硬膜外阻滞对老年腹腔镜胆囊切除患者围术期心肌损伤的影响

The effects of epidural block on myocardial damage during perioperation in old patients undergoing cholecystectomy by abdominoscope

目的:观察硬膜外阻滞对老年患者腹腔镜下行胆囊切除时围术期心肌损伤的影响。方法:择期腹腔镜下行胆囊切除术老年患者40例,ASAⅠ～Ⅱ级。其中男25例,女15例,年龄64～78岁。将患者随机分为两组,每组20例,分别接受全麻复合硬膜外麻醉(GEA组)和全身麻醉(GA组)。GEA组在全麻诱导前行硬膜外穿刺,间隙选择T8～9,局麻药选用2%的利多卡因。两组患者全麻诱导均采用静注依托咪酯0.2～0.3mg/kg、芬太尼3～4μg/kg、顺式阿曲库铵0.1～0.15mg/kg,维持采用吸入1%～3%七氟醚,静脉泵注丙泊酚、瑞芬太尼和顺式阿曲库铵。GEA组每小时持续经硬外导管注入2%利多卡因6mL直至手术结束。GA组单纯用全麻,全麻诱导和维持方案与GEA组相同。两组患者术中出血均<200mL,手术时间<2h,保持两组患者的血流动力学平稳并用肌松监测仪监测使两组患者达到相同的肌松程度。两组患者分别于麻醉前(T0)、手术结束时(T1)、术后4h(T2)和术后8h(T3)抽取静脉血测血浆中心肌肌钙蛋白Ⅰ(cTnI)和心肌肌酸激酶同工酶(CK-MB)的变化情况。结果:两组患者的血浆CK-MB和cTnⅠ浓度在手术结束后逐渐升高,全麻复合硬膜外组与单纯全麻组相比,复合组的血浆CK-MB和cTnI浓度在T1～T3各时点显著降低(P<0.05)。结论:硬膜外阻滞可以降低老年腹腔镜胆囊切除术患者围术期的心肌损伤程度。

Objective：To evaluate the influence of epidural block on myocardial damage in old patients under- going eholeeysteetomy by abdominoscope. Methods： 40 ASA I-Ⅱ patients （25 males, 15 females） aged 64 78 yr undergoing cholecystectomy by abdominoscope were randomized to receive either general combined epidural anesthesia （group GEA, n=20） or pure general anesthesia （group GA,n：20）. In group GEA tho- racic 8-9 （T8-9） vertebral clearance for puncture and epidural catheter was placed before general anesthesia. A test dose of 4mL 2% lidocaine was given. When correct positioning of the epidural catheter was confirmed, general anesthesia was induced with etomidate 0. 2-0.3mg/kg, fentanyl 3-4/μg/kg and syn--atracurium0. 1 0. 15mg/kg, anesthesia was maintained with inhalation 1% ~ 3 % sevoflurane, pumping propofol 4 - 6mg· kg^-1·h^-1, remifentanil 5-10μg·kg^-1·h^-1 and syn-atracurium 0. 140. 2mg·kg^-1·h^-1. 2% lidoeaine was continuously infused at a rate of 6mL. h-1 during operation. In group GA, the patients received the same gener- al anesthesia technique with group GEA and received only general anesthesia. All the patients lost blood less than 200mL and the time of operation was within 2 hours, and the hemodynamics stable and the same muscle relaxation were maintained in two groups. Vein blood samples were collected and the plasma concentrations of myo--caicium protein I（cTnI） and creatine kinase--MB（CK--MB） were observed at the time point before in- duction of anesthesia （T0）, at the end of operation （T1） and 4h （T2）, 8h （T3） after operation. Results： The plasma concentrations of cTnI and CK--MB in two groups upgraded increasingly after operation, and compared with group GE, the level of cTnI and CK--MB in group GEA decreased significantly after operation（T1-T3） （P （ 0. 05）. Conclusion： Epidural block can significantly reduce the myocardial damage in old patients under- going cholecystectomy by abdominoscope.