压力囊泡指示性装置在椎管内麻醉中的临床应用性研究

发布时间：2018-01-21 20:27

本文关键词： 硬膜外腔压力椎管内麻醉囊泡高龄患者压力囊泡硬膜外腔　出处：《山东大学》2016年博士论文　论文类型：学位论文

【摘要】：椎管内麻醉是目前广泛应用于临床的麻醉方式之一…,将麻醉药物注入椎管内腔隙如蛛网膜下腔或硬膜外腔,从而阻断脊神经的冲动传导,使其所支配的相应区域产生麻醉作用。根据药物注入腔隙的不同,椎管内麻醉主要分为硬膜外腔阻滞,硬膜外-腰麻联合阻滞和蛛网膜下腔阻滞。椎管内麻醉的优点包括：抑制手术引起的应激反应优于全麻；可用于术后镇痛,且镇痛效果优于静脉镇痛,全身副作用轻；麻醉后下肢血管扩张,血流加速,降低深静脉血栓的发生率；同时促进肠蠕动,有利于恢复肠道功能。硬膜外麻醉是指通过局部麻醉药的弥散,使脊神经根阻滞,产生镇痛效果,并且可根据手术部位,选择不同的穿刺点,并且可根据手术需要,通过硬膜外导管推注局麻药满足不同手术时间的需要。硬腰联合麻醉是结合硬膜外麻醉和蛛网膜下腔麻醉各自的特点,既有起效快,阻滞完善的优点,又可通过硬膜外导管注入局麻药延长麻醉时间。目前最常用的为硬膜外麻醉和硬腰联合麻醉,硬膜外穿刺技术是实施成功的椎管内麻醉的关键技术,如果硬膜外穿刺操作不当或判断失误,可引起组织或神经的损伤；损伤血管引起硬膜外血肿；硬膜外穿刺针误入蛛网膜下腔等并发症,产生严重的后果,甚至威胁患者的生命。自19世纪末发明椎管内麻醉以来,判断硬膜外穿刺成功的方法主要是靠麻醉医生的主观判断,穿透黄韧带的落空感,推动玻璃注射器阻力消失法(见图1)及气泡压缩试验等,而没有专属判断工具和指标,穿刺传统的判断方法存在误判的可能,主要与操作者的主观因素以及硬膜外腔结构、穿刺间隙及椎体钙化等客观因素有关。因此为了减少椎管内麻醉并发症,除提高操作者硬膜外穿刺技术外,有必要研究一个客观的硬膜外穿刺成功判断装置。本研究旨在观察国家新型专利-压力囊泡指示器在硬膜外穿刺中的可行性和指示的准确性。在本研究中的压力囊泡指示器也是利用以往教科书中的正压气囊试验(如图2)的原理,由一个压力囊泡来持续测定针尖处的阻力。压力囊泡指示装置是在普通注射器(5m1)距针筒前端1cm处的侧壁上开孔(如图3),开孔处覆盖有弹性橡胶薄膜。穿刺时用压力囊泡指示器抽取生理盐水5ml,接硬膜外穿刺针尾端,当进针深度超过皮下软组织,到达韧带或筋膜等致密组织时,推动注射器针栓2.Oml,由于针尖受到致密组织的阻力,针筒内压力增加,薄膜会向外膨胀,凸起形成一个直径约1.5cm的液体压力囊泡(如图4)。手离开针栓(继续穿刺进针)时,由于注射器针筒与针栓之间设计有适当的摩擦阻力,可阻止囊泡内压力迫使针栓自动后退,故压力囊泡仍可保持膨胀状态。此时双手持针继续穿刺(见图5),当穿刺针突破黄韧带的瞬间,针尖处压力突然下降,阻力降低,囊泡内的液体快速流出,囊泡迅速瘪掉,为穿刺成功提供了一个可视信号。此装置能自动持续监测穿刺过程,用明确、迅速、可靠的客观指标提示穿刺针已到达合适的穿刺深度。摆脱了硬膜外穿刺一直靠人的主观判断的现状,实现操作工具专业化和判断指标客观化；同时提高操作安全性,减少人为误判的风险。临床教学中,学生操作时,老师没有了“手感”,难以判断学生的穿刺深度,使用压力囊泡指示器众人都可以看到囊泡的变化,适合于临床带教。压力囊泡指示器首次采用可视信号自动监测技术,降低了对操作经验的依赖,使穿刺操作难度下降；提高了操作安全性,减少人为误判的风险,降低了医疗事故隐患。硬膜外穿刺过程中麻醉医生可以不间断的双手操作,为硬膜外麻醉领域带来了革命性的技术进步。随着生活水平的提高,高龄患者日益增多,有研究证实椎管内麻醉虽然对老年患者的循环功能有一定影响,但麻醉经过相对平稳,对合并心脑血管疾病的老年患者更为适合,减低术后血栓形成和心血管并发症的发生率,并会大大降低全麻药物引起的术后认知功能障碍(POCD)的发生率,而且还可避免气管插管全麻引起的术后并发症吸入性入肺炎及肺不张的发生率。但老年患者血管壁大多硬化而失去弹性,脆性增大,应尽量保证穿刺轻柔,减少损伤出血机率,提高穿刺的成功率。由于老年患者的棘上韧带、棘间韧带钙化而失去弹性,椎间隙变窄,脊柱后凸或侧弯,造成穿刺困难,因此老年患者多采用侧入路穿刺路径,本研究第二部分中就是观察压力囊泡指示器在老年患者侧入路硬膜外穿刺中的应用效果。第一部分压力囊泡指示性装置在临床椎管内麻醉操作中的可行性及应用效果目的测定硬膜外腔隙的压力；测定压力囊泡指示器的工作压力；观察压力囊泡指示性装置在临床椎管内麻醉操作中的可行性及应用效果。方法1.120名病人,年龄18-60岁,硬膜外穿刺间隙T10-L3,无硬膜外穿刺禁忌症,心肺功能无异常,常规进行硬膜外穿刺,穿刺针针尾通过三通连接压力传感器,测量硬膜外腔的压力。2.随机抽取120个压力囊泡指示器,每个压力囊泡指示器抽取5m1生理盐水,前端连接压力传感器,推动注射器针栓2.Oml,使囊泡鼓起,囊泡大小维持5秒钟不变,此时记录囊泡压力为囊泡的工作压力。3.拟施行椎管内麻醉的病人400例,随机分为两组(n=200),压力囊泡组(P组)和传统方法组(C组),无硬膜外穿刺禁忌症,患者均采取正中入路硬膜外穿刺,硬膜外穿刺针末端连接压力囊泡指示器,P组当针尖穿过皮肤及皮下疏松组织后,推动压力囊泡指示器的针栓,使压力囊泡充盈,缓慢进针,当针尖到达硬膜外腔的瞬间,由于囊泡和硬膜外腔的压力差,囊泡会迅速瘪掉,提示穿刺针已到达硬膜外腔,观察并记录压力囊泡指示器指示穿刺成功情况,并与传统判断方法比较。C组使用传统的判断方式进行硬膜外穿刺。比较两组的硬膜外穿刺操作时间、并发症发生率及穿刺成功率,并观察麻醉效果。结果1.硬膜外腔隙压力测定结果：患者硬膜外腔隙压力为(9.8±4.3)mmHg.2例患者穿刺时注射器有回血,注入局麻药后麻醉效果不满意,剔除压力测定研究,并采取相应措施处理。2.囊泡压力测定结果：推注2m1液体使囊泡鼓起,囊泡工作压力为(72±4)mmHg.3.囊泡指示器应用效果：P组囊泡指示成功200例,确认硬膜外穿刺成功200例,符合率100%。其中囊泡迅速指示者197例,延迟指示者3例,改变进针方向重新穿刺,均迅速指示。C组穿刺成功196例,1例在传统方法判断穿刺成功后,置入硬膜外导管失败,3例出现误穿入蛛网膜下腔。结论1.本研究测定的硬膜外腔隙是一低正压结构,范围接近于中心静脉压,临床的负压现象可能仅出现在硬膜外穿刺针顶开硬脊膜的瞬间。2.在椎管内麻醉硬膜外穿刺操作中,当穿刺针突破黄韧带进入硬膜外腔时,压力囊泡和硬膜外腔之间的压力差使压力囊泡迅速瘪掉,此时再用传统判断方法验证,两种判断方法的吻合率为100%。与传统方法相比,缩短操作时间,降低了穿刺并发症。3.压力囊泡指示器在硬膜外穿刺过程中,操作简便,通过持续观察针尖处阻力的变化,为穿刺及时提供“刹车信号”,可作为椎管内麻醉穿刺的辅助判断工具,提高穿刺成功率和安全性,具有临床应用价值。第二部分压力囊泡指示器在高龄患者侧入路硬膜外穿刺中的应用研究目的探讨压力囊泡指示器在高龄患者侧入路硬膜外穿刺中的应用,以提高高龄患者硬膜外穿刺的成功率,降低麻醉并发症,提高麻醉质量。方法1.选择ASA Ⅱ～Ⅲ级的高龄患者(75-92岁)120例,拟行下肢骨科手术,术前腰椎平片示所有患者均有不同程度的腰椎钙化。2.所有患者常规消毒铺单,采用侧入路硬膜外穿刺,P组患者当穿刺针穿过皮肤及皮下疏松组织后,推注注射器,使囊泡充盈,穿刺过程中持续观察压力囊泡的变化,若穿刺过程中针尖遇到骨质,则应将硬膜外穿刺针退至皮下,重新调整穿刺针方向,当囊泡迅速瘪掉后,证明穿刺针到达硬膜外腔隙,再用传统方法进行判断,并计算指示成功率。结果：在120例高龄患者中均有3例因硬膜外穿刺困难改为气管插管全麻,剔除该实验。P组其余117例患者采用压力囊泡指示器均顺利完成硬膜外穿刺的指示,压力囊泡正确指示率100%。结论：压力囊泡指示器在穿刺针进入硬膜外腔时,由于囊泡内压力与硬膜外腔的压力差,囊泡迅速瘪掉,准确提示穿刺针到达硬膜外腔。此指示装置结构简单,成本低,使用简便。而且适用于高龄患者侧入路硬膜外穿刺,提高了穿刺成功率和安全性。
