腰-硬联合麻醉在下肢骨折急诊手术中的应用

Application of combined spinal-epidural anesthesia to emergency operation on lower extremity fractures

目的探讨腰-硬联合麻醉在下肢骨折急诊手术中的应用。方法急诊行下肢开放性骨折手术108例,随机分为腰-硬联合麻醉组(CSEA组,Ⅰ组)和持续硬膜外麻醉组(CEA组,Ⅱ组),Ⅰ组针内针法蛛网膜下腔注入含罗哌卡因15～20 mg重比重液3 ml,拔出针内针向头侧置管3 cm;Ⅱ组行硬膜外穿刺,向头侧置管3 cm,给予0.5%罗哌卡因10～15 ml。记录两组患者麻醉前后心率(HR)、收缩压(SBP)、舒张压(DBP)、脉搏血氧饱和度(SpO2)变化情况、麻醉起效时间、感觉阻滞程度、运动阻滞程度、不良反应发生情况。结果Ⅰ组与Ⅱ组相比,麻醉起效更快,局麻药用量更少,Bromage评分较高,辅助用药例数较少,Ⅰ组SBP、DBP下降较明显(P<0.05),但使用麻黄碱例数差异不大,恶心、呕吐发生率无差异(P>0.05);两组患者麻醉后,SBP、DBP下降和HR上升明显(P<0.05),而SpO2变化不明显(P>0.05),均未发生术后头痛。结论 CSEA兼有脊髓麻醉和硬膜外麻醉的优点,麻醉起效快、阻滞完善、用药量少、持续时间长,在下肢骨折急诊手术方面,明显优于单纯硬膜外麻醉,该方法值得推广应用。

Objective To discuss the application of combined spinal-epidural anesthesia to emergency operation on lower extremity fractures. Methods Emergency open surgery on lower limb fractures were carried out on 108 patients who were randomly divided into the group receiving combined spinal-epidural anesthesia （CSEA group, group i ）and the group receiving continuous epidural anesthesia（ CEA group,group H ）. Group I received subarachnoid injection with 3 ml hyperbaric solution which contained 15-20 mg ropivacaine with the needle within the needle method, and then the internal needle was taken out and the catheter were placed 3 cm to the head side. Group ~ received the epidural puncture, and the catheter were placed 3 cm to the head side. This group also received 10-15 ml 0.5% ropivacaine. The changes of heart rate before and after the anesthesia,systolic blood pressure（SBP） ,diastolic blood pressure（ DBP）, pulse saturation of blood oxygen（ SpO2 ）, the onset time of anesthesia, the degree of sensory block, the degree of motion block, and adverse event were all recorded. Results Compared with the conditions in group , group I had a faster onset time of anesthesia, less amount of local anesthetic, higher Bromage score, and less cases using the adjuvant medication. The SBP and DBP of group I decreased more significantly（P 〈0.05 ）,but there was no significant difference in the number of cases using ephedrine and the incidence of nausea and vomiting between the two groups （ P 〉 0.05 ）. After the anesthesia, the SBP and DBP of both groups decreased significantly, and HR increased significantly （ P 〈 0.05 ）. SpO2 did not change significantly （ P 〉 0.05 ）. Postoperative headache did not occur in both groups. Conclusion CSEA has the advantages of both spinal and epidural anesthesia including faster anesthetic effect, complete block, less medication, and long duration. In the emergency operation on lower extremity fractures, this method is superior to epidural anesthesia and worthwhile to be promoted.