不同晶体液对腰硬联合麻醉下应用止血带行下肢骨科手术患者循环和

1、不同晶体液对腰硬联合麻醉下应用止血带行下肢骨科手术患者循环和代谢的影响        【摘要】    【关键词】  止血带;腰硬联合麻醉;血流动力学;血气分析;乳酸盐        【关键词】 止血带;腰硬联合麻醉;血流动力学;血气分析;乳酸盐    The effect of different crystal solution to the patients ci

2、rculation and metabolism who using tourniquet when taking the lower extremity surgery under CSEA    ZHANG Hua，SUN Xiao-hua.Tianjin Hospital，Tianjin 300211，China    【Abstract】 Objective To observe that when given different crystal solution， the changes of patients circul

3、ation and metabolism who using tourniquet when taking the lower extremity surgery under CSEA.Methods 30 patients who will take the selected lower extremity surgery are divided into sodium acetate group(group A) and sodium lactated Ringers solution group(group L)randomly， 15 cases each group. Adoptin

4、g CSEA and using tourniquet during surgery. The puff time is till the end of the operation major step and total puff time reaching 120mins. The puff pressure is systolic pressure adding 100150mmHg. Measuring the MAP and HR 30min， 60min， 90min before and after puffing and 1min， 3min， 5min， 10min， 30m

5、in after deflation， as well as the blood gas index and blood lactated content 5min， 10min， 30min before puffing and after deflation.Results The difference of sex ratio， age， weight， ASA grade ratio， the tourniquet puff time and puff pressure has no statistical meaning in both two groups(P>0.05).

6、There is no obvious changes of MAP when at 30min， 60min， 90min after puffing than before puffing in both two groups(P>0.05). HR increased at 90min after puffing in group A (P<0.05)， moreover HR didnt change obviously at anytime of puffing in group L. HR increased at anytime after deflation tha

7、n before it in both two groups， obviously at 1min and 3min (P<0.01)， the increasing of HR reached the peak at 1min. MAP fall at 1min after deflation (P<0.05)，there is no obvious changes at 3min and anytime after deflation than before puffing(P>0.05)， there is no difference of the changes of

8、 MAP and HR between groups. The changes of blood gas index， PaCO2 increased obviously in both two groups at 5min after deflation (P<0.01)， there is no difference between groups. The pH and BE are obviously lower at anytime after deflation than before puffing (P<0.01)， the lowest value is at 5m

9、in after inflation. The comparison difference of pH and BE at 5min after deflation between groups has statistical meaning， group L is lower than group A. HCO-3 reduced at anytime after deflation， there has statistical meaning at 5min and 30min(P<0.05)， there isnt difference between groups. P50， N

10、a+ and Ca2+ in blood serum has no change before and after puffing. The serum K+ rose obviously at anytime after deflation (P<0.05)， reached the peak at 10min after deflation， there is no difference between groups. The arterial lactated content roses obviously at anytime after deflation (P<0.05

11、)， reached the peak at 10min after deflation， the comparison difference at 5min， 10min between groups has statistical meaning， group L is higher than group A. Conclusion Using tourniquet in lower extremity orthopedic surgery under CSEA can offer a relatively perfect anesthesia effect and stable hemo

12、dynamics， a transient hypercapnia and hyperkalemia can be observed in patients， compared with the sodium acetate infusion in surgery， the phenomenon of transiently higher blood lactated and lower blood pH was found in lactated Ringers solution infusion patients.    【Key words】 tourniq

13、uet;CSEA;hemodynamics;blood gas analysis;acetated    肢体矫形手术通常需要应用止血带以获得清晰、无血视野。大量文献报道了止血带充/放气过程、肢体缺血时间、缺血范围、麻醉所引起的循环和代谢改变，然而在应用止血带过程中使用不同晶体液对循环和代谢的影响还鲜有报道。本研究旨在探讨腰硬联合麻醉（CSEA）下应用止血带行下肢骨科手术，不同晶体液对循环和代谢的影响，为术中处理及液体选择提供依据。    1 资料与方法    1.1 一般资料 选择非肿瘤下肢手术需上止血

14、带患者30例，男23例，女7例，ASA 级，年龄1763岁，体重5099kg。术前无循环及呼吸系统疾病，肝肾功能无异常。手术种类包括胫、腓骨骨折切开复位内固定术19例，膝韧带重建术8例，股骨骨折切开复位内固定术2例，跟骨骨折切开复位内固定术1例，全部病例均未用骨水泥等非生物材料。随机将患者分为醋酸钠林格液组（A组）和乳酸钠林格液组（L组），每组15例。    1.2 麻醉方法 麻醉前30min肌注咪唑安定0.05mg/kg。入室后常规监测ECG、SpO2、BP、T，面罩吸氧，氧流量4L/min。在输液对侧上肢行桡动脉穿刺测压及采集动脉血样。腰硬联合麻醉选择腰34间