[Abstract]:Intraspinal anesthesia is one of the most widely used clinical anesthetic methods at present. The anesthetic injection, spinal cavity gap such as subarachnoid or epidural cavity, thereby blocking the nerve impulse conduction, the corresponding region of its control. According to the anesthetic effect of different anesthesia drugs injected into space, mainly divided into epidural spinal and epidural spinal anesthesia combined anesthesia and subarachnoid space subarachnoid block. Advantages of spinal anesthesia include: stress response inhibition is superior to general anesthesia induced by operation; can be used for postoperative analgesia, and better analgesic effect than intravenous analgesia, systemic side effects of light; lower extremity vascular dilatation after anesthesia, blood flow speed, reduce the incidence of deep venous thrombosis; and promote peristalsis, is conducive to the recovery of intestinal function. Epidural anesthesia is through the dispersion of local anesthetics, block the spinal nerve root, have analgesic effect, and according to the operation site, choose different puncture points, and according to the need of surgery, Through an epidural catheter infusion of local anesthetics to meet the needs of different operation time. Combined spinal epidural anesthesia combined with epidural anesthesia and subarachnoid anesthesia with their own characteristics, both the advantages of rapid onset of complete block, but also through the epidural catheter injection of local anesthetics to extend the anesthesia time. The most commonly used for epidural anesthesia and the combined spinal epidural anesthesia, epidural puncture technique is the key to the successful implementation of the spinal anesthesia epidural puncture, if improper operation or judgment, can cause tissue or nerve injury; vascular injury caused by epidural hematoma; epidural puncture needle into the subarachnoid space and other complications, have serious consequences even threaten the life of patients. Since the end of nineteenth Century the invention of spinal anesthesia, the judgment method of epidural puncture success mainly depends on the subjective judgment of the anesthesiologist, empty into the Yellow ligament, Push the glass syringe resistance disappearance method (see Figure 1) and bubble compression test, but not the exclusive judgment tools and indicators, determine the existence of the traditional method of puncture misjudgment, the subjective factors and the operator and epidural cavity structure, the objective factors and vertebral puncture gap calcification. So in order to reduce the complications of spinal anesthesia. In addition to improve the epidural puncture technique, it is necessary to study an objective epidural puncture device. The purpose of this study is to observe the accuracy and feasibility of national patent - indicating the pressure bladder indicator in epidural puncture in. In this study the pressure bladder indicator is using the old textbooks in positive pressure the airbag test (Figure 2) the principle, by a pressure of the vesicles to continuous measurement