老年膝髋关节置换应用罗哌卡因腰椎硬膜外联合麻醉：置换后不良反应率低

doi:10.3969/j.issn.2095-4344.2015.22.007

摘要/Abstract

摘要：

背景：老年人下肢关节手术常选用全麻或者连续硬膜外麻醉。单纯的硬膜外麻醉效果确切，容易控制，肌肉松弛效果较好，但是麻醉诱导时间相对较长，对控制膀胱腹膜反折处疼痛不理想，而且循环系统干扰受到腰麻过程中影响相对较大。
目的：探讨在老年下肢骨关节置换过程中罗哌卡因腰椎硬膜外联合应用的麻醉效果。
方法：纳入菏泽市立医院在2013年9月至2014年11月收治的下肢人工关节置换的老年患者90例，其中膝关节置换52例，髋关节置换38例，随机分为2组，每组45例。对照组采用连续硬膜外麻醉，观察组采用罗哌卡因腰椎硬膜外联合麻醉。观察并比较两组患者在置换过程中的生命体征、麻醉起效时间、局麻药诱导量、镇痛效果及置换后不良反应。
结果与结论：置换过程中对照组患者在心率、脉搏、动脉血氧饱和度均低于观察组，观察组患者置换过程中的基本生命体征更加稳定，两组对比差异有显著性意义(P < 0.05)。观察组患者麻醉起效时间、局麻药诱导量明显优于对照组，两组对比差异有极显著性意义(P < 0.01)。对照组镇痛效果优秀率为67%，低于观察组89%，两组比较差异有显著性意义(P < 0.05)。对照组患者置换后出现呕吐10例、呼吸困难4例，不良反应发生率为31%；观察组出现呕吐3例，呼吸困难2例，不良反应发生率为11%，对照组不良反应发生率显著高于观察组(P < 0.05)。提示罗哌卡因腰椎硬膜外联合麻醉在老年下肢骨关节置换过程中镇痛效果好，麻醉起效时间短，局麻药诱导量低，置换后不良反应发生率低。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

关键词: 植入物, 人工假体, 罗哌卡因, 硬膜外麻醉, 腰椎硬膜外联合麻醉, 膝关节置换, 髋关节置换, 老年, 镇痛

Abstract:

BACKGROUND: General anesthesia or continuous epidural anesthesia can be commonly selected for lower limb joint surgery in the elderly. The effect of epidural anesthesia is precise, and can be easily controlled. The effect of muscle relaxation is good. However, the time of anesthesia induction is relatively long, and it is not ideal in the control of pain in the visceral peritoneum reflection region. Moreover, circulatory system interference can be greatly affected by lumbar anesthesia.
OBJECTIVE: To evaluate the effects of combined spinal-epidural anesthesia with ropicavaine in elderly patients undergoing lower limb arthroplasty.
METHODS: Ninety patients undergoing lower limb arthroplasty admitted to Heze Municipal Hospital from September 2013 to November 2014 were chosen and were equally and randomly assigned to two groups, including 52 cases of knee replacement and 38 cases of hip replacement. Patients in the control group received
continuous epidural anesthesia. Patients in the observation group received combined spinal-epidural anesthesia with ropicavaine. Vital signs, onset time of anesthesia, drug consumption, analgesic effect and postoperative side effects were observed and compared in both groups.
RESULTS AND CONCLUSION: Heart rate, pulse, and arterial oxygen saturation were significantly lower in the control group than in the observation group. Vital signs in the observation group were more stable, and the significant difference was detected between the two groups (P < 0.05). Onset time of anesthesia and drug consumption were significantly better in the observation group than in the control group, showing very significant differences between the two groups (P < 0.01). The excellent and good rate of analgesic effects was lower in the control group (67%) than in the observation group (89%), which showed significant differences between the two groups (P < 0.05). In the control group, vomiting appeared in 10 cases and dyspnea appeared in 4 cases, with an incidence of side effect of 31%. In the observation group, vomiting appeared in 3 cases and dyspnea in 2 cases, with the incidence of side effects of 11%. The incidence of side effect was significantly higher in the control group than in the observation group (P < 0.05). These data indicate that combined spinal-epidural anesthesia with ropicavaine showed good analgesic effect in elderly patients receiving lower limb arthroplasty. The onset time of anesthesia was short. Drug consumption was low. The incidence of side effects was low.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Arthroplasty, Replacement, Knee, Arthroplasty, Replacement, Hip, Anesthesia, Epidural

中图分类号:

R318

牛宣耀. 老年膝髋关节置换应用罗哌卡因腰椎硬膜外联合麻醉：置换后不良反应率低[J]. 中国组织工程研究, 2015, 19(22): 3477-3481.

