【作者】 杨琳；

【导师】 徐世元；

【作者基本信息】 南方医科大学 ， 麻醉学（专业学位）， 2022， 硕士

【摘要】 研究背景中国目前有1.409亿糖尿病成年患者,位居全球首位,而糖尿病患者面临更高的手术概率及手术风险,长期高血糖的刺激可导致周围神经及自主神经病变,局部麻醉因其对患者生理功能影响小等优点广泛应用于临床麻醉。局麻药存在神经毒性,动物模型研究证明局麻药对糖尿病动物产生的阻滞作用较非糖尿病者显著增强,推测高糖环境对神经细胞的损伤导致其对局麻药敏感性增强,但糖尿病患者对局麻药感觉、运动神经阻滞敏感性是否增强的相关报道较少。本研究拟采取前瞻性对照方法,比较2型糖尿病患者与非糖尿病患者等比重罗哌卡因蛛网膜下腔阻滞后阻滞时效及围术期并发症发生情况,并分析其相关因素。方法本研究方案经南方医科大学珠江医院伦理委员会批准(批准号2021-KY-071-02),经预实验估算总样本量共88例(糖尿病组:非糖尿病组=1:1)。糖尿病组(DM组)及非糖尿病组(N组)患者取侧卧位于L3-4椎间隙以0.5%等比重盐酸罗哌卡因3ml行蛛网膜下腔阻滞麻醉,记录麻醉实施及手术过程、围术期并发症发生情况。主要观察指标:分别使用10g单丝压力觉及改良Bromage评分评估蛛网膜下腔阻滞后的感觉、运动阻滞持续时间;次要观察指标:感觉、运动阻滞起效时间,围术期低血压、心动过缓、寒战、恶心、呕吐、头痛、局麻药全身毒性反应、暂时性神经病学综合征、马尾神经综合征等发生情况。采用SPSS Statistics 26.0进行统计学分析。结果本研究共纳入105例患者,3例因更改麻醉方式退出试验,最终采集DM组41例、N组61例,共102例患者。两组在人口学资料、麻醉及手术情况上均无统计学差异。DM组血浆血糖、75g 口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)2h血糖、糖化血红蛋白等均高于N组,10g单丝压力觉、密歇根周围神经病变筛选表(Michigan neuropathy screening instrument,MNSI)分数均低于 N组,组间差异均具统计学意义(P<0.05)。蛛网膜下腔阻滞后,两组最高感觉阻滞平面、运动阻滞起效时间无统计学差异;与N组相比,DM组感觉阻滞起效时间缩短(DM:55.00s,N:72.00s,P=0.014)、感觉及运动阻滞持续时间显著延长(DM:370.63±57.50min,N:344.28±54.64min,P=0.023;DM:221.85±47.67min,N:201.93±44.56min,P=0.034);DM组患者低血压、寒战发生率均高于N组(DM:48.8%,N:23.0%,P=0.007;DM:7.3%,N:0.0%,P=0.032),两组心动过缓、恶心、呕吐的发生无统计学差异,且均未观察到头痛、局麻药全身毒性反应、暂时性神经病学综合征及马尾神经综合征的发生。感觉阻滞起效时间、感觉及运动阻滞持续时间及低血压的发生,与糖尿病病程、血浆血糖、OGTT2h血糖、糖化血红蛋白、糖尿病并发症、10g单丝压力觉及MNSI检查分数相关(|rs|>0.2,P<0.05)。结论1.2型糖尿病患者对0.5%等比重盐酸罗哌卡因蛛网膜下腔阻滞时效的敏感性增强,与糖尿病病程,糖化血红蛋白、血浆血糖、OGTT 2h血糖水平,MNSI分数相关,表明糖尿病病程长、血糖控制不佳、合并周围神经病变者,可增强罗哌卡因蛛网膜下腔阻滞时效的敏感性。2.2型糖尿病患者盐酸罗哌卡因蛛网膜下腔阻滞后低血压出现的峰值时间提前,低血压及寒战的发生率增高,提示与糖尿病自主神经病变有关。3.术中单独使用地塞米松、牛痘疫苗接种家兔炎症皮肤提取物注射液或二者联用不影响0.5%等比重盐酸罗哌卡因蛛网膜下腔阻滞时效。更多还原

