神经阻滞麻醉对老年心脏患者下肢手术围术期心血管并发症的影响

Effects of combined lumbar plexus and sciatic nerve block on perioperative cardiovascular complications in elderly patients with heart disease undergoing lower limb surgery

目的:观察后路腰丛联合坐骨神经阻滞用于并发心脏病的老年患者行下肢手术的临床麻醉效果,探讨该方法是否能降低患者围术期心血管并发症的发生率。方法:拟行择期膝关节镜手术并发心脏疾患的老年患者60例,随机分为两组,每组30例,其中A组采用常规腰硬联合麻醉;B组采用神经刺激器定位辅助后路腰丛联合坐骨神经阻滞。记录手术中不同时间点的平均动脉压(MAP)、心率(HR)变化,感觉、运动阻滞起效和维持时间,术后镇痛效果及术后72 h的心血管不良事件发生率。结果:两组患者麻醉前后HR变化组间比较无明显统计学差异,A组患者麻醉后MAP呈下降趋势,在麻醉后10 min及15 min,MAP明显低于B组患者(P<0.05),在其余时间点两组间无明显统计学差异。而B组患者各时间点的MAP无明显变化。A组患者术后心血管不良事件发生率为23%,明显高于B组(10%,P<0.05)。A组患者感觉、运动阻滞起效时间[(1.3±0.9)min和(4.1±2.3)min]均短于B组[(7.9±2.4)min和(15.2±4.1)min,P<0.05]。但B组患者感觉阻滞维持时间[(418±103)min]明显长于A组[(182±99)min,P<0.05],且运动阻滞维持时间[(282±68)min]明显短于A组[(305±76)min,P<0.05]。术后6 h B组患者的VAS评分[(1.1±0.2)分]明显低于A组[(5.2±1.7)分,P<0.05]。结论:对于并发心血管疾患的老年高危患者施行下肢手术,采用后路腰丛联合坐骨神经阻滞麻醉,更有利于术中维持稳定的血流动力学,并减少术后心血管并发症的发生率,术后镇痛时间更长,有利于患者的术后恢复。

AIM： To investigate the feasibility of combined lumbar plexus and sciatic nerve block in elderly patients with heart disease undergoing lower limb surgery and whether this modality of anesthesia could decrease the incidence of perioperative cardiovascular complications. METHODS： Sixty elderly patients undergoing arthroscopic knee surgery were divided randomly into combined lumbar plexus and sciatic nerve block group （ PNB group, n = 30 ） and combined spinal and epidural anesthesia group （CSEA group, n =30）. Changes of mean arterial blood pressure （MAP） and heart rate （HR） at different time points during operation, onset and recovered time of sensory, motor nerve block, analgesic persistent time and perioperative cardiovascular complications were recorded. RESULTS： There were no significant differences in HR at different time points between groups （P 〉0. 05）. MAP in CSEA group was significantly lower at 10- and 15-min timepoints after injection of local anesthetics compared with that in the PNB group （P 〈 0. 05 ）. The incidence of perioperative cardiovascular complications in the CSEA group （23%） was significantly higher than in the PNB group （17%） （P 〈0. 05 ）. Sensory and motor nerve onset time in CSEA group [ （ 1.3 ± 0. 9） min and （4. 1 ± 2.3 ） rain ] was shorter than in the PNB group [ （7.9±2.4） rain and （15.2 ±4. 1 ） min （P 〈0. 05） ], whereas the sensory nerve maintenance time in the PNB group [ （418± 103） mini was longer than that in CSEA group [ （ 182 ＋99） mini, and the motor nerve maintenance time in PNB group [ （282 _＋ 68 ） min] was shorter than in the CSEA group [ （305 ± 76） min, P 〈 0. 05 ]. Postoperative 6-h VAS scores in PNB group （ 1.1 ± 0. 2） were significantly lower than those in the CSEA group [ （5.2 ± 1.7 ）, P 〈 0. 05 ]. CONCLUSIONS： Combined lumbar plexus and sciatic nerve block is suitable for elderly patients with heart disease undergoing lower limb procedures by providing a longer analgesia, stable hemodynamics and fewer cardiovascular complications