腰麻与复合麻醉用于足踝手术的临床研究

发布时间：2018-12-08 07:38

【摘要】：目的:腰麻作为一项运用超过一百年历史的传统麻醉方式,因其所需学习周期短,便于实施及花费较少而广泛应用于下肢手术。近十年来,随着超声引导技术在我国区域麻醉领域的应用而逐渐展现出自己独有的优势。本项研究致力于比较传统的腰麻与超声引导下股神经和坐骨神经阻滞复合保留自主呼吸的全身麻醉在足踝外科手术中的运用。方法:将80位ASA I级的足踝外科手术患者随机分成2组,每组40名患者。第一组(腰麻组)40名患者施行腰麻,于L3-4间隙进行穿刺,并在蛛网膜下腔注入0.5%罗哌卡因25mg。第二组(复合麻醉组)40名患者先进行超声引导下股神经(0.5%罗哌卡因10ml)与坐骨神经(0.5%罗哌卡因20ml)阻滞,起效后再复合保留自主呼吸(采用3mg-5mg/kg的丙泊酚与1ug/kg的芬太尼诱导,并用喉罩作为气道管理工具)的全身麻醉,麻醉维持采用2%-2.5%的七氟醚,氧流量为1.2L/min。比较两组病例麻醉准备时间,施行麻醉所需时间,麻醉起效时间,手术时间,复苏室使用时间,术后镇痛时间,术后进食流质所需时间与术后进食固体食物所需时间。同时记录基础状态,麻醉后即刻,麻醉后5min,麻醉后10min,麻醉后15min,麻醉后30min,进入复苏室时,离开复苏室时七个时间段的平均动脉压及心率。随访术后24h,48h,72h三个时间段的VAS评分以及头痛,恶心呕吐,尿潴留,穿刺部位痛等并发症的情况。术后派出专人进行麻醉满意度调查定量评分。结果:在时间方面,复合麻醉组患者的麻醉前等待时间,术后禁饮及禁食时间少于腰麻组患者,而复苏室使用时间,手术操作时间,感觉阻滞时间及运动阻滞时间长于腰麻组患者,差异有统计学意义。在心率的比较中,复合麻醉组在麻醉后5min,麻醉后10min及麻醉后15min三个时间段的心率均低于腰麻组,差异有统计学意义。在血压的比较中,复合麻醉组在麻醉后即刻,麻醉后5min及麻醉后15min三个时间段的血压均低于腰麻组,差异有统计学意义。复合麻醉组在术后24h,48h,72h三个时间段的VAS评分均低于腰麻组。复合麻醉组的麻醉满意度评分显著高于腰麻组。结论:复合麻醉可以提高患者术后镇痛效果,延长术后镇痛时间,缩短术后禁食禁饮时间,提高患者满意度。超声引导下股神经和坐骨神经阻滞复合保留自主呼吸的全身麻醉对足踝外科的手术具有广泛的应用前景。因其学习周期较腰麻长,且达到熟练掌握的程度较腰麻难,故而对骨科专科麻醉医师提出了新的挑战。
[Abstract]:Objective: as a traditional anaesthesia with more than 100 years history, spinal anesthesia is widely used in lower extremity surgery because of its short learning period, easy to implement and less cost. In the last ten years, with the application of ultrasonic guidance technology in regional anesthesia in China, it gradually shows its own unique advantages. The purpose of this study was to compare the application of traditional spinal anesthesia with ultrasound guided femoral nerve and sciatic nerve block combined with autonomic breathing anesthesia in ankle and foot surgery. Methods: 80 patients with ASA I ankle surgery were randomly divided into 2 groups with 40 patients in each group. The first group (spinal anesthesia group) 40 patients underwent spinal anesthesia at the L3-4 space puncture and subarachnoid injection of 0.5% ropivacaine 25 mg. 40 patients in the second group (compound anesthesia group) received ultrasound guided femoral nerve block (0.5% ropivacaine 10ml) and sciatic nerve block (0.5% ropivacaine 20ml). The anesthesia was maintained with 2-2.5% sevoflurane, which was induced by propofol from 3mg-5mg/kg and fentanyl from 1ug/kg and used laryngeal mask as airway management tool. Oxygen flow is 1.2 L / min. The anaesthesia preparation time, anaesthesia onset time, operation time, resuscitation room use time, postoperative analgesia time, postoperative fluid consumption time and postoperative solid food consumption time were compared between the two groups. At the same time, the basic state, immediately after anesthesia, 5 minutes after anesthesia, 10 minutes after anesthesia, 15 minutes after anesthesia and 30 minutes after anesthesia were recorded. The mean arterial pressure and heart rate were recorded when entering the resuscitation chamber and leaving the resuscitation chamber. The VAS scores and complications of headache, nausea and vomiting, urinary retention, and pain at puncture site were observed 24 hours, 48 hours and 72 hours after operation. After the operation, a special person was sent to investigate the quantitative score of anesthetic satisfaction. Results: in terms of time, the waiting time before anesthesia, the time of drinking ban and fasting after operation in the compound anesthesia group were less than those in the spinal anesthesia group, while the time of using the resuscitation room and the operating time of the operation were less than those in the spinal anesthesia group. Sensory block time and motor block time were longer than that of spinal anesthesia group, the difference was statistically significant. In the heart rate comparison, the heart rate of the compound anesthesia group was lower than that of the spinal anesthesia group at 5 min after anesthesia, 10min after anesthesia and 15min after anesthesia, and the difference was statistically significant. In the comparison of blood pressure, the blood pressure in the combined anesthesia group was lower than that in the spinal anesthesia group immediately after anesthesia, 5min after anesthesia and 15min after anesthesia, and the difference was statistically significant. The VAS scores in the combined anesthesia group were lower than those in the spinal anesthesia group at 24 hours, 48 hours and 72 hours after operation. The score of anesthesia satisfaction in compound anesthesia group was significantly higher than that in spinal anesthesia group. Conclusion: compound anesthesia can improve postoperative analgesia effect, prolong postoperative analgesia time, shorten time of fasting and drink ban, and improve patients' satisfaction. Ultrasound-guided general anesthesia of femoral nerve block and sciatic nerve block combined with autonomic respiration has a wide application prospect in ankle surgery. Because the learning cycle is longer and the degree of mastering is more difficult than that of spinal anesthesia, it poses a new challenge to orthopedic anesthesiologists.
【学位授予单位】：上海交通大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R614.27

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