【Abstract】 Background China currently has 140.9 million adults with diabetes,ranking first globally.Diabetic patients face a higher probability of surgery and surgical risks.The stimulation of long-term hyperglycemia can lead to peripheral and autonomic neuropathy.Regional anesthesia is widely used because of its advantages,such as the low impact on patients’ physiological functions.Local anesthetics are neurotoxic,and studies in animal models have demonstrated that local anesthetics produce significantly enhanced blockade in diabetic animals compared with non-diabetics,presumably due to the damage to nerve cells in the high-glucose environment leading to their increased sensitivity to local anesthetics.However,whether T2DM enhanced the sensitivity of local anesthetics in sensory and motor blocks in patients has not been thoroughly evaluated.This study used a prospective controlled approach to compare the sensory and motor blockade and the incidence of perioperative complications after isobaric ropivacaine subarachnoid block in T2DM patients with non-diabetic patients to analyze their associated factors.Methods The Medical Ethics Committee approved this study of Zhujiang Hospital of Southern Medical University,China(approval number 2021-KY-071-02)before implementation.The sample size estimated by pre-experiment was 88 cases(DM group:non-diabetic group=1:1).Patients in the diabetic group(DM group)and non-diabetic group(N group)were anesthetized by spinal anesthesia with 3 ml of 0.5%isobaric ropivacaine hydrochloride in the L3-4 interspace in a lateral position,and the anesthesia and surgical procedures and perioperative complications were recorded.Primary endpoints:duration of sensory and motor block after subarachnoid block separately evaluated by 10g Semmes-Weinstein monofilament test and modified Bromage scale;secondary endpoints:the onset time of sensory and motor block,the occurrence of perioperative hypotension,bradycardia,shivering,nausea,vomiting,headache,local anesthetic systemic toxicity,transient neurological syndrome and cauda equina syndrome.SPSS Statistics 26.0 was used for statistical analysis.Results A total of 105 patients were enrolled,and 3 cases withdrew from the trial due to a change of anesthesia.Forty-one patients in the DM group and 61 patients in the N group totaling 102 cases,were finally collected.There was no statistical difference between the two groups regarding demographic,anesthesia,and surgery characteristics.Plasma glucose,OGTT 2h PG,and glycosylated hemoglobin level were higher in the DM group than in the N group,and 10g monofilament test score and MNSI score were lower than in the N group.The differences between the groups were statistically significant(P<0.05).After the subarachnoid block,the maximum blockage dermatome level and the onset time of motor block were not statistically different between the two groups;compared with the N group,the DM group had a shorter sensory block onset time(DM:55.00s,N:72.00s,P=0.014)and a significantly prolonged sensory and motor block duration(DM:370.63±57.50min,N:344.28±54.64min,P=0.023;DM:221.85±47.67min,N:201.93±44.56min,P=0.034);the DM group was more likely to have hypotension and shivering than the N group(DM:48.8%,N:23.0%,P=0.007;DM:7.3%,N:0.0%,P=0.032).There was no statistical difference in the occurrence of bradycardia,nausea,and vomiting.Both groups did not observe postoperative headache,systemic toxicity of local anesthetics,TNS,and CES.The onset time of the sensory block,duration of sensory and motor block,and occurrence of hypotension were correlated with diabetic duration,plasma glucose,OGTT 2h PG,glycosylated hemoglobin level,diabetic complications,10g monofilament test,and MNSI test score(|rs|>0.2,P<0.05).Conclusions 1.Patients with T2DM were more sensitive to 0.5%isobaric ropivacaine hydrochloride subarachnoid block,the duration of the subarachnoid block with 0.5%ropivacaine hydrochloride was correlated with the diabetic duration,glycosylated hemoglobin level,plasma glucose,OGTT 2h PG,and MNSI score,suggesting that the sensitivity of subarachnoid block with ropivacaine could be enhanced in patients with long duration of T2DM,poor plasma glucose control,and peripheral neuropathy.2.After the subarachnoid block of ropivacaine hydrochloride,the time of peak hypotension was earlier in T2DM patients,and the incidence of hypotension and shivering was higher than that in non-diabetic patients,suggesting that it is related to diabetic autonomic neuropathy.3.Intraoperative use of dexamethasone alone or Neurotropin injection or combination did not affect the efficacy of 0.5%ropivacaine hydrochloride in the subarachnoid block.更多还原