15、隙穿刺，脊麻用药为重比重0.5%罗哌卡因1.62.0ml，硬膜外头端置管3cm。麻醉平面控制在胸810以下。术中根据麻醉情况经硬膜外导管给予2%利多卡因及0.75%罗哌卡因。在止血带放气前15min及放气后15min避免硬膜外腔给药。    1.3 补液 A组患者入室后输入醋酸钠林格液，速度68ml(kg· h)。脊麻后改输聚明胶肽注射液10ml(kg·h)防治低血压，术中输入醋酸钠林格液。待止血带放气后，快速输入聚明胶肽。L组以乳酸钠林格液取代醋酸钠林格液。    1.4 使用止血带 麻醉效果确切后，将止血带缚于

16、大腿根部。切皮前用弹力绷带自足部开始向近心端加压重叠缠绕驱血，直至止血带处，然后充气。充气压力为充气前患者的收缩压加100150mmHg，体型较胖者酌情加大充气压力，但最高充气压力不超过300mmHg。手术主要操作步骤结束或止血带充气时程达120min时放气。放气过程要缓慢，历时11.5min。    1.5 观察指标 (1)分别于止血带充气前即刻（T0）、充气后30min（TI1）、充气后60min（TI2）、充气后90min（TI3）以及放气后1min（TD1）、放气后3min（TD2）、放气后5min（TD3）、放气后10min（TD4）、放气后30min（

17、TD5）记录心率（HR）、收缩压（SBP）、舒张压（DBP）和平均动脉压(MAP)。(2)分别于T0、TD3、TD4、TD5各时点采集动脉血，行血气分析、电解质及乳酸含量测定。    1.6 统计学处理 计量资料以均数±标准差（x±s）表示，采用SPSS13.0统计软件进行统计学处理，组内采用配对t检验，组间采用两独立样本均数t检验。P<0.05为差异有显著性。    2 结果    2.1 两组患者一般资料及术中情况的比较 两组性别比、年龄、体重、ASA分级比、止血带充气时间、

18、充气压力差异均无显著性（P0.05），见表1。患者麻醉均满意，术中未诉止血带疼痛、患肢酸麻、沉重，无不适感。    2.2 血流动力学指标 止血带充气30min、60min和90min时，两组MAP较充气前均无明显变化（P>0.05）。充气90min后，A组HR增加（P<0.05），而L组在充气各时点HR无明显变化。两组在止血带放气后各时点HR均较放气前增加，其中1min、3min时增加明显（P<0.01），1min时HR增加达高峰。MAP在放气后1min时下降（P<0.05），3min及其后各时点与充气前相比无明显变化（P>0.05

19、），MAP及HR变化组间比较差异无显著性，见表2。表1 两组患者一般资料及术中情况的比较表2 两组患者术中各时点血流动力学指标的比较  注：与T0相比，*P<0.05，* P<0.01    3 讨论    应用止血带期间动脉血压会逐渐升高，初期因为止血带充气前驱血使单侧下肢缺血。充气3045min后，止血带疼痛即成为MAP升高的主因1，2。研究表明，无髓鞘C纤维与止血带疼痛传导有关3，4。Villa H 等发现，不同麻醉方法止血带疼痛的发生率差别巨大：全麻67%，局部静脉麻醉18.6%，脊麻2.7%，臂神经丛阻

20、滞2.5%5。提示在椎管内麻醉下行下肢手术，止血带疼痛发生率较低。本研究两组均采用CSEA，无一例出现止血带疼痛，有效避免了止血带疼痛所致的血压升高。    止血带放气后，体内血液涌入缺血下肢，乳酸、二氧化碳、组胺等随止血带放气进入循环，引起微循环广泛开放，使回心血量骤然减少，心排血量减少、血压下降。本研究两组患者在止血带放气后各时间点心率均高于充气前，只有放气后1min时MAP下降（P<0.05），3min时即恢复到放气前水平，与文献报道略有差异6，考虑与本研究均为择期手术患者，无术前急性失血，患者基础状态和代偿力良好、术中容量补充充足，且在止血带放气前1

21、5min及放气后15min控制硬膜外给药，有利于循环功能代偿有关。MAP及HR变化组间比较差异并无显著性。    止血带放气后引起PaCO2升高可能与缺血肢体无氧代谢活动增加，酸性代谢产物聚积有关。再灌注后这些物质进入循环，使PaCO2迅速上升。本研究止血带放气后5min，PaCO2明显升高（P<0.01），放气后10min， PaCO2基本回到基线水平。PaCO2组间比较无差异。    随输液剂进入体内的乳酸盐在体液中是以阴离子形式存在，不会致成酸中毒。由于乳酸钠林格液的电解质组成近似于细胞外液，可大量快速输入用于补充细胞外液欠缺。大量输入乳酸钠林格液，由于该输液剂本身的pH低于7.0，所以对细胞外液会致成一定程度酸碱紊乱及高乳酸血症7。    动脉血pH值和BE值在止血带放气后即明