不同麻醉方式对冠心病患者下肢关节置换手术围手术期容量负荷的影响

Effect of different anesthesia methods on perioperative volume load of lower limb joint replacement in patients with coronary heart disease

目的对比研究全身麻醉、椎管内麻醉复合全身麻醉及腰丛神经阻滞复合全身麻醉三种麻醉方法对冠心病患者下肢关节置换手术围手术期容量负荷的影响.方法纳入2017年1月至2018年11月在湖北航天医院行择期下肢关节置换的冠心病患者120例,美国麻醉医师协会(ASA)分级为Ⅱ~Ⅲ级,采用随机数字表法将患者随机分为三组:全身麻醉组(A组)、椎管内麻醉联合浅全身麻醉组(B组)和腰丛神经阻滞联合浅全身麻醉组(C组),每组40例.观察并记录三组患者入室后(T0)、麻醉诱导即刻(T1)、手术开始即刻(T2)、手术开始后1 h(T3)和手术结束时(T4)的平均动脉压(MAP)、心率(HR)、心脏指数(CI)、每搏指数(SVI)和每搏变异度(SVV);记录三组患者的手术时间和麻醉时间,记录三组并发症的发生率.结果T1时,三组患者HR、MAP、CI和SVI均低于T0,SVV均高于T0,差异有统计学意义(P<0.05);T1时B组患者的MAP、CI和SVI显著低于A组和C组[T1时:(76.8±5.4)mmHg(1mmHgi0.133 kPa)比(84.4±14.9)和(86.4±19.1)mmHg,(1.9±0.6)L/(min·m^2)比(2.5±0.7)和(2.3±0.5)L/(min·m^2)、(35.5±11.5)ml/m^2比(40.5±11.8)和(39.2±10.3)ml/m^2;T2时:(74.6±6.7)mmHg比(89.9±17.8)和(82.8±19.7)mmHg、(2.6±0.7)L/(min·m^2)比(2.8±0.7)和(2.6±0.4)L/(min·m^2)、(38.2±13.7)ml/m^2比(44.9±7.9)和(45.8±8.3)ml/m^2],且T1时B组SVV显著高于A组和C组[(15.6±2.1)%比(13.8±4.3)%和(13.9±2.9)%],差异有统计学意义(P<0.05);T2~T4时A组的HR和MAP均显著高于B组和C组,差异有统计学意义(P<0.05).C组患者术后高血压或低血压及不稳定型心绞痛的发生率显著低于A组和B组[5.0%(2/40)比20.0%(8/40)和35.0%(14/80)],差异有统计学意义(P<0.05).结论腰丛神经阻滞联合浅全身麻醉用于冠心病患者关节置换术时围手术期容量负荷指标波动较小,血流动力学更为稳定,且术后发生心血管不良事件的概率较其他两组更低,故较为安全.

Objective To compare the effects of general anesthesia,intraspinal anesthesia combined with general anesthesia and lumbar plexus block combined with general anesthesia on the volume load of lower limb joint replacement surgery in patients with coronary heart disease. Methods One hundred and twenty patients (ASA classification Ⅱ-Ⅲ) with coronary heart disease who underwent selective lower extremity arthroplasty in Hubei Aerospace Hospital from January 2017 to November 2018 were randomly divided into three groups: general anesthesia group (group A), spinal canal combined with superficial general anesthesia group (group B) and lumbar plexus nerve block combined with superficial general anesthesia group (group C), with 40 cases in each group. The mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), stroke volume index (SVI) and stroke volume variation (SVV) were observed and recorded at the time of entering operation room (T0), immediate induction of anesthesia(T1), immediately after the operation (T2), 1 h after surgery (T3) and at the end of the operation (T4) in three groups. The operation time, anesthesia time and the incidence of complications of the three groups were recorded. Results At T1, HR, MAP, CI and SVV of the three groups were lower than T0, and SVV were higher than T0, and there were significant differences (P < 0.05). At T1 and T2, the MAP, CI and SVI in group B were significantly lower than those in group A and group C[T1:(76.8 ± 5.4) mmHg (1 mmHg=0.133 kPa)vs.(84.4 ± 14.9) and (86.4 ± 19.1) mmHg,(1.9 ± 0.6) L/(min·m^2) vs.(2.5 ± 0.7) and (2.3 ± 0.5) L/(min·m^2),(35.5 ± 11.5) ml/m2 vs.(40.5 ± 11.8) and (39.2 ± 10.3) ml/m^2;T2:(74.6 ± 6.7) mmHg vs.(89.9 ± 17.8) and (82.8 ± 19.7) mmHg,(2.6 ± 0.7) L/(min·m^2) vs.(2.8 ± 0.7) and (2.6 ± 0.4) L/(min·m^2),(38.2 ± 13.7) ml/m^2 vs.(44.9 ± 7.9) and (45.8 ± 8.3) ml/m^2], and at T1, the SVV of group B was significantly higher [(15.6 ± 2.1)% vs.(13.8 ± 4.3)% and (13.9 ± 2.9)%], and there were significant differences (P < 0.05). At T2-T4, the HR and MAP of group A were significantly higher than those of the other two groups (P < 0.05). The incidence of hypertension, hypotension and unstable angina pectoris in group C was significantly lower than that in group A and group B [5.0%(2/40) vs. 20.0%(8/40) and 35.0%(14/80)](P < 0.05). Conclusions Lumbar plexus block combined with shallow general anesthesia is safer for patients with coronary heart disease because of its smaller fluctuation of volume load index, more stable hemodynamics and lower incidence of cardiovascular adverse events.