不同麻醉方法对老年髋关节置换术患者术中血气及应激反应的影响

Effects of different anesthesia methods on blood gas parameters and stress response during hip replacement in elderly patients

目的观察不同麻醉方法对老年髋关节置换术患者术中血气及应激反应的影响,为临床麻醉方法的选择提供依据。方法选择ASAⅡ～Ⅲ级、择期行髋关节置换术的老年患者45例,随机分为三组:硬膜外麻醉组(A组),全身麻醉组(B组),腰丛神经阻滞复合全麻组(C组),每组15例。所有患者入室后行桡动脉穿刺置管,持续监测MAP和HR。A组穿刺点选择L2～3,穿刺成功后先注入2%利多卡因3～5ml作为试验量,再经硬膜外导管注入0.5%罗呱卡因5～8ml,调节麻醉平面不超过T10。B组麻醉诱导采用咪唑安定、芬太尼、维库溴铵和丙泊酚静注,气管插管后接麻醉机行机械通气,麻醉维持用七氟烷、维库溴铵。C组麻醉诱导前行腰丛神经阻滞,注射0.375%甲磺酸罗呱卡因20～30ml,然后进行全麻诱导。各组分别于麻醉前(T0)、切皮前1min(T1)、扩髓时(T2)、骨水泥灌注后(T3)、术毕(T4)经非输液前臂静脉采血标本,测定血糖(GLU)及血清皮质醇浓度(COR)。同时在各时点采集动脉血行血气分析。结果与T0时比较,A、B两组T1时MAP、HR显著下降(P<0.05);组间相比,B组T2时MAP、HR高于A、C组(P<0.05)。B组术后各时间点GLU、COR明显升高(P<0.05),且高于A、C组。A组T2的PaO2低于T0(P<0.05)。A组T2、T3的PaCO2显著升高,且高于B、C组(P<0.05)。结论在老年患者髋关节置换术中,采用全身麻醉复合腰丛阻滞既可有效的进行呼吸管理,又能调控应激反应,患者循环影响轻微,是值得推荐的麻醉方法。

Objective Observe the impact of different anesthetic techniques on blood gas parameters and stress response in the elderly hip replacement patients, to provide the basis for the choice of methods of clinical anesthesia. Methods 45 cases of elderly patients undergoing elective hip replacement were randomly divided into 3 groups of 15 cases. All patients were done by radial artery puncture catheter, continuous monitoring MAP and HR. Group A （epidural anesthesia） selected L2-3 intervertebral space, was given injection of 2% lidocaine 3-5 ml, then injection of 0.5% ropivacaine 8 ml, adjusting the level of anesthesia does not exceed the T10. Group B （general anesthesia） was induced with midazolam, fentanyl, vecuronium and etomidate emulsion and maintained with sevoflurane and vecuronium. Group C （general anesthesia combined with lumbar plexus block） was given lumbar plexus block with 0. 375% ropivacaine 20- 30 ml, and then the induction of general anesthesia. Groups before anesthesia （To） and before skin incision 1 rain （T1）, reamed （T2）, after the infusion of bone cement （T3）, the operation finished （T4） by the non--infusion of the forearm venous blood samples, first blood glucose after the chemiluminescence method for the determination of serum cortisol （COR）, while monitoring the blood gas parameters for each time point. Results After anesthesia, the MAP, HR in group A and B significantly decreased （P 〈 0.05）. Between the groups, the MAP, HR in group 13 were higher than A and C at T2 （P 〈 0.05）. The GLU and COR in group B were significantly increased （P 〈 0.05）. The PaO2 in group A was significantly lower than T0 at T2 （P 〈 0.05）. At Tz and T3, the PaCOz in group A was higher than in group B and C （P 〈 0.05）. Conclusions During hip replacement in elderly patients,light general anesthesia combined with lumbar plexus block is effective for respiratory management and inhabitation of the stress response, and the hemodynarnics is stable, the anesthetic method is recommended.