不同剂量布比卡因蛛网膜下腔...年患者髋部手术低血压的影响_李泰佯.pdf

临床研究不同剂量布比卡因蛛网膜下腔阻滞对老年患者髋部手术低血压的影响李泰佯张磊李莹孟璐张晓敏樊佳威侯凯耀张二飞DOI:1012089/jca202303007基金项目:延安市基于 EAS 下的临床麻醉管理科技创新团队项目(202121)作者单位:716000延安大学附属医院麻醉科(李泰佯、张磊、李莹、孟璐、张晓敏、樊佳威、张二飞);延安大学医学院临床医学系(侯凯耀)通信作者:张二飞，Email:zhangerfei09 126com【摘要】目的观察脑脊液稀释不同剂量布比卡因蛛网膜下腔阻滞对老年患者髋部手术低血压的影响。方法选择 2020 年 12 月至 2022 年 2 月拟在腰硬联合麻醉下行髋部手术的患者 137例，男 45 例，女 92 例，年龄 75100 岁，BMI 1332 kg/m2，ASA 或 级。根据不同布比卡因用量，随机分为四组:布比卡因 3.75 mg 组(B1 组，n=33)、布比卡因 5.0 mg 组(B2 组，n=34)、布比卡因 7.5 mg 组(B3 组，n=35)和布比卡因 10.0 mg 组(B4 组，n=35)。四组患者于 L23或 L34实施腰硬联合麻醉，以 0.1 ml/s 的速度 B1 组注入蛛网膜下腔 0.1875%布比卡因 3.75 mg，B2 组注入0.25%布比卡因 5.0 mg，B3 组注入 0.375%布比卡因 7.5 mg，B4 组注入 0.5%布比卡因 10.0 mg。记录患者改良虚弱指数(mFI)，手术时间、手术类型、术中净入量，术中低血压总体发生率、早期低血压发生率，上升至最高阻滞平面时间、阻滞节段数、感觉神经阻滞持续时间、硬膜外用药率、单侧阻滞率。结果B1 组和 B2 组术中低血压总体发生率和早期低血压发生率明显低于 B3 组和 B4 组(P0.05)。B2 组和 B3 组上升至最高阻滞平面时间和感觉神经阻滞持续时间明显短于 B4 组(P0.05)。B1 组感觉神经阻滞持续时间明显短于 B2 组、B3 组和 B4 组(P0.05)。B1 组硬膜外用药率明显高于 B2 组、B3 组和 B4 组(P0.05)，B2 组明显高于 B4 组(P0.05)。B1 组和 B2 组单侧阻滞率明显高于 B3 组和 B4 组(P0.05)。结论脑脊液稀释 0.25%布比卡因 5.0 mg 蛛网膜下腔阻滞用于老年髋部手术患者，术中低血压发生率低，单侧肢体阻滞率高，无需侧卧等待，缩短了切皮时间，麻醉后血流动力学平稳，更利于老年患者髋部手术蛛网膜下腔阻滞。【关键词】老年;髋部手术;布比卡因;低血压;血流动力学Effect of different doses of bupivacaine subarachnoid block on hypotension in elderly patients under-going hip surgeryLI Taiyang，ZHANG Lei，LI Ying，MENG Lu，ZHANG Xiaomin，FAN Jiawei，HOU Kaiyao，ZHANG Erfei Department of Anesthesiology，Affiliated Hospital of Yan an University，Yan an 716000，ChinaCorresponding author:ZHANG Erfei，Email:zhangerfei09 126com【Abstract】ObjectiveTo observe the effect of different doses of bupivacaine subarachnoid blockdiluted with cerebrospinal fluid on hemodynamic stability in elderly patients undergoing hip surgeryMethodsA total of 137 patients with hip surgery under combined spinal-epidural anesthesia fromDecember 2020 to February 2022 were selected，there were 45 males and 92 females，aged 75100 years，BMI 1332 kg/m2，ASA physical status or According to the dosage of bupivacaine，the patientswere randomly divided into four groups:bupivacaine 3.75 mg group(group B1，n=33)，bupivacaine 5.0mg group(group B2，n=34)，bupivacaine 7.5 mg group(group B3，n=35)and bupivacaine 10.0 mggroup(group B4，n=35)The four groups were given combined lumbo-epidural anesthesia at L23or L34The subarachnoid space was injected with 0.1875%bupivacaine 3.75 mg in group B1，0.25%bupivacaine5.0 mg in group B2，0.375%bupivacaine 7.5 mg in group B3，0.5%bupivacaine 10.0 mg in group B4 ata rate of 0.1 ml/s The patientsmodified frailty index(mFI)，operation time，operation type，intraopera-tive