老年患者硬脊膜外腔阻滞诱导期的容量治疗

Fluid administration in elderly patients during induction of epidural anesthesia

目的观察老年患者硬脊膜外腔阻滞中血流动力学的变化及预防性容量治疗对血流动力学的影响,以探索恰当的预防性容量治疗方法。方法 80例择期行下肢手术的老年患者(年龄>60岁)根据容量治疗方法分为4组,每组20例。无容量治疗组:不进行预防性容量治疗。乳酸钠林格液组:静脉滴注乳酸钠林格注射液10 mL/kg。晶胶液组:按1:1比例静脉滴注乳酸钠林格注射液和6%羟乙基淀粉(HES)200/0.5(商品名为万汶)10 mL/kg。HES组:单纯使用6%HES 200/0.5 10 mL/kg。分别在食管超声放置后15 min(T_0)、扩容15 min(T_1)、硬脊膜外腔注射药物10 min(T_2)和15 min(T_3),记录心脏指数(CI)、平均动脉压(MAP)、心率(HR)和中心静脉压(CVP)。结果无容量治疗组在T_3时间点的CI和T_2、T_3时间点的MAP均显著低于T_0时间点(P值均<0.05)。乳酸钠林格液组在T_1、T_2、T_3时间点的CI与T_0时间点的差异均无统计学意义(P值均>0.05),在T_2、T_3时间点的MAP均显著低于T_0时间点(P值均<0.05)。晶胶液组在T_3时间点的CI显著高于T_0时间点(P<0.05),在T_2、T_3时间点的MAP均显著低于T_0时间点(P值均<0.05)。HES组在T_2、T_3时间点的CI显著高于T_0时间点(P值均<0.05),各时间点的MAP与T_0时间点的差异均无统计学意义(P值均>0.05)。HES组T_3时间点与T_0时间点的CI差值和MAP差值显著高于其他3组(P值均<0.05)。4组各时间点间的HR、CVP的差异均无统计学意义(P值均>0.05)。结论老年患者在硬脊膜外腔阻滞麻醉诱导期会出现血流动力学紊乱,应用6%HES预防性扩容治疗可以有效防止此类不良反应。

Objective To observe the hemodynamic change and to investigate the effects of different fluid preload strategies on hemodynamics in elderly patients during epidural anesthesia. Methods Eighty elderly patients （age〉60 years） scheduled for selective operation of lower extremity under epidural anesthesia were randomized into non-preload group （no infusion before epidural anesthesia）, Ringer group （intravenous drip of Ringer＇s solution 10 mL/kg〉, HES and Ringer＇s group （1 ： 1 intravenous drip of 6 % hydroxyethyl starch [HES 200/ 0.51 and Ringer＇s solution 10 mL/kg） and HES group （6% HES 200/0.5） according to different fluid preload strategies. There were 20 patients in each of the four groups. Cardiac index （CI）, mean arterial pressure （MAP）, heart rate （HR〉 and central venous pressure （CVP〉 were measured and recorded at T0 （ 15 minutes after the placement of transesophageal echocardiography probe）, T1 （15 minutes after infusion）, T2 （10 minutes after epidural injection of drugs） and T3 （15 minutes after epidural injection of drugs）. Results CI at T3 and MAP at T2, T3 were sJgnJfJcantly lower than those at To Jn non-preload group （all P〈0.05）. Ringer group： There were no significant difference in CI between T1 and To, T2 and To, T3 and T0（all P〉0.05）, while MAP were significantly decreased at T2 and T3 as compared with To （all P〈0.05）. HES and Ringer group. CI was significantly increased at T3, while MAP were significantly decreased at T2 and T3as compared with To （all P〈0.05）. HES group.. CI at T2 and T3 were significantly higher than that at To （all P〈0.05）, but there was no significant difference in MAP between To and other three time points （P〉0.05）. ACI （CI at T3 minus CI To time point） and AMAP （MAP at T3 minus MAP at To ） in HES group was significantly higher than those in the other three groups. There were no significant differences in HR and CVP at each time point in each group （all P〉0.05）. Conclusion The induction of epidural anesthesia may cause hemodynamic disturbances in elderly patients. 6% HES as the preload fluid before anesthesia is effective in preventing this adverse effect. （Shanghai Med J, 2012, 35： 651-654）