经骶管连续硬膜外阻滞在小儿腹部和会阴部手术后镇痛的应用

发布时间：2018-03-12 16:03

  本文选题：骶管　切入点：硬膜外阻滞　出处：《广西医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的探讨经骶管连续硬膜外阻滞用于小儿腹部和会阴部手术后镇痛的安全性及有效性。方法选择行择期腹部、会阴部手术的患儿84例,分为三组,每组各28例,C组:静吸复合全身麻醉组;S组:全身麻醉+单次骶管阻滞;E组:全身麻醉+经骶管连续硬膜外阻滞+PCEA。三组患儿均在手术室外静注咪达唑仑0.1mg/kg,待安静后推入手术室,常规连接心电监护仪。麻醉诱导:三组均采用静脉麻醉快速诱导方法,S组全麻诱导后予0.25%罗哌卡因0.8ml/kg进行单次骶管阻滞,E组全麻诱导后经骶裂孔穿刺置入硬膜外导管,对于腹部手术将导管头端置入L2~L3水平,肛门或直肠手术导管头端置入至超过L5~S1水平,尿道手术导管头端置入S2~S3水平。导管置入成功后注射1%利多卡因2ml作为试验剂量,5min后若无蛛网膜下腔阻滞迹象、生命征稳定,再注入0.25%罗哌卡因(总量0.8ml/kg,注入总量的1/3~1/4)。麻醉维持:三组术中均采用静吸复合维持麻醉,按需要适时追加镇痛药物,E组术中每隔1h从硬膜外导管追加一次罗哌卡因(每次追加总量的1/3~1/4)。术毕将患儿送麻醉后复苏室(PACU)。E组于拔除气管导管后启动硬膜外镇痛泵(PCEA),镇痛泵药物浓度为0.1%罗哌卡因+1μg/ml芬太尼,总量150ml,持续泵入0.1ml·kg-1·h-1,PCA剂量、负荷量0ml/h,使用48h后撤除硬膜外镇痛泵。观察指标:记录患儿的一般情况、手术种类、手术时间、用药时间、术后禁食时间及术后住院时间;记录术后1h、4h、8h、12h、24h、36h、48h、72h的心率(HR)、FLACC疼痛评分、Ramsay镇静评分;记录手术结束至术后72h内镇痛、镇静药物的追加使用情况;记录术后第二天家长疼痛评估PPPM量表评分;记录术后发热、呕吐、呼吸抑制、皮肤瘙痒、尿潴留、局麻药中毒等不良反应以及神经损伤、穿刺部位局部或椎管内感染等并发症的发生情况。结果最终入选观察者共为72例,其中C组23例,S组24例,E组25例。(1)三组患儿一般情况、手术种类、手术时间、用药时间、术后禁食时间、术后住院时间比较无显著差异(P0.05)。(2)术后48hPPPM量表评分比较,S组和E组高于C组,E组高于S组(P0.05)。(3)术后各时点FLACC疼痛评分比较,S组和E组明显低于C组,E组明显低于S组(P0.05);三组患儿术后镇静评分比较无显著差异(P0.05)。(4)E组术后72h内追加其他镇痛药物的人数和次数明显少于S组和C组(P0.05);C组术后0~4h之间有4例患儿追加镇痛药物,S组和E组没有患儿追加镇痛药物,S组术后24~48h时段追加镇痛药物人数明显少于S组和C组(P0.05);三组术后72h内追加镇静药的人数和次数以及术后呕吐、发热的发生率的比较无显著差异(P0.05);三组术后72h内均未发生呼吸抑制、皮肤瘙痒、尿潴留、局麻药中毒,也无患儿发生神经损伤、穿刺部位局部或椎管内感染等并发症。结论(1)经骶管连续硬膜外阻滞能为小儿腹部、会阴部手术后提供持续有效的镇痛,是一种安全有效的术后镇痛方式。0.1%罗哌卡因+1μg/ml芬太尼经骶管连续硬膜外阻滞用于小儿腹部、会阴部手术后镇痛可取得满意效果。(2)单次骶管阻滞可为小儿腹部、会阴部手术后4~6h内提供较好的镇痛效果。
[Abstract]:Objective to investigate the sacral epidural anesthesia in pediatric abdominal and perineal analgesia after operation safety and effectiveness. Methods for elective abdominal perineal surgery patients 84 cases were divided into three groups, 28 cases in each group, group C: general anesthesia group; group S: whole body anesthesia + single sacral anesthesia; group E: general anesthesia + through sacral epidural block +PCEA. three groups of children were in operation outside the intravenous injection of midazolam 0.1mg/kg, quietly pushed into the operation room, connected conventional ECG monitor. Anesthesia induction: three groups were treated with rapid intravenous anesthesia induction method, induced by S group after general anesthesia with 0.25% ropivacaine 0.8ml/kg single sacral block group E after induction of anesthesia with sacral hiatus epidural catheter was puncture for abdominal surgery, the tip of catheter placement L2~L3, anal or rectal surgery catheter tip placement to exceed the level of L5~S1, urethral surgery The end of the catheter placement of S2~S3 catheter. After successful injection of 1% lidocaine 2ml as test dose, 5min without subarachnoid block signs, vital signs are stable, and then injected 0.25% ropivacaine (total 0.8ml/kg, total injection 1/3~1/4). Anesthesia: three groups of patients with anesthesia, according to the needs of timely additional analgesic drugs, patients in group E every 1H catheter from epidural ropivacaine and another (each additional 1/3~1/4 of the total). After operation, the children sent post anesthesia recovery room (PACU).E group started to epidural analgesia pump after extubation (PCEA), the drug concentration of 0.1% ropivacaine for analgesia pump +1 g/ml fentanyl, total 150ml, 0.1ml and kg-1 continued to pump into the H-1, the dose of PCA, load 0ml/h, the removal of epidural analgesia pump after using 48h. Observation index: generally, record the children's type of surgery, operative time, postoperative medication time. 绂侀�熸椂闂村強鏈�鍚庝綇闄㈡椂闂，

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