股神经联合椎旁神经阻滞在高龄患者髋关节手术中的应用

摘要

目的 评价股神经、胸腰椎旁神经联合阻滞在高龄患者髋关节手术的应用价值. 方法 将65例行髋关节术的70岁以上患者按抽签法随机分为全身麻醉(general anesthesia,GA)组、椎旁神经阻滞(paravertebral block,PVB)组,PVB组分别于股神经和T12、L3椎体行PVB,采用周围神经刺激器定位,局麻药为0.375％罗哌卡因与1％利多卡因混合液10 ml,并留置导管.GA组采用全凭静脉全身复合麻醉.比较两组患者手术开始30 min、手术结束时的平均动脉压(mean arterial pressure,MAP)、心率(heart rate,HR)和心肌氧耗指数以及术后送重症监护病房(intensive care unit,ICU)、留置导尿、视觉模拟评分(visual analogue scale,VAS)、复苏室评分、术后下呼吸道感染情况. 结果 两组患者术前一般情况、美国麻醉医师协会(ASA)分级、手术时间、MAP、HR和心肌氧耗指数差异无统计学意义.手术开始30 min HR和心肌氧耗指数GA组比PVB组低(P＜0.05),HR分别为(68±11)次/min和(80±11)次/min、心肌氧耗指数(8 807±1 883)和(10 362±2 433).与麻醉前比较,两组患者MAP、HR和心肌氧耗指数的变化均显著降低(P＜0.05).PVB组在手术后的MAP、HR和心肌氧耗指数均低于GA组(P＜0.05),MAP分别为(88±12) mmHg(1 mmHg=0.133 kPa)和(101±15) mmHg、HR(75±11)次/min和(84±19)次/min、心肌氧耗指数(9 706±2 009)和(12 687±4 119).与麻醉前比较PVB组MAP、HR及心肌氧耗指数低于术前(P＜0.05),GA组差异无统计学意义.PVB减少术后需送ICU、下呼吸道感染及留置导尿人数,与GA比较,差异有统计学意义(P＜0.05). 结论 股神经、胸腰椎旁神经联合阻滞可以安全有效地应用于高龄患者的髋关节手术,其生理干扰轻微,且术后需送ICU及留置导尿概率小,有效降低下呼吸道感染,有效降低心肌氧耗指数,提高了术后患者的安全性和舒适度.%Objective To evaluate the application value of combined femoral and thoracolumbar paravertebral nerve blocks in the hip joint operations of elderly patients.Methods Sixty five patients aged over 70 undergoing hip joint operation were randomly divided into general anesthesia group (GA) and paravertebral nerve block (PVB) group.In the PVB group,each patient received a combined femoral nerve-thoracolumbar paravertebral nerve block with the aid of a neurostimulator,and a 10 ml mixture of 0.75％ bupivacaine and 2％ lidocaine was used in each block.In the GA group,a total intravenous general combined anesthesia was applied to each patient.Mean arterial pressures (MAP),heart rates (HR) and myocardial oxygen consumption indexs were recorded 30 minites after the surgery started and when it finished.In addition,indwelling catheter management,visual analogue scale scores,resuscitation room indexes,and lower respiratory tract infections in the intensive care unit (ICU) were evaluated postoperatively.Results There were no differences in demographic data,ASA status,operation time,preoperative MAP,HR and myocardial oxygen consumption index of patients between the two groups.MAP,HR and myocardial oxygen consumption index of two groups 30 minites after the start of operations were lower than those of preoperative baseline values,respectively (P＜0.05),and the HR and myocardial oxygen consumption index of GA group were both lower than those of the PVB group (P＜0.05),the HR of GA group and PVB group were (68±11) beats/min and (80±11) beats/min,the myocardial oxygen consumption index of GA group and PVB group were (8 807±1 883) and (10 362±2 433).MAP,HR and myocardial oxygen consumption index in the PVB group was obviously lower than the GA group postoperatively (P＜0.05),MAP(88±12) mmHg(1 mmHg=0.133 kPa) vs (101±15) mmHg,HR(75±11) beats/min vs (84±19) beats/min,myocardial oxygen consumption index,(9 706±2 009) vs (12 687±4 119),respectively,and preoperatively (which was of no statistical significance).The length of ICU stay,infections of lower respiratory tracts,and the need for urinary catheters for patents in the PVB group were significant lower than those in Group GA (P＜0.05).Conclusions We conclude that the combined femoral-thoracolumbar parave rtebral nerve block can be safe and effective for the hip surgery,associated with minor physiological disturbance,lower myocardial oxygen consumption index,and higher postoperative comfort and safety.