双穿刺点法联合腰麻硬膜外麻醉对肾移植受者术中血流动力学影响

1、双穿刺点法联合腰麻硬膜外麻醉对肾移植受者术中血流动力学影响                   作者：王警卫，王军，常江，杜文涛，曹艳，蒋敢【摘要】  目的：探讨双穿刺点法联合腰麻硬膜外麻醉（DSTCSEA）对肾移植术受者血流动力学的影响以及术中、术后对植入肾功能恢复的影响. 方法：选取需行同种异体肾移植患者120例，随机分为单点硬膜外麻醉组（EA组）（n=68）和DSTCSEA组（DCSEA组）（n=52

2、）. EA组行T12L1椎间隙行硬膜外麻醉；DCSEA组先于T11,12或T10,11行硬膜外穿刺并置管，再于L2,3行脊椎麻醉，术中由硬膜外导管追加局麻药. 监测血流动力学指标，术中移植肾见尿时间，术后24 h尿量并分析. 结果：两种麻醉方法对患者血流动力学影响差异均有统计学意义（P<0.05），在移植肾血流开放时两组血流动力学指标无明显差别，两组移植肾功能恢复差异无统计学意义（P>0.05）. 两组局麻药总用药量差异有统计学意义（P<0.05）. 结论：DSTCSEA具有局麻药总用药量少，麻醉效果确切等优点，可安全用于肾移植手术. 【关键词】  肾移植；血流动力

3、学；麻醉，脊椎；麻醉，硬膜外【Abstract】 AIM: To study the influence of the double segment technique of combined spinalepidural anesthesia (DST of CSEA) on the recipients hemodynamics during kidney transplantation, and the influence on short and longterm posttransplant kidney function. METHODS: Total 120 patients u

4、ndergoing kidney transplantation were randomized into 2 groups: continuous epidural anesthesia group (Group EA) (n=68) and DST of CSEA group (Group DCSEA) (n=52). All the patients were measured  for ABP, CVP, ECG, heart rate (HR) and SPO2. In the Group EA, epidural anesthesia was performed via

5、the T12L1 interspace. Patients in Group DCSEA were anesthetized spinally via the L2-3 interspace after catheterization was taken via the T11,12 or T10,11 interspace at extradural space, and through the epidural catheter followed by local anesthetics during operation. The central hemodynamics indices

6、 were recorded and analyzed. The indices of the time of earlier urine onset, volume of  local anesthetic, urine output in 24 h were also analyzed.  RESULTS:  There was statistical difference in the hemodynamics before and after anaesthetization in both 2 groups, but there was no signi

7、ficant difference in the time of earlier urine onset and posttransplant kidney function. However, the volume of local anesthetic was significantly less in Group DCSEA than in Group EA. CONCLUSION:  DST of CSEA is associated with litter volume of local anesthetic and better function of anesthesi

8、a in kidney transplantation compared with EA, and can be used safely for kidney transplantation anesthesia.【Keywords】  kidney transplantation; hemodynamics; anesthesia, epidural; anesthesia, spinal0  引言    联合腰麻硬膜外麻醉（combined spinalepidural anesthesia，CSEA）具有局麻药总用药量少，麻醉效果确切等优

9、点1，广泛用于下腹部，会阴及下肢手术. 双穿刺点法联合腰麻硬膜外麻醉（double segment technique of combined spinalepidural anesthesia，DST of CSEA）即硬膜外麻醉穿刺点与脊椎麻醉穿刺点不同，其可达到更广泛的麻醉区域. 我们将其应用于肾移植手术，并对其产生的血流动力学影响进行了观察与分析.1  对象和方法1.1  对象  尿毒症患者120（男48，女72）例，年龄2452岁，体质量3875 kg，ASA级. 患者术前均常规行血液透析治疗，手术前日加透析治疗1次，正规治疗高血压均1 mo以上，无麻醉

10、手术禁忌症，无麻醉术前用药. 已除外麻醉失败，以及改为全身麻醉等病例. 随机分为持续单点硬膜外麻醉组(epidural anesthesia，EA) （EA组） 68例和DSTCSEA组(DCSEA组) 52例.1.2  方法  患者进入手术室后均在非动静脉造瘘侧行桡动脉持续动脉测压、颈内静脉穿刺置管，开放静脉通路，用Philips MP20监护仪监测ABP,CVP,ECG,心率（HR）和非供氧状态下指脉氧饱和度（SpO2），常规持续吸氧. EA组均于T12L1椎间隙行硬膜外穿刺置管，先给20 g/L利多卡因5 mL试验量，5 min后无脊麻症状后给予20 g/L利多卡因1

11、0 mL，以后根据麻醉平面和肌肉松弛程度，每次追加7.5 g/L布比卡因510 mL.DCSEA组均取术侧卧位，床头端稍高位（约510°），先于T11,12或T10,11行硬膜外穿刺并置管备用，再于L2,3行脊椎麻醉，给予100 g/L葡萄糖配制成5 g/L布比卡因重比重混合液2.53.0 mL，患者平卧，调整麻醉平面至T6水平. 术中根据麻醉平面及肌肉松驰程度由T11,12或T10,11硬膜外导管给予20 g/L利多卡因5 mL试验量，无麻醉平面异常后给7.5 g/L布比卡因58 mL. 硬外管给局麻药时间应尽量避开移植肾血流开放前后30 min，以免麻醉致移植肾血流开放时血压过低

12、而使移植肾灌流量减少.    麻醉效果确切后即静脉给予咪达唑仑2 mg、芬太尼0.05 mg、氟哌利多2.5 mg. 手术开始即给予甲基强的松龙250 mg加入50 g/L葡萄糖注射液250 mL静滴，维持至移植肾血流开放. 术中补液以平衡盐液为主，胶体液与晶体液的比例为13，失血多时需输新鲜血，使CVP保持于714 cmH2O(1 cmH2O=0.098  kPa)稍高水平. 移植肾血流开放前给予甲基强的松龙500 mg，速尿80 mg，环磷酰胺200 mg静注，见尿后给予200 g/L甘露醇100200 mL静滴.    监测项目：记录进入手术室时（T0），椎管内麻醉效果确切后手术开始时（T1），开放移植肾血流时（T2），开放移植肾血流后（T3），开放移植肾血流后30 min（T4），手术结束时（T5），患者的SBP, DBP, MAP, CVP, HR,