【作者】 赵亮；

【导师】 王喜军；

【作者基本信息】 广西医科大学 ， 麻醉学， 2015， 硕士

【摘要】 目的观察临床常用的不同麻醉方法全身麻醉(GA)和硬膜麻醉(EA),在膝关节镜下交叉韧带重建术中的临床应用效果,从不同方面比较两种不同麻醉方法的优点和缺点,从而对两种不同麻醉方法在膝关节镜下交叉韧带重建术中的应用做出临床效果的分析和评价。方法随机选择广西医科大学第一附属医院2012年10月～2015年2月之间,择期行膝关节镜下单侧交叉韧带重建术的患者共60例,ASAⅠ～Ⅱ级、年龄18-65岁、男女性别不限。将上述患者按照随机数字表方法均分为两组：全身麻醉组(GA组)和硬膜外麻醉组(EA组),每组患者各30例。GA组：患者以静脉靶控输注丙泊酚、瑞芬太尼并静脉注射顺阿曲库铵诱导,诱导完成后行气管内插管接麻醉机控制呼吸,术中以丙泊酚、瑞芬太尼静脉靶控输注及吸入七氟烷维持麻醉深度,并根据手术刺激强度及术中患者反应情况调整靶控速率及吸入麻醉药浓度；EA组：患者于L2-3行硬膜外穿刺,并向足侧置入硬膜外导管3cm,通过硬膜外导管给2%利多卡因3ml试验剂量,观察该组患者硬膜外阻滞平面出现并排除全脊麻后通过硬膜外导管给予0.75%的罗哌卡因,调节硬膜外阻滞平面使其达到T1o-S5水平,术中通过硬膜外导管适量追加0.75%罗哌卡因以维持硬膜外阻滞平面在T1o-S5水平。术中均常规监测心电图、心率、无创血压、动脉血氧饱和度,观察并记录两组患者麻醉前(T0)、麻醉后5分钟时(T1)、麻醉后30分钟时(T2)、麻醉后60分钟时(T3)、手术结束时(T4)和出手术室时(T5)的舒张压(DBP)、收缩压(SBP)、心率(HR)和动脉血氧饱和度(Sp02)；测定两组患者麻醉前快速血糖(BS)和麻醉后60分钟快速血糖(BS)并比较其变化情况；观察并记录术后1小时、术后3小时、术后12小时和术后24小时两组患者的疼痛评分(VAS疼痛评分)情况；记录两组患者围术期相关不良反应发生发生情况,并加以对比分析。结果两组患者ASA分级、年龄、性别、手术时间等一般情况的比较差异均无显著性(P>0.05),两组患者均可顺利完成手术；麻醉后T1-T4各时间点GA、EA两组患者DBP、SBP均较麻醉前T0时降低,差异有统计学意义(P<0.05)。T0-T3各时间点GA、EA两组患者DBP、SBP组间比较,差异均无显著性(P>0.05)。T4时GA组患者DBP较EA组患者高,差异有统计学意义(P<0.05)。T4时GA、EA两组患者SBP组间比较,差异均无显著性(P>0.05)。T5时GA组患者DBP、SBP均较EA组患者高,差异有统计学意义(P<0.01)；GA组患者HR在T0-T5各时间点波动较EA组患者大,T1-T4各时间点EA组患者HR均较GA组患者高,差异有统计学意义(P<0.05或P<0.01)；GA、 EA两组患者SpO2在T1～T5各时间点均较To时升高,差异有统计学意义(P<0.05)。T2、T3时GA组患者SpO2均较EA组患者高,差异有统计学意义(P<0.05)；GA、 EA两组患者麻醉后60分钟快速血糖均较麻醉前升高,差异有统计学意义(P<0.05)。麻醉后60分钟GA组快速血糖值高于EA组,差异有统计学意义(P<0.05)；GA组术后1小时、术后3小时VAS疼痛评分高均于EA组,差异有统计学意义(P<0.05)。术后12小时、术后24小时两组VAS疼痛评分差异均无显著性(P>0.05)；两组患者围术期相关不良反应比较差异有统计学意义(P<0.05),EA组高于GA组。结论膝关节镜下交叉韧带重建术采用全身麻醉和硬膜外麻醉均安全有效,无严重不良反应,并能获得较满意的麻醉效果。全身麻醉术中较硬膜外麻醉更有利于维持血流动力学的稳定,可控性更好,围术期相关不良反应发生率更低但术中血糖波动较大,术后早期疼痛发生率较高；膝关节镜下交叉韧带重建术应根据患者不同的病理生理特点选择不同的麻醉方法。更多还原

