高龄患者髋部骨折手术麻醉策略优化

Optimized strategy of anesthesia for elderly patients undergoing surgery of hip fracture

目的:观察3种麻醉方案用于高龄患者髋部骨折手术的效果,以优化高龄患者髋部骨折手术的麻醉策略。方法:选择行髋部骨折内固定术的患者90例,美国麻醉医师学会(American Society of Anesthesiologists,ASA)Ⅱ或Ⅲ级,年龄80~92岁,随机分为3组(n=30):腹股沟韧带上髂筋膜间隙联合骶丛神经阻滞组(S组)、腰-骶丛神经阻滞组(L组)和腰-硬联合麻醉组(C组)。S组腹股沟韧带上髂筋膜间隙阻滞给予0.375%罗哌卡因40 mL,骶丛神经阻滞给予0.375%罗哌卡因20mL。L组腰丛神经阻滞给予0.375%罗哌卡因40 mL,骶丛神经阻滞给予0.375%罗哌卡因20 mL。C组蛛网膜下腔注射0.5%罗哌卡因2.5mL行腰-硬联合麻醉。3组术中静脉泵注右美托咪定,负荷剂量为0.5μg/kg,维持剂量为0.25μg/(kg·h)。记录患者入室(T0)、摆放体位(T1)、麻醉后3 min (T2)、麻醉后5 min (T3)、麻醉后10 min (T4)、麻醉后30 min (T5)、切皮即刻(T6)、麻醉后60 min (T7)及麻醉后120 min (T8)时的平均动脉压(mean arterial blood pressure,MAP)及心率(heart rate,HR)。记录T0、T1、T6、术后12 h (T9)及术后24 h (T10)的直观类比标度(visual analog scale,VAS)评分。记录麻醉时间、手术时间、出血量、液体输注量、右美托咪定用量、血管活性药物应用及镇痛补救情况。记录局部麻醉药中毒、神经损伤、血管损伤、全脊髓麻醉等不良事件发生情况。结果:与C组、L组比较,S组麻醉时间缩短,T1时点MAP、HR、VAS评分降低(P<0.05);与C组比较,S组、L组液体输注量、麻黄碱应用率降低,右美托咪定用量增加,T9、T10时点VAS评分降低,T2、T3、T4时点MAP升高,T2、T3时点HR下降(P<0.05)。3组手术时间、出血量、阿托品应用率、镇痛补救率、T0、T6时点VA S评分及不良反应发生率差异均无统计学意义(均P>0.05)。结论:超声引导下腹股沟韧带上髂筋膜间隙联合骶丛神经阻滞,操作简便易行,能减轻体位摆放导致的疼痛,维持血流动力学稳定,可有效用于高龄患者髋部骨折手术麻醉术后镇痛。

Objective:To observe the anesthetic effect of 3 anesthetic schemes for elderly patients undergoing surgery of hip fracture,so as to optimize the strategy of anesthesia.Methods:Ninety elderly patients undergoing internal fixation surgery of hip fracture,aged 80-92 years,with American Society of Anesthesiologists(ASA) Ⅱ or Ⅲ,were randomly assigned into 3 groups(n=30):a supra-inguinal fascia iliaca compartment block combined with sacral plexus block group(group S),a lumbar plexus combined with sacral plexus block group(group L),and a combined spinal and epidural anesthesia group(group C).In group S,supra-inguinal fascia iliaca compartment block was performed with 0.375% ropivacaine 40 mL,and sacral plexus block was performed with 0.375%ropivacaine 20 mL.In group L,lumbar plexus block was performed with 0.375% ropivacaine 40 mL and sacral plexus block was performed with 0.375% ropivacaine 20 mL.In group C,combined spinal and epidural anesthesia was performed with 0.5% ropivacaine 2.5 mL.Dexmedetomidine was injected during the surgery.The loading dose of dexmedetomidine was 0.5 μg/kg, and the maintenance dose was 0.25 μg/(kg·h).The mean arterial blood pressure(MAP) and heart rate(HR) of the patients were recorded at operation room admission(TO),positioning(T1),3 min after anesthesia(T2),5 min after the anesthesia(T3),10 min after the anesthesia(T4),30 min after the anesthesia(T5),skin incision(T6),60 min after the anesthesia(T7),and 120 min after the anesthesia(T8).The visual analogue scale(VAS) were recorded at T0,T1,T6,12 hours after the surgery(T9),and 24 hours after the surgery(T10).The time of anesthesia,the time of surgery,the amount of bleeding,volume of fluid infusion,consumption of dexmedetomidine,consumption of vasoactive agents,and rescue analgesia were recorded.Adverse events such as local anesthetic poisoning,nerve injury,vascular injury,and total spinal block were recorded.Results:Compared with group C and group L,the time of anesthesia,MAP,HR and VAS at T1 were decreased in group S(P<0.05).Compared with group C,volume of fluid infusion,application rate of ephedrine,HRs at T2,T3,and VAS scores at T9,T10 were decreased in group S and group L(P<0.05).Compared with group C,consumption of dexmedetomidine,and MAPs at T2,T3,T4 were increased in group S and group L(P<0.05).There was no statistically significant difference in term of the time of surgery,the amount of bleeding,application rate of atropine,the rate of rescue analgesia,VAS scores at T0,T6,and the incidence of adverse events(P>0.05).Conclusion:Ultrasound-guided supra-inguinal fascia iliaca compartment block combined with sacral plexus block is easy to operate.It could alleviate the pain caused by position change,and maintain hemodynamic stability.Therefore,it could be effectively used in anesthesia of hip fracture and postoperative analgesia for elderly patients.