不同剂量舒芬太尼与右美托咪定术前静脉用药复合超声引导髂筋膜神经阻滞对老年髋关节置换术患者的镇痛效果及应激水平的影响

Effects of preoperative intravenous administration of different doses of sufentanil and dexmedetomidine combined with ultrasound-guided fascia iliac nerve block on analgesic efficacy and stress level in elderly patients undergoing hip arthroplasty

目的探讨不同剂量舒芬太尼与右美托咪定术前静脉用药复合超声引导髂筋膜神经阻滞对老年髋关节置换术患者的镇痛效果及应激水平的影响。方法将接受髋关节置换术治疗的100例老年患者随机分为A组、B组、C组、D组,每组25例,分别在神经阻滞前静脉注射0.1μg/kg舒芬太尼、0.2μg/kg舒芬太尼、0.3μg/kg舒芬太尼和等体积生理盐水,然后静脉泵注右美托咪定,各组均于静脉泵注右美托咪定10 min后在超声引导下行髂筋膜神经阻滞,术中静脉泵注瑞芬太尼维持麻醉。记录患者入室时(T_(0))、神经阻滞操作前(T_(1))、手术切皮即刻(T_(2))、手术开始后15 min(T_(3))、手术开始后30 min(T_(4))、术毕即刻(T_(5))的平均动脉压(MAP)、心率,于T_(2)、T_(3)、T_(4)记录患者脑电双频指数(BIS)值、躁动-镇静量表(RASS)评分;于T_(0)、T_(1)、T_(2)、T_(5)记录患者疼痛视觉模拟量表(VAS)评分;记录患者术中瑞芬太尼消耗总量及术中不良反应情况;于T_(0)和T_(2)检测患者血清皮质醇及指尖血糖水平。结果4组患者的心率、MAP、BIS值、RASS评分、疼痛VAS评分差异均有统计学意义,在T_(1)、T_(2)、T_(5),B组和C组的心率和MAP均低于A组和D组(均P<0.05);在T_(3)和T_(4),D组、A组、B组、C组的心率和MAP依次降低(均P<0.05);在T_(2)和T_(3)时,B组和C组患者的BIS值均低于A组、D组,RASS评分均高于A组、D组(均P<0.05),A组患者的BIS值低于D组,RASS评分高于D组(均P<0.05)。在T_(2),B组和C组患者的血清皮质醇和指尖血糖水平均低于A组、D组,A组血清皮质醇和指尖血糖水平低于D组(均P<0.05)。在T_(1)和T_(2),B组和C组患者的疼痛VAS评分均低于A组、D组,A组患者的疼痛VAS评分低于D组(均P<0.05)。B组、C组术中瑞芬太尼消耗总量均少于A组、D组,A组用量少于D组(均P<0.05)。C组有2例(8.0%)患者在手术过程中出现呼吸频率<12次/min,有5例(20.0%)患者出现MAP<65 mmHg,其他3组术中未出现上述不良反应。结论对于行髋关节置换术治疗的老年患者,给予术前舒芬太尼和右美托咪定静脉用药复合超声引导髂筋膜神经阻滞有利于增强镇痛效果,减轻患者手术应激反应,减少术中阿片类镇痛药的用量,且以0.2μg/kg舒芬太尼剂量效果最佳。

Objective To investigate the effects of preoperative intravenous administration of different doses of sufentanil and dexmedetomidine combined with ultrasound-guided fascia iliac nerve block on analgesic efficacy and stress level in elderly patients undergoing hip arthroplasty.Methods A total of 100 elderly patients,who were to undergo hip arthroplasty,were randomly divided into group A,group B,group C and group D,with 25 cases in each group,and received intravenous injections of 0.1μg/kg sufentanil,0.2μg/kg sufentanil,0.3μg/kg sufentanil,and an equal volume of normal saline,respectively,before nerve block,followed by intravenous pumping of dexmedetomidine.Each group received fascia iliac nerve block under ultrasound guidance 10 minutes after intravenous pumping of dexmedetomidine,and undertook intravenous pumping of remifentanil to achieve anesthesia maintenance during operation.Patients′mean arterial pressure(MAP)and heart rate were recorded at the time of entering the operating room(T_(0)),before nerve block operation(T_(1)),immediately after skin incision(T_(2)),15 minutes after operation(T_(3)),30 minutes after operation initiation(T_(4)),and immediately after the end of operation(T_(5));moreover,patients′bispectral index(BIS)values and Richmond Agitation-Sedation Scale(RASS)scores were recorded at T_(2),T_(3) and T_(4),the Visual Analogue Scale(VAS)scores for pain of the patients were recorded at T_(0),T_(1),T_(2) and T_(5),the total consumption of intraoperative remifentanil and the incidence of intraoperative adverse reactions of the patients were recorded;furthermore,patients′serum cortisol and fingertip blood glucose levels at T_(0) and T_(2)were detected.Results There were statistically significant differences in heart rate,MAP,BIS values,RASS scores,and VAS scores for pain between the four groups,and at time points T_(1),T_(2) and T_(5),groups B and C reported lower heart rates and MAP than groups A and D(all P<0.05).At T_(3) and T_(4),heart rates and MAP decreased in group D,group A,group B and group C successively(all P<0.05);at T_(2) and T_(3),groups B and C yielded lower BIS values and higher RASS scores than groups A and D(all P<0.05),and group A exhibited a lower BIS value and a higher RASS score than group D(all P<0.05).At T_(2),groups B and C had lower serum cortisol and fingertip blood glucose levels than groups A and D,and group A obtained lower serum cortisol and fingertip blood glucose levels than group D(all P<0.05);at T_(1) and T_(2),groups B and C had lower VAS scores for pain than groups A and D,and group A had a lower VAS score for pain than group D(all P<0.05).The total consumption of remifentanil during operation was lower in groups B and C than in groups A and D,which was less in group A than in group D(all P<0.05).There were two(8.0%)cases having a respiratory rate<12 per minute occurred during operation and five(20.0%)having MAP<65 mmHg in group C,and the aforementioned adverse reactions did not occur during operation in the other three groups.Conclusion For elderly patients undergoing hip arthroplasty,preoperative intravenous administration of sufentanil and dexmedetomidine combined with ultrasound-guided fascia iliac nerve block is beneficial to enhance the analgesic efficacy,diminish patients′surgical stress reactions,and reduce intraoperative opioids consumption;moreover,sufentanil at the dose of 0.2μg/kg exhibits an optimum efficacy.