of tip resistance. The pressure bladder indicator is the common syringe needle distance (5m1) The front side wall of the barrel opening on the 1cm (Figure 3), the hole is covered with elastic rubber film. Puncture with the pressure bladder indicator extraction of saline 5ml after epidural puncture needle end, when the depth of the needle than subcutaneous soft tissue, ligaments and fascia to dense tissue, push the syringe the needle pin 2.Oml, due to the tip by dense tissue resistance, the needle cylinder pressure increases, the film expands outward, the liquid pressure capsule of a diameter of about 1.5cm are formed on the bubble (Figure 4). Left hand needle pin (to puncture needle), due to friction between the appropriate design of the syringe barrel with the needle bolt, can prevent the vesicle pressure forced the pintle back automatically, so the pressure can still maintain a vesicle expanded state. At this time the hands holding the needle to puncture (see Figure 5), when the needle break ligamentum moment, tip pressure suddenly dropped, the resistance decreased, the vesicles within the liquid quickly Quick outflow of vesicles rapidly deflated, for a successful puncture of a video signal. The device can automatically and continuously monitoring the puncture process, with a clear, rapid, reliable objective index has reached the depth of puncture needle tip appropriate. To get rid of the epidural puncture has been relying on the subjective judgment of the situation, to achieve the operating tool professional and andobjective; at the same time improve the safety, reduce the risk of human error. In the clinical teaching, students' operation, the teacher did not "feel", it is difficult to determine the puncture depth of the students, the use of the pressure bladder indicator and everyone can see changes in the vesicles, suitable for clinical teaching. The pressure bladder indicator for the first time using visual signal automatic monitoring technology, reduce the dependence on the operation experience, the difficulty of the puncture operation decreased; improve operation safety, reduce the risk of human error, reduce the medical. The risks. Epidural puncture during anesthesia doctors can uninterrupted operation for epidural anesthesia with both hands, the field has brought revolutionary technological progress. With the improvement of living standards, more and more elderly patients, although studies have shown that spinal anesthesia has a certain effect on the circulatory function of elderly patients after anesthesia, but relatively stable, the elderly for patients with cardiovascular and cerebrovascular diseases is more suitable for thrombosis and cardiovascular complications, reduce the incidence of postoperative, and will greatly reduce the general anesthesia drug induced postoperative cognitive dysfunction (POCD) incidence rate, but also can avoid the complications of tracheal intubation anesthesia inhalation in the incidence of pneumonia and atelectasis. But most of elderly patients with vascular wall sclerosis and loss of elasticity, brittleness increases, should try to ensure the puncture is gentle, reduce the damage probability of bleeding, improve the power due to the old puncture. In patients with spine