超声引导腰丛阻滞联合全麻在高龄患者髋关节置换手术中的应用

Application of ultrasound-guided lumbar plexus block combined with general anesthesia in elderly patients with hip replacement

目的观察超声引导下腰丛阻滞联合全麻在高龄患者髋关节置换术的临床应用效果和价值。方法选择行髋关节置换术的高龄患者60例,年龄70~95岁,男45例,女15例,按手术时间顺序分组,奇数归入传统的气管插管全麻组(A组),偶数归入腰丛神经阻滞联合喉罩全麻组(B组),每组30例。A组行全凭静脉麻醉;B组行腰丛阻滞联合喉罩全麻,先摆侧卧位,患侧肢体在上,B超引导行腰丛阻滞,效果确定后行全麻诱导置入喉罩,全麻维持的药物同A组,但剂量视术中情况调控。记录麻醉前(T0)、手术开始切皮时(T1)、手术开始后5 min(T2)、扩髓时(T3)、手术结束时(T4)、拔除导管或喉罩时(T5)的心率(HR)、平均动脉压(MAP);记录术后拔导管(喉罩)时间、下床活动时间、出院时间和术后2、4、8、12、24 h的VAS评分及术后24 h静脉自控镇痛(PCA)药物用量。结果两组HR、MAP比较差异有统计学意义(P<0.05),从T0到T5,随着时间推移,两组的HR、MAP均有显著波动(P<0.01),B组的HR、MAP较A组更平稳(P<0.01)。两组拔管时间、下床活动时间及出院时间比较差异有统计学意义(P<0.001),B组拔管时间、下床活动时间及出院时间均短于A组。两组不同时点VAS评分比较差异有统计学意义(P<0.05),从T0到T5,随着时间推移,两组的VAS评分均有显著波动(P<0.01),B组的VAS评分较A组更低(P<0.01)。A组24 h PCA镇痛药量为(83±7)mL,B组为(56±6)mL,两组比较差异有统计学意义(t=16.040,P<0.001)。结论与传统的插管全麻比较,B超引导下腰丛神经阻滞联合喉罩全麻应用于高龄患者髋关节置换术中,不但血流动力学更平稳,并且术后苏醒快速舒适,术后早期镇痛效果更好,有利于患者的康复,明显缩短了下床活动时间和出院时间。

Objective To observe the clinical effect and value of ultrasound-guided lumbar plexus block combined with shallow general anesthesia in elderly patients undergoing hip replacement.Methods 60 elderly patients(aged 70~95 years old,45 males and 15 females)who underwent hip replacement were randomly divided into two groups according to operation time sequence,with 30 cases in each group.Patients with odd number were included in the traditional tracheal intubation general anesthesia group(group A),and those with even number were included in lumbar plexus block combined with laryngeal mask general anesthesia group(group B).The group A underwent total intravenous anesthesia,and the group B underwent lumbar plexus block combined with 30 induction of laryngeal mask,the drugs maintained by general anesthesia were the same as those in the group A,but the dosage was controlled according to the situation during operation.The heart rate(HR)and mean arterial pressure(MAP)were recorded before anesthesia(T0),at the beginning of skin cutting(T1),5 min after the beginning of operation(T2),at the time of reaming(T3),at the end of operation(T4),and at the time of extubation of catheter or laryngeal mask(T5).In addition,the time of extubation of catheter(laryngeal mask),the time of getting out of bed,the time of discharge,the VAS score of 2,4,8,12 and 24 hours after operation as well as analgesic dosage of patient-controlled intravenous analgesia(PCA)24 h after operation were recorded.Results The difference of HR and MAP between the two groups was statistically significant(P<0.05).From T0 to T5,the HR of the two groups fluctuated significantly over time(P<0.01).From T0 to T5,HR and MAP of the two groups fluctuated significantly(P<0.01),and those of the group B were more stable than those of the group A(P<0.01).The difference of the time of extubation of catheter,the time of getting out of bed and the time of discharge of the two groups was statistically significant(P<0.001),and those time in the group B were shorter than those of the group A.There was statistically significant difference in VAS score between the two groups at different time points(P<0.05).From T0 to T5,VAS score of the two groups fluctuated significantly over time(P<0.01),and the VAS score of the group B was lower than that of the group A(P<0.01).The analgesic dosage of 24 h PCA in the group A was(83±7)mL,and that of the group B was(56±6)mL,and the difference between the two groups was statistically significant(t=16.040,P<0.001).Conclusion Compared with traditional intubation general anesthesia,the application of B-ultrasound-guided lumbar plexus block combined with laryngeal mask general anesthesia in the hip replacement of the elderly patients not only has a more stable hemodynamics,but also has a fast and comfortable postoperative recovery.It has a better effect of early postoperative analgesia,which is conducive to the recovery of the patients,and significantly shorten the time of getting out of bed and discharge.