【Abstract】 Objective To observe the clinical application effect of two kinds of anesthetic methods (general anesthesia and epidural anesthesia) in arthroscopic cruciate ligament reconstruction, and to compare the advantages and disadvantages of the two anesthesia methods, in order to analyze and evaluate the clinical effect.Methods A total of 60 patients who received arthroscopic cruciate ligament reconstruction, from October 2012 to February 2015 were randomly selected from the First Affiliated Hospital of Guangxi Medical University, the patients had American Society of Anesthesiologists (ASA Ⅰ～ Ⅱ), the age was 18～65 years old. The patients were divided into general anesthesia (GA) group and epidural anesthesia (EA) group,30 cases in each group. Patients in GA group received target-controlled infusion of propofol and remifentanil, tracheal intubation was conducted after induced with cisatracurium, and the surgery was maintained with target-controlled infusion of propofol and remifentanil, and supplemented by sevoflurane and fentanyl according to surgical stimulation and intra-operative patients’responses. Patients in EA group received L2～3 epidural puncture and implanted with 3 cm epidural catheter to the foot side, and then injected with 3 ml lidocaine with the concentration of 2% through epidural catheter, after anesthetic level appeared,0.75% ropivacaine was injected through epidural catheter, the anesthesia level was adjusted to T10～S5 level and maintained with appropriately injection of 0.75% ropivacaine through epidural catheter. The electrocardiogram, heart rate, noninvasive blood pressure and arterial oxygen saturation, and recorded the diastolic blood pressure (DBP), systolic blood pressure (SBP), heart rate (HR) and arterial oxygen saturation (SpO2) of the patients in two groups before anesthesia (To), at 5 minutes (Ti),30 minutes (T2), and 60 minutes (T3) after anesthesia, after surgery (T4), and out of operation room (T5) were monitored. The blood glucose level of the patients in two groups were tested and compared before anesthesia and 60 minutes after anesthesia. The VAS score and peri-operative anesthesia-related complications were observed and recorded.Results There were no significant differences in patients’age, gender, ASA grading and operation time (P>0.05), all the patients completed the surgery successfully. The SBP of two groups at To time point were higher than that at Ti～T4 time points, and the difference was significant (P<0.05). There were no significant differences in DBP and SBP at T0～T3 time points between two groups (P>0.05). The DBP of GA group was higher than that of EA group at T4 time point, and the difference was significant (P<0.05). There was no significant difference in SBP at T4 time point between two groups (P>0.05). The DBP and SBP of GA group at T5 time point were higher than those of EA group, and the differences were significant (P<0.01).The HR fluctuations of GA group at T0～T5 time points were bigger than the EA group, and the HR of EA group at T1～T4 time points were higher than the GA group, and the differences were significant (P<0.05). The SpO2 of GA group at T2 and T3 time points were higher than those of EA group (P<0.05). The blood glucose at 60 minutes after anesthesia of two groups were higher than those before anesthesia (P<0.05), and the blood glucose of GA group was higher than that of EA group (P<0.05). The early postoperative VAS score of GA group was higher than EA group, and there was statistical significance (P<0.05). There were sinificant differences in perioperative anesthesia-related complications between two groups (P<0.05), and the complications of EA group were higher than that of GA group.Conclusions Both GA and EA for arthroscopic cruciate ligament reconstruction are safe and effective without adverse reaction, and can achieve satisfactory anesthetic effect. GA is more conducive to maintain hemodynamic stability with better controllability and low perioperative anesthesia-related complication rate when compared with EA, but can cause large fluctuation of blood glucose. GA has higher incidence of early pain than EA;Arthroscopic cruciate ligament reconstruction should be conducted with different anesthesia methods according to different pathological and physiology characteristics.更多还原