腰麻-硬膜外联合麻醉在小儿外科手术及术后镇痛的应用

Application of combined epidural-spinal anesthesia in pediatric surgery and postoperative analgesia

目的 :观察罗哌卡因与布比卡因在小儿腰麻 硬膜外联合麻醉 (combinedspinal epiduralanesthesia,CSEA)麻醉的效果、术后镇痛效果和不良反应。方法 :选择 5 0例行下腹部及以下手术的患儿 ,年龄为 6～ 1 4岁 ,随机分为两组 :罗哌卡因Ropivacaine(R)组 2 5例和布比卡因Bupivacaine(B)组 2 5例 ,全部采用CSEA麻醉。R组注入腰麻药为 :1 0g·L-1 罗哌卡因 1 .5ml+注射用水 0 .5ml+1 0 0g·L-1 葡萄糖 1ml。B组注入腰麻药物为 :7.5g·L-1 布比卡因 2ml+1 0 0g·L-1 葡萄糖 1ml。两药的终末浓度皆为 5g·L-1 。给药剂量按以下公式计算 :药量 (ml) =[年龄(岁 )× 0 .2 +体重 (kg)× 0 .0 5 ]/ 2。当手术超过 1 .5h ,开始向硬膜外腔输注局麻药物 :R组为 2 .5 g·L-1 罗哌卡因1mg·kg-1 ·h-1 ,B组为 2 .5g·L-1 布比卡因 1mg·kg-1 ·h-1 。研究中观察血压、心率、氧饱和度 ,麻醉平面 ,VAS评分 ,下肢运动阻滞的变化。术后两组均进行硬膜外镇痛 ,各为 0 .75g·L-1 罗哌卡因 1 0 0ml或布比卡因加入曲马朵2 0 0mg和氟哌利多 5mg。硬膜外持续输注 3ml·h-1 (6～ 9岁 )或 4ml·h-1 (1 0～ 1 4岁 ) ,必要时由患儿或其父母自控镇痛每次 2ml,间隔时间为 1 5min。观察镇痛效果、下肢运动恢复情况及术后 2 4h患儿恶心、呕吐?

Objective: To compare the anesthetic and analgesic efficacy of ropivacaine and bupivacaine and their side reactions in combined spinal epidural anesthesia (CSEA) and postoperative analgesia in pediatric surgery. Methods: Fifty children for lower abdominal surgery, aged 6-14 years, were randomly assigned to receive either ropivacaine (Group R, n =25) or bupivacaine (Group B, n =25) for CSEA. Spinal injection for Group R was a mixture of 1.5 ml of 10 g·L -1 ropivacaine, 0.5 ml distilled water and 1ml of 100 g·L -1 dextrose. The injection for Group B was the same as that for Group R except 0.5 ml of 7.5 g·L -1 bupivacaine . The terminal concentrations of anesthetics were 5 g·L -1 for the two groups. The injection volume was calculated as: ml=(age×0.2+weight×0.5)/2. When operations prolonged to 1.5 h, epidural infusion at the rate of 1 mg·kg -1 ·h -1 started with 2.5 g·L -1 ropivacaine for Group R and 2.5 g·L -1 bupivacaine for Group B. The observed variables were the changes in blood pressure, heart rate, SpO 2, block level, visual analogue scores, and motor block. Epidural postoperative analgesia was performed for Group R with 100 ml of 0.75 g·L -1 ropivacaine to which 100 mg tramadol and 5 mg were added, and for Group B with 100 ml of 0.75 g·L -1 bupivacaine instead. Backgroup infusion was 3 ml·h -1 for the children aged 6-9 years or 4 ml·h -1 for the children aged 10-14 years, bolus was 2 ml controlled by children or their parents when necessary, and locktime was 15 min. The observed variables were the efficacy of postoperative analgesia, recession of motor block of legs, and the incidence of headache, nausea and vomiting, leg numbness, and urinary retention within 24 h after operation. Results: There was no significant difference between the two groups in block level. Motor block was much milder in Group R than that in Group B during operation, and recessed faster after operation. Only one case of nausea occurred in each group, and one case of urinary retention in Group B without statistical significance. Conclusion: Either ropivacaine or bupivacaine can be satisfactorily used in CSEA for analgesia during and after operation. However, ropivacaine has a weaker motor block than bupivacaine, which benefits early walking after operation and recovery of bowl movement.