图/表（结果） 5

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中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

引言

材料方法

设计：随机对照试验。
时间及地点：于2013年9月至2014年11月在菏泽市立医院完成。
对象：菏泽市立医院在2013年9月至2014年11月收治行人工关节(包括髋关节和膝关节)置换的老年患者90例，其中男56例，女34例；年龄60-75岁，平均(64.75±6.83)岁；体质量55-75 kg，平均(62.60±4.87) kg；身高153-180 cm，平均(169.54±7.62) cm；膝关节置换52例，髋关节置换 38例。美国麻醉师协会(American society of anesthesiologists，ASA)临床分级[2]：Ⅰ级58例，Ⅱ级32例。其中合并冠心病8例，糖尿病7例，高血压19例，慢性支气管炎3例，脑梗死后遗症2例。术前常规检查患者的血尿常规、便常规以及生化指标均无明显异常。对合并症术前给予适当的内科治疗。
采用随机数字表法将90例患者分为对照组和观察组[3]，每组45例。对照组采用连续硬膜外麻醉，观察组采用罗哌卡因腰椎硬膜外联合麻醉。
比较两组患者在年龄、性别、体质量、并发症等基本资料方面差异无显著性意义(P > 0.05)。
纳入标准^[4]：①无严重的心、肺、肝、肾等疾病。②无硬膜外麻醉史。③无硬膜外麻醉禁忌证。④无心脏、神经系统手术史。⑤无精神疾病家族史。⑥患者及家属同意该研究并签署知情同意书。
排除标准^[5]：①有脊柱外伤史或者脊柱畸形。②患者穿刺部位感染。③患者对局麻药过敏。④患者具有凝血功能障碍。⑤患有神经系统疾病。⑥术前合并症未得到很好控制的患者。⑦慢性背部疼痛。⑧不愿意配合该研究的患者。
材料：文章中使用的髋关节假体及膝关节假体均具有良好的生物相容性。
方法：
置换前准备：冠心病患者使用营养心肌的药物，扩张冠状动脉；糖尿病患者术前预防性应用抗生素，控制血糖在6.5-9 mmol/L；高血压患者将血压控制在160/90 mm Hg (1 mm Hg=0.133 kPa)以下[6]。
术前常规禁食8 h以上，术前半小时常规肌注苯巴比妥钠0.1 g，阿托品0.5 mg。入室后常规检测心电图、脉搏、动脉血氧饱和度。开放静脉，静脉滴注乳钠林格氏液。采用面罩吸氧，流量3 L/min。
连续硬膜外麻醉^[7]：患者采取侧卧体位，头高脚低，通过L2-3或者L3-4间隙硬膜外穿刺成功后，硬膜外腔头侧置管3 cm左右，采取平卧体位后 3-5 mL试验量2%利多卡因注入硬膜外腔。观察5 min后，患者没有发生明显的不良反应，排除全脊麻和局麻药毒性反应，分次注入10-15 mL 2%利多卡因。
术中按需追加局麻药，结合患者的实际情况，间隔 45 min追加6 mL麻醉药物。调整麻醉平面于T10以下，最高不超过T8水平。
罗哌卡因腰椎硬膜外联合麻醉^[8]：患者采取侧卧体位，头高脚低，通过L2-3或者L3-4间隙硬膜外穿刺成功后，蛛网膜下隙穿刺借助25 G腰麻醉针，拔出针芯，流出脑脊液，针口朝向尾侧。以每8 s 1 mL的推注速度注入2.0-2.5 mL的10-15 mg和生理盐水混合液。依照手术的实际需要，间隔90 min通过硬膜外导管注入3-5 mL 0.5%罗哌卡因。调整麻醉平面于T10以下。
麻醉期间患者出现心率低于55次/min，肌肉注射0.25-0.5 mg阿托品；出现收缩压低于90 mm Hg时，静注10-15 mg麻黄碱以缓解症状；如果患者在术中使用骨水泥，骨水泥会引起患者不同程度的血压下降、心肌缺氧、心率代偿性增快，在使用骨水泥前常规静注10 mg地塞米松，加快输液速度或者提前静注5-10 mg麻黄碱，从而维持血压和心率在一个较好的水平^[9]。
主要观察指标：对两组患者心率、脉搏、动脉血氧饱和度进行检测；观察并比较两组患者的麻醉起效时间、局麻药诱导量、镇痛效果及置换后不良反应。
镇痛效果评定标准^[10]：
差：患者有明显疼痛，肌肉紧张，需改为全身麻醉或者采用更大剂量的镇痛药完成手术；
良：患者感到微弱疼痛，尚且可以忍受，完成手术需要使用强化镇痛药；
优：患者感觉不到疼痛，肌松良好，手术顺利完成。
统计学分析：应用SPSS 17.0统计软件进行统计学分析处理，统计描述各组数据均以x(_)±s来表示；两组间计量资料的比较采用t 检验；计数资料比较进行卡方检验，P < 0.05时为差异有显著性意义。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

