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【摘要】 目的 对比研究单纯全麻与硬膜外加全麻对全髋置换术患者的血液流变学的影响。方法 16例ASAⅠ～Ⅱ级,行择期全髋置换术患者随机分为两组。Ⅰ组为全麻组,Ⅱ组为硬膜外加全麻组,诱导前硬膜外给2%利多卡因5 ml,有平面后行全麻诱导,全麻用药与Ⅰ组相同,术中用利多卡因硬膜外阻滞,每50 min给药6～8 ml,术后24 h内用0.5%布比卡因镇痛,Ⅰ组术后肌注哌替啶镇痛。结果 两组血液流变学的主要差异:Ⅱ组的血液还原粘度、血浆粘度及纤维蛋白原浓度术中明显下降,术后恢复接近术前。Ⅰ组这三项指标术中也明显下降,但术后3 d内均反跳明显高于术前。结论 硬膜外阻滞能更好地抑制应激反应,其对血流变学的影响更有利于预防术后下肢静脉炎和静脉血栓的形成。
【关键词】 全身麻醉;硬膜外麻醉;血液流变学
The Clinic Research on Effects of Different Anesthetic Techniques on Haemorheology in Patients Undergoing Total Hip Replacement
YIN Mei-hua,ZHANG Jing,CHAI Chang-hua.Department of Anesthesiology, The People’s Hospital of Liaoning Province,Shenyang 110016,China
【Abstract】 Objective The study was undertaken to compare the effects of general anaesthesia and epidural block plus general anaesthesia on haemorheology.Methods Sixteen adult patients,ASA grade Ⅰ～Ⅱ,scheduled for elective total hip replacement were divided randomly into two groups.Group Ⅱ(n=8),5 ml,2% lidocaine were given epidurally before induction of anaesthesia,and every 50 min 6～8 ml was added after induction.The group Ⅰ was not given epidural anesthisisa,and the general anaesthesia method of both groups was similar in induction and maintenance.In 24 hours after operation,0.5% bupivacaine was given epidurally in group Ⅱ and pethidineim.in group Ⅰ for pain relief.Results The blood reducing viscocity,plasma viscocity and concentration of fibrinogen were decreased markedly during operation in two groups.These index recovered to the level of preoperation on the third postoperative day in group Ⅱ,but were higher than that in group Ⅰ.Conclusion As compared with the general anaesthesia,epidural anaesthesia may attenuate the endocrine responses to stress more effectively and improve haemorheology,which is helpful in preventing deep venous thrombosis postoperatively.
【Key words】 General anaesthesia;Epidural anaesthsia;Haemorehology
作者单位:110016 辽宁省人民医院麻醉科
下肢骨科手术,特别是全髋置换术和股骨头置换手术后,深静脉炎和深静脉血栓的发生率较高[1,4]。血液流变学的改变是引起这一并发症的一个相关因素。本研究对比观察单纯全麻与硬膜外阻滞加全麻对全髋置换术患者的血液流变学的影响。
1 资料与方法
1.1 病例选择 选ASAⅠ～Ⅱ级行全髋置换手术患者16例,随机分为两组,每组8例,年龄50～75岁,每组均为男3例、女5例,无严重心血管疾病及血液系统疾病,术前血常规检查正常。
1.2 麻醉方法 术前30 min肌注哌替啶50 mg、异丙嗪25 mg、东莨菪碱0.3 mg。两组全麻诱导均用芬太尼2～2.5μg/kg、硫喷妥钠6～8 mg/kg、维库溴铵60 μg/kg、气管插管后麻醉维持用0.8%～1.0%异氟醚、50%～60%氧化亚氮、氧气。取样期间保持血流动力学稳定。硬膜外加全麻组(Ⅱ组)在麻醉诱导前先于L��1～2�间隙行硬膜外穿刺置管,用2%利多卡因阻滞,麻醉效果确切后,再行全麻诱导。术中每隔50 min～1 h追加2%利多卡因6～8 ml。两组取样期间均输注平衡盐液,第2次取样前输液量控制在500 ml以内,第3次取血样前输液量控制在1 500～2 000 ml以内,不输血及其他液体。Ⅰ组术后间断肌注哌替啶镇痛,Ⅱ组留置硬膜外导管48 h,用0.5%布比卡因镇痛。
1.3 样本采集 分别于诱导前、患者清醒未吸氧时、诱导后30 min、切皮以前、诱导后90 min各取桡动脉血10 ml,其中1 ml作血气分析用,其余9 ml用于测血液流变学的各项指标。另外,术后第3天再采血1次,测血流变学指标。
1.4 统计学分析 计量资料以x±s表示,用配对t检验进行显著性检验,P
表1
全麻组围麻期血液流变学参数的变化(x±s)
麻醉前麻醉后30 min麻醉后90 min术后3～5 d
全血粘度切变率(mPa.s)230L/s3.33±0.312.99±0.49*2.38±0.83**�2.75±0.58*
46L/s4.52±0.733.81±0.57*3.62±0.99**�3.66±0.71**�
5.75L/s5.71±1.825.38±1.67*5.26±1.26*5.20±1.33**�
血浆粘度(mPa.s)1.28±0.061.26±0.101.24±0.031.35±0.12*
红细胞比积(%)35.6±2.6031.6±2.99**�31.3±3.45**�26.4±6.65**�
红细胞刚性指数0.912±0.020.895±0.050.898±0.080.908±0.09
红细胞聚集指数1.819±0.321.687±0.35*1.460±0.95**�1.794±0.32
血液还原粘度9.65±0.599.12±0.49*9.16±0.59*10.52±1.17**�
血小板聚集率(%)68.9±21.466.4±17.4*64.9±11.8**�58.1±12.8**�
血浆纤维蛋白原(g/L)3.96±1.113.39±1.13*3.27±0.95**�5.81±2.20**�
注:与麻醉前比较*P
