穿刺,取L2～3一次注入蛛网膜下腔:A组左旋布比卡因3mg+芬太尼20μg,B组布比卡因3mg+芬太尼20μg,然后向上置入硬膜外导管4cm,术中酌情硬膜外注入2%利多卡因2～4ml。观察感觉、运动阻滞和血液动力学变化。当SBP下降到90mmHg或下降原SBP的30%以下时,静脉注射麻黄碱5～6mg。HR下降至55次/min或下降原HR的20%以下时,静脉注射阿托品0.3～0.5mg。结果40例皆麻醉满意,感觉阻滞2组均达T5～T8,运动阻滞达3级者A组低于B组(60.0%vs95.0%,P<0.05)。2组腰麻后SBP、DBP和HR水平无明显改变(P均>0.05)。A组1例、B组2例静脉注射了麻黄碱。结论小剂量左旋布比卡因或布比卡因复合芬太尼腰麻在高龄病人下肢手术中有优良的麻醉效果和稳定的血液动力学变化。

Objective To examine anesthesia effect and hemodynamic changes produced by small dose levobupivacaine and bupivacaine co-administered with fentanyl in spinal anesthesia for hip replacement in aged patients.Methods Forty aged patients（aged 80-97years,ASA II-Ⅲ） undergoing hip replacement were randomly divided into two groups：group A and group B（n=20,each）.Lumbar puncture was performed at the L2-3 interspace for subarachnoid injection and then epidural insertion upward 4 cm.The patients received a spinal anesthetics wether levobupivacaine 3 mg（group A） or bupivacaine 3 mg（group B） plus fentanyl 20 μg respectively.The anesthesia was maintained with epidural administration with 2% lidocaine 24 ml if necessary during the surgery.The extent of sensory blockade was assessed by pin-prick;the degree of motor blockade was recorded by Bromage score;hemodynamic changes and adverse events were observed and then compared.BP,HR,SpO2 and ECG were continously monitored during surgery.A systolic pressure below 90 mm Hg or a decrease of 30% from a baseline was defined as hypotension which was treated with intravenous bolus of ephedrine 5-6 mg .Heart rate fell below 55 per minute or a decrease of 20% from a baseline was treated with intravenous bolus of atropine 0.3-0.5mg.Results All patients had satisfactory anesthesia.There was no significant difference in sensory blockade between the two groups.The motor blockade（Bromage score 〉1） was longer and better in group B than that in group A.SBP,DBP and HR did not change significantly in group A and B after spinal anesthesia;one patient needed a single dose of 5 mg ephedrine in group A,in contrast,two patients received single dose of 5 mg ephedrine in group B.Conclusions A small dose of levobupivacaine 3 mg or bupivacaine 3 mg plus fentanyl 20 μg may provide satisfactory spinal anesthesia and cause less hypotension which almost do not require vasopressor support for the aged patients of spinal anesthesia.