0.33%不同容积等比重罗哌卡因蛛网膜下腔阻滞对高龄股骨颈骨折患者麻醉效果疗效观察

Clinical analysis on 0. 33% different volume isobaric ropivacaine for spinal anesthesia in elderly patients undergoing femoral neck fracture surgery

目的探讨0.33%不同容积等比重罗哌卡因蛛网膜下腔阻滞对股骨颈骨折老年患者的安全性和有效性,并研究不同年龄段老年患者局部麻醉药的合适容积。方法选取自2013年3月1日至2014年10月12日解放军180医院收治的150例股骨颈骨折患者为研究对象,采用随机数字表法将所有患者分为A组、B组、C组,每组各50例。各组按年龄段又分为a组70~80岁、b组>80岁两个亚组。所有患者均采用健侧卧位,穿刺间隙为L3~L4椎间隙,采用脑脊液将1%盐酸罗哌卡因注射液稀释成0.33%(1.0 ml罗哌卡因+2.0 ml脑脊液),A组、B组、C组分别给予2.2 ml、2.0 ml、1.8 ml。记录注药前(T_0)、注药后3 min(T_1)、5 min(T_2)、10 min(T_3)、15 min(T_4)、20 min(T_5)和30 min(T_6)时的平均动脉压(MAP)、心率(HR)和感觉阻滞平面高度;记录麻醉后至ΔSV≤10期间,进行冲击试验的次数,以及T_6时的Bromage评分、蛛网膜下腔的阻滞效果、感觉平面消退时间、术中和术后相关并发症的发生情况。结果蛛网膜下腔阻滞有效率Aa组、Ab组、Bb组均为100.0%(30/30),明显高于Ba组的67.9%(19/28)、Ca组的4.0%(1/25)、Cb组的72.0%(18/25),差异均有统计学意义(P<0.05)。Aa组T_1~T_5时、Ab组T_2~T_6时和Bb组T_3~T_5时MAP均较T_0时明显降低;Aa组T_1~T_5时,Ab组、Bb组T_1~T_6时,HR均较T_0时明显加快,差异均有统计学意义(P<0.05)。Aa组、Ab组和Bb组患者的感觉平面T_1~T_3时均明显高于T_6时,Aa组、Bb组T_1~T_6各时间点感觉平面高度均高于Ab组,差异有统计学意义(P<0.05)。Ab组Bromage评分明显低于Aa和Bb组,而冲击试验次数和感觉平面消退时间均明显多于Aa组和Bb组,差异有统计学意义(P<0.05)。Ab组术中并发症(低血压、恶心呕吐、寒战)的发生率均明显高于Aa和Bb组,差异有统计学意义(P<0.05);3组术后并发症的发生率,两两比较,差异均无统计学意义(P>0.05)。结论 0.33%等比重罗哌卡因2.2 ml和2.0 ml分别能为70岁以上和80岁以上股骨颈骨折患者提供满意的蛛网膜下腔阻滞麻醉效果,安全可行。但70~80岁患者和80岁以上患者分别应用0.33%等比重罗哌卡因2.2 ml和2.0 ml可使循环更稳定。

Objective To investigate the safety and effectiveness of 0. 33% different volume isobaric ropivacaine and how much volume is proportion to the different age ranges for spinal anesthesia in elderly patients who undergoing femoral neck fracture surgery.Methods A retrospective study was performed on 150 cases of patients with femoral neck fracture who were admitted from 1 st January2013 to 12 nd October 2014. Patients were divided into the Group A,Group B and Group C（ 0. 33% isobaric ropivacaine 2. 2 ml,2. 0 ml and 1. 8 ml）,with 50 cases in each group. According to different age ranges（ 70-80 years and elder than 80 years）,patients were subdivided into the a groups and b groups. Lumbar puncture at the L3-4 interspinous spaces was performed in the non-surgical lateral decubitus in all patients. The 1% ropivacaine was diluted to 0. 33% ropivacaine with cerebrospinal fluid（ 1. 0 ml ropivacaine ＋2. 0 ml cerebrospinal fluid）. Group A,B and C received 0. 33% ropivacaine 2. 2 ml,2. 0 ml and 1. 8 ml,respectively. Mean arterial pressure（ MAP）,heart rate（ HR） and sensory block level at the pre-receiving ropivacaine（ T0） and post-receiving ropivacaine 3 minu tes（ T1）,5 minutes（ T2）,10 minutes（ T3）,15 minutes（ T4）,20 minutes（ T5）,30 minutes（ T6） were recorded; times of fluid impact test after spinal anesthesia to ΔSV≤10,Bromage scores at T6,effective spinal anesthesia,regressive time of the sensory level and intraoperative and postoperative complications were recorded. Results The rate of effective spinal anesthesia in the Group Aa,Ab and Bb were100%（ 30/30）,which were significantly higher than that in the Group Ba 67. 9%（ 19/28）,Group Ca 4. 0%（ 1/25） and Group Cb 72. 0%（ 18/25）,（ P 0. 05）. MAP in the Group Aa at T1-T5,Group Ab at T2-T6 and Group Bb at T3-T5 were significantly reduced than those at T0; HR in the Group Aa at T1-T5,Group Ab and Bb at T1-T6 were significantly faster than those at T0,and all the differences were statistically significant（ P 0. 05）. Sensory block level in Group Aa,Ab and Bb at T1-T3 were significantly higher than those at T6; sensory block level in Group Aa and Bb at T1-T6 were significantly higher than that in Group Ab（ P〈0. 05）. Bromage score in Group Ab were significantly lower than that in Group Aa and Bb; times of fluid impact test and regressive time of the sensory level in the Group Ab were significantly more than those in Group Aa and Group Bb（ P〈0. 05）. The rate of intraoperative complications（ hypotension,nausea and vomiting,chills） in the Group Ab was significantly higher than that in Group Aa and Bb（ P〈0. 05）;there was no statistically significant difference in postoperative complications in comparison between each two groups among the Group Aa,Ab and Bb（ P〉0. 05）. Conclusion The 0. 33% isobaric ropivacaine 2. 2 ml for elder than 70 years old and 2. 0 ml for elder than 80 years old patients are safe and effective for spinal anesthesia who undergoing femoral neck fracture surgery,2. 2 ml for 70-80 years old and 2. 0 ml for elder than 80 years old patients has more stable circular function.