ligament, interspinal ligament calcification and loss of elasticity, intervertebral space narrowing, kyphosis or scoliosis caused by puncture is difficult, therefore, in elderly patients with lateral approach puncture path, the second part of this study is to observe the pressure bladder indicator into the application effect of the road in the epidural puncture in elderly patients the first part of the pressure side. Vesicles indicative to the feasibility and application effect of anesthesia device operation in clinical determination of spinal epidural space pressure; Determination of the pressure bladder indicator work pressure; observe the pressure vesicles indicative of anesthesia device feasibility and application effect of operation in clinical intraspinal. Methods 1.120 patients, age 18-60 old, epidural puncture gap T10-L3, no contraindication of epidural puncture, heart and lung function abnormalities, routine epidural puncture, puncture needle tail through the three connecting pressure sensor, The measurement of epidural pressure.2. were randomly selected from 120 pressure bladder indicator, each pressure bladder indicator extraction 5m1 saline, is connected to the front end of the pressure sensor, push the syringe needle pin 2.Oml, the vesicles swelled, vesicle size for 5 seconds at constant pressure for recording vesicle vesicle working pressure.3. to effect of spinal anesthesia in 400 patients, were randomly divided into two groups (n=200), pressure vesicle group (P group) and the traditional group (C group), no contraindication of epidural puncture, patients were treated by midline epidural puncture, epidural puncture needle is connected at the end of the pressure bladder indicator, P group when the needle through the skin and subcutaneous tissue loose, push the needle bolt pressure bladder indicator, so that the pressure of vesicle filling, slowly into the needle, when the needle tip reaches the epidural moment, because vesicles and epidural pressure difference, vesicles will quickly deflated, suggesting that the needle has To the epidural cavity, observe and record the pressure bladder indicator of successful puncture, and compared with the traditional method to determine the.C group used to judge the traditional way of epidural puncture. Epidural puncture operation time between the two groups, the complication rate and the success rate of puncture, and to observe the effect of anesthesia. Results 1. epidural pressure results: Patients with epidural pressure (9.8 + 4.3) mmHg.2 patients puncture syringe back to the blood, injecting local anesthetics after anesthesia is not satisfactory, determination of eliminate pressure, and take appropriate measures to deal with.2. vesicle pressure determination results: injection of 2M1 liquid to vesicle vesicle muster, working pressure (72 + 4) mmHg.3. vesicles indicator application effect: group P vesicles 200 cases of successful instructions, confirm the epidural puncture was successful in 200 cases, the coincidence rate of 100%. vesicles immediately instructed in 197 cases, 3 cases of delayed instructions, change The needle direction to puncture, quickly instructed the.C puncture was successful in 196 cases, 1 cases of puncture success in traditional method after