net intake，overall incidence of intraoperative hypotension，incidence of early hypotension，the time torise to the highest plane level，number of block segments，duration of sensory nerve block，epidural medica-tion rate，and unilateral block rate were recorded esultsThe overall incidence of intraoperative hypoten-sion and the early incidence of intraoperative hypotension in groups B1 and B2 were significantly lower thanthose in groups B3 and B4(P 0.05)The time to rise to the highest block plane and the duration of sen-062临床麻醉学杂志 2023 年 3 月第 39 卷第 3 期J Clin Anesthesiol，March 2023，Vol39，No3sory nerve block in groups B2 and B3 were significantly shorter than those in group B4(P 0.05)Theduration of sensory nerve block in group B1 was significantly shorter than that in groups B2，B3 and B4(P 0.05)The rate of epidural drug use in group B1 was significantly higher than that in groups B2，B3 andB4(P 0.05)，and that in group B2 was significantly higher than that in group B4(P 0.05)The uni-lateral block rate in groups B1 and B2 was significantly higher than that in groups B3 and B4(P 0.05)ConclusionCerebrospinal fluid dilution of 0.25%bupivacaine 5.0 mg subarachnoid block is used in eld-erly hip surgery patients，with a low incidence of intraoperative hypotension and a high unilateral limb blockrate，no need to wait at side-lying position，shortening thetime for cutting skin，stable hemodynamics afteranesthesia，which is more conducive to the subarachnoid block of hip surgery in the elderly【Key words】Aged;Hip surgery;Bupivacaine;Hypotension;Hemodynamics我国人口老龄化加速1，老年患者髋部骨折发病率逐年增加2。术中稳定血流动力学是保障其围术期安全的关键因素3。首选轻比重单侧蛛网膜下腔阻滞(患侧向上)，建议使用生理盐水将0.75%布比卡因稀释至 0.2%成为轻比重布比卡因液用小剂量(5.07.5 mg)，推注 3040 s，患侧肢体向上体位保持 10 15 min 后实施手术操作3。临床工作中，用脑脊液稀释布比卡因实施蛛网膜下腔阻滞，起效相对缓慢，血流动力学平稳，单侧肢体阻滞率高。因此，蛛网膜下腔给药后无需侧卧等待，缩短了切皮时间。本研究探索脑脊液稀释不同剂量布比卡因蛛网膜下腔阻滞对老年髋部手术患者术中低血发生率和神经阻滞效果的影响，以期寻找出更适合于老年患者的布比卡因剂量，为临床应用提供参考方案。资料与方法一般资料本研究经医院伦理委员会批准(2020041)，在 中 国 临 床 试 验 注 册 中 心 注 册(ChiCT2200058711)。患者或家属签署知情同意书。选择 2020 年 12 月至 2022 年 2 月急诊或择期拟在腰硬联合麻醉下行髋部手术的老年患者，性别不限，年龄 75100 岁3，BMI 1332 kg/m2，ASA或级。排除标准:腰硬联合麻醉禁忌证或拒绝使用腰硬联合麻醉，合并其他部位需手术治疗的骨折，严重的功能失代偿的系统性疾病，改良虚弱指数(modified frailty index，mFI)0.6。剔除标准:术中更改其他麻醉方法，术中出血量400 ml。将患者随机分为四组:布比卡因 3.75 mg 组(B1组)、布比卡因 5.0 mg 组(B2 组)、布比卡因 7.5 mg组(B3 组)和布比卡因 10.0 mg 组(B4 组)。麻醉方法患者术前禁食 6 h，禁饮 2 h。入室后开放外周静脉通路，蛛网膜下腔麻醉前输入复方乳酸钠 300500 ml，行桡动脉穿刺，有创动脉压监测。静脉注入帕瑞西布纳 20 mg 后，放置侧卧位麻醉体位(患肢在上)，于 L23或 L34实施椎管内穿刺。均由麻醉科医师采用旁正中把持式入路椎管内穿刺技术实施腰硬联合麻醉4，16 G 硬膜外针斜面与脊柱纵轴平行，穿刺成功后使用 25 G 针行蛛网膜下腔穿刺，穿刺针前端注药口指向患侧肢体一侧，脑脊液流出通畅后，将预设剂量的布比卡因混合液