讨论

老年人常常合并其他基础疾病，而且体质较弱，加之骨质疏松，再生能力差，下肢骨折是老年人常见的损伤，人工关节置换作为替代严重受损关节的措施，在严重的骨关节疾病中具有维持关节活动度，维持关节稳定性和消除关节疼痛的作用^[11]。

人工关节置换是在生物医学工程学、医学和人工关节生物力学等多学科推动下发展起来，近几十年的研究和临床时间中逐渐成熟，关节畸形得到纠正，关节疼痛得到解除，关节功能得到恢复，提高了患者的生活质量，已成为骨科临床常用的标准手术之一^[12-32]。

对老年人行下肢骨关节置换，老年人对麻醉和手术耐受力差，所以要选用有针对性的科学麻醉方式，以达到用药安全、麻醉作用发挥快、较好的镇痛作用的目的。老年人下肢关节手术常选用全麻或者连续硬膜外麻醉^[33]。单纯的硬膜外麻醉效果确切，容易控制，肌肉松弛效果较好，但是麻醉诱导时间相对较长，对控制膀胱腹膜反折处疼痛不理想，而且循环系统干扰受到腰麻过程中影响相对较大。硬膜外麻醉中镇痛不完全会对老年患者造成极大的危害，影响血液动力学，会因阻滞不全影响手术的正常进行^[34]。

本研究采用罗哌卡因腰椎硬膜外联合麻醉应用于老年下肢骨关节置换。罗哌卡因是一种纯左旋式异构体的酰胺类手术硬膜外局麻药，具有安全、有效、易耐受、脂溶性小、作用时间长的特点[35]，对心血管系统和中枢神经系统毒性低，阻滞分离感觉与运动神经，抑制心脏的传导和兴奋的作用较弱，有利于心血管中枢起代偿作用，保持血压平稳。罗哌卡因局部作用于脊髓血管，延缓对局麻药的吸收，可继续用于术后镇痛^[36]。硬膜外麻醉可以对神经元有效的抑制，对交感神经产生明显的阻滞效果，降低了儿茶酚胺浓度，有利于手术应激反应的降低^[37]。

本研究采用的麻醉方法具有以下优点：①避免了麻醉后麻醉体位与手术体位的转换，对血流动力学影响小。 ②所需麻醉药物剂量低，降低了患者过敏反应的发生率以及减少了不良反应和术后并发症。③局部麻药经脑脊液直接在脊神经根产生作用，更加完善骶神经阻滞，减轻了内总牵拉反应，具有便于操作、镇痛效果完善、肌肉松弛度较好、阻滞时间快^[38]。

综上所述，罗哌卡因腰椎硬膜外联合在老年下肢骨关节置换过程中镇痛效果好、麻醉起效时间短、局麻药诱导量低、术中不良反应发生情况小，是一种安全有效的麻醉方法，值得临床推广使用。中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程