罗哌卡因切口浸润对癫痫病灶切除术后患者早期认知功能影响

发布时间：2018-03-20 02:18

本文选题：0.5%罗哌卡因　切入点：切口浸润　出处：《中南大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：开颅手术切皮前应用局麻药物切口浸润可通过阻断外周疼痛传导的途径减少麻醉用药的用量,减轻术中患者血流动力学波动及抑制手术中应激反应的强度。本研究通过观察在术中使用罗哌卡因切口浸润麻醉后,对高选择性癫痫病灶切除术的患者术后早期认知功能的影响,了解其临床应用的价值。方法：经湖南省脑科医院伦理委员会批准,选取本院2013年10月-2014年4月行癫痫病灶切除术患者共40例,病灶部位均为右侧颞叶,手术方式为高选择性癫痫病灶切除术,ASA Ⅰ-Ⅱ级,年龄18-45岁。将患者随机分成两组每组各20例,即罗哌卡因实验组(R组)与生理盐水对照组(C组)。手术切皮前实验组给予0.5%罗哌卡因200mg(40m1)切口周围浸润阻滞,对照组于切皮前给予等容的生理盐水亦行切口浸润。两组患者选择的麻醉方式均为全麻气管内插管机械控制呼吸。诱导麻醉用药具体为：咪达唑仑(0.05mg/kg),丙泊酚(1mg/kg),芬太尼(3ug/kg),阿曲库胺(0.6mg/kg).术中根据需要调整丙泊酚注射液泵注速度；以及间断追加芬太尼注射液维持患者镇静镇痛；另予以阿曲库胺注射维持手术必要的肌松。术中持续正压控制呼吸,根据个体情况调整呼吸参数。并且术中通过BIS值监测维持手术麻醉深度(BIS值控制在40-55)。密切监测患者术中生命体征情况,维持血压波动范围在术前血压±20%,如果术中血压低至基础血压的20%以下,则根据病因进行处理。术中选取特定的时间点分别记录下两组患者MAP、心率,另在T1(麻醉诱导前10min)、T2(手术切皮后10min)、T3(入术后复苏室后10min)抽血查患者血糖和血清皮质醇值。分别记录两组患者术中输液量、尿量、失血量、及手术耗时时间,统计术中麻醉药用量。术毕苏醒后出术后复苏室后均使用术后镇痛泵镇痛。镇痛用药均为：舒芬太尼2μ g／kg+托烷司琼5mg,以生理盐水稀释至80ml。本研究对所有患者术前及术后进行两次神经精神功能测试。内容为选择韦氏成人智力量表及记忆量表里的7项敏感项目,两次测试时间分别在术前1天和术后7天。判定术后认知功能障碍的标准为国际术后认知功能障碍研究组推荐的复合Z分法——即复合Z分大于1.96亦可是超过两项测验中出现的单次Z分大于1.96可诊断术后认知功能障碍。结果：1.两组患者对比一般情况如性别比例、年龄、身高体重、ASA分级无统计学差异(P0.05)；两组患者术中情况如手术时间、出血量、尿量、输液用量、及术中咪达唑仑和阿曲库胺药物用量无统计学差异(P0.05)；2.两组患者在术中T2时的血清皮质醇值比较,R组较C组比数值降低显著,有统计学差异(P0.05),而两组患者各时间点的血糖值比较无统计学差异；3.两组患者术中芬太尼及丙泊酚用量对比：C组芬太尼的总量为1.02±0.18mg，R组芬太尼总量为0.74±0.13mg。R组芬太尼总量较对照组减少,有统计学差异(P0.05)；C组丙泊酚用量为883.31±212.43mg,R组丙泊酚用量为543.28±176.53mg,R组与C组对比有统计学差异(P0.05)；4.两组患者术后认知功能情况比较：R组患者(0.5%罗哌卡因组)有2例病人出现了早期术后认知功能改变,发生率为10%；C组(生理盐水组)有6例病人出现了早期术后认知功能改变,发生率为30%。R组较C组比较其差异有统计学意义(P0.05)。结论：1.癫痫患者行高选择性癫痫病灶切除术中应用0.5%罗哌卡因切口浸润可以减少术中芬太尼和丙泊酚的用量。2.癫痫患者行高选择性癫痫病灶切除术中应用0.5%罗哌卡因切口浸润可以降低术后早期认知功能障碍的发生率。图4幅,表10个,参考文献34篇。
[Abstract]:Objective: local anesthetic infiltration can be incision by blocking the way of peripheral pain reduction of anesthetic drug dosage before skin incision craniotomy, lessen the intensity of hemodynamic fluctuations and inhibition of the stress response during surgery during the operation. The aim of this study was to use ropivacaine incision during operation after infiltration anesthesia effect on early cognitive function high selective resection of epileptic patients, understand the value of its clinical application.
Methods: with the approval of the Hunan provincial Brain Hospital Ethics Committee of the hospital in October 2013 April -2014 for epileptic foci resection were 40 cases, the lesion was the right temporal lobe, the operation mode for the high selectivity of epileptic foci resection, ASA I-II, age 18-45 years old. The patients were divided into two groups of the 20 cases, namely the ropivacaine group (group R) and saline control group (C group). The surgical incision in the experimental group were given 0.5% ropivacaine 200mg (40m1) incision infiltration around the block, in the control group before skin incision with saline tolerance also incision infiltration. Two groups of patients with choice of anesthesia for general anesthesia endotracheal intubation mechanical ventilation induced anesthesia. Specifically: midazolam (0.05mg/kg), propofol (1mg/kg), fentanyl (3ug/kg), atracurium (0.6mg/kg) during the operation. According to the need to adjust the infusion speed and Propofol Injection; Intermittent fentanyl injection to maintain sedation analgesia; the other to atracurium injection to maintain the necessary surgical muscle relaxant. Intraoperative continuous positive pressure breathing control, according to the individual situation. And adjust respiratory parameters by intraoperative BIS monitoring to maintain the depth of anesthesia (BIS value is 