epidural catheter failure occurred in 3 cases of error into the subarachnoid space. Conclusion: 1. this study was to determine the epidural space is a low pressure structure, range close to the central venous pressure, negative clinical phenomena may only appear in the epidural anesthesia epidural puncture needle top opening dural.2. moment in spinal puncture operation, when the puncture needle enters the epidural cavity through the ligamentum flavum, pressure difference between the pressure bladder pressure vesicles and epidural cavity bubble deflated quickly, then the traditional verification at this time judgment method, two methods are compared with the rate of 100%. with the traditional method, shorten operation time, reduce the complications of puncture.3. the pressure bladder indicator in the epidural puncture process, simple operation, through continuous observation of tip resistance Changes in the puncture provide timely brake signal, the auxiliary judgment can be used as a tool of spinal anesthesia puncture, improve the safety and success rate of puncture, has clinical application value. The second part of the pressure bladder indicator in elderly patients. Objective side into the road in the epidural puncture of the pressure bladder indicator into the application of road epidural puncture in elderly patients with side, in order to improve the elderly patients with epidural puncture success rate, reduce the complications of anesthesia, improve the quality of anesthesia in elderly patients. Methods 1. ASA II ~ III level (75-92 years old) in 120 patients undergoing lower extremity surgery, Department of orthopedics, preoperative lumbar radiographs showed that all patients had different degree the lumbar.2. calcification in all patients using the conventional disinfection shop, volar epidural puncture, patients in the P group when the puncture needle through the skin and subcutaneous tissue loose after injection syringe, the vesicle filling, puncture process In the continuous observation of changes in pressure vesicles, if encountered during puncture needle bone, it should be returned to the subcutaneous epidural puncture needle, re adjust the direction of the puncture needle, when the vesicles rapidly deflated after the proof of the needle to the epidural space, use the traditional method to judge, and calculate the success rate. The results indicate in 120 cases of elderly patients in 3 cases with epidural puncture for difficult tracheal intubation, excluding the experimental group.P the remaining 117 cases were treated by the pressure bladder indicator were successfully completed epidural puncture indication of pressure vesicle accurately indicates the rate of 100%. on the pressure bladder indicator in the epidural puncture needle the vesicle cavity, internal pressure and epidural pressure difference, vesicles rapidly deflated, accurate and prompt the needle to the epidural cavity. The indicating device has the advantages of simple structure, low cost, easy to use. It is suitable for the elderly patients with lateral approach Epidural puncture improves the success rate and safety of the puncture.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614.4

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