40-55). Close monitoring of vital signs during surgery the situation, to maintain blood pressure fluctuation in preoperative blood pressure + 20%, if intraoperative low blood pressure to basal blood pressure below 20%, according to the etiology. Select the specific time points were recorded in two groups of patients with MAP, the heart rate in the operation, the other in the T1 (10min before induction of anesthesia (T2), after surgical incision 10min (T3), into the recovery room after surgery and 10min) to check blood glucose and serum cortisol values were recorded. The patients in the two groups of patients with transfusion volume, urine volume, blood loss, and the operation time, amount of intraoperative anesthetic surgery recovery after surgery. After the recovery room after the use of postoperative analgesia pump. Analgesia were: sufentanil 2 g / kg+ 5mg tropisetron, two neuropsychological tests for all patients before and after diluted with saline to 80ml.. The research content for the selection of 7 sensitive items Wechsler Adult Intelligence amount table and memory scale, two test time respectively before 1 days and 7 days after operation. Determine the postoperative cognitive dysfunction criteria for postoperative cognitive dysfunction in the international research group recommended that Z composite method of Z composite is greater than 1.96 but also more than a single Z is greater than 1.96 can be divided into diagnosis postoperative cognitive dysfunction in two test.
Results: 1. patients in the two groups were compared with the general situation of sex ratio, age, height and weight, there was no significant difference in ASA grade (P0.05); the two groups of patients in the operation time, bleeding volume, urine volume, transfusion amount, and intraoperative midazolam and atracurium dosage had no statistical difference (P0.05; 2.) serum cortisol in two groups of patients with intraoperative T2 value when compared to the R group than in C group was significantly lower than the values, there were significant differences (P0.05), and the two groups of patients with blood glucose values showed no significant difference; 3. patients in the two groups of fentanyl and propofol dosage were compared: the total amount of fentanyl group C was 1.02 + 0.18mg, R + 0.13mg.R group fentanyl total 0.74 total fentanyl group compared with the control group decreased, there was significant difference (P0.05); the dosage of propofol in group C was 883.31 + 212.43mg, the dosage of propofol in group R was 543.28 + 176.53mg, R group and C group compared with significant difference (P0.05); compare the cognitive function of the patients of 4. groups: two patients in group R (0.5% ropivacaine group) in 2 cases of early postoperative cognitive function change, the incidence rate was 10%; C group (saline group) in 6 cases of early postoperative cognitive function change, incidence rate there was statistical significance in 30%.R group than in C group compared the difference (P0.05).
Conclusion: 1. epilepsy patients underwent high selective resection of epileptic foci infiltration may infiltrate can reduce postoperative cognitive dysfunction in early stage of the occurrence rate of application of 0.5% ropivacaine fentanyl and propofol in the operation incision to reduce the dosage of.2. in patients with epilepsy in highly selective epileptic focus resection in the application of 0.5% ropivacaine incision. 4 charts, 10 tables and reference 34 articles.

【学位授予单位】：中南大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

【参考文献】