不同麻醉方法對(duì)全髖置換術(shù)患者的血液流變學(xué)的影響臨床觀察

1、不同麻醉方法對(duì)全髖置換術(shù)患者的血液流變學(xué)的影響臨床觀察遼寧省人民醫(yī)院麻醉科 110016尹美華 張靜 蔡長(zhǎng)華目的：對(duì)比研究單純?nèi)榕c硬膜外加全麻對(duì)全髖置換術(shù)患者的血液流變學(xué)的影響。方法：16例ASA級(jí)，行擇期全髖置換術(shù)患者隨機(jī)分為兩組。組為全麻組，組為硬膜外加全麻組，誘導(dǎo)前硬膜外給2利多卡因5ml，有平面后行全麻誘導(dǎo)，全麻用藥與組相同，術(shù)中用利多卡因硬膜外阻滯，每50min給藥68ml，術(shù)后24h內(nèi)用0.5布比卡因鎮(zhèn)痛，組術(shù)后肌注哌替啶鎮(zhèn)痛。結(jié)果：兩組血液流變學(xué)的主要差異：組的血液還原粘度、血漿粘度及纖維蛋白原濃度術(shù)中明顯下降，術(shù)后恢復(fù)接近術(shù)前。組這三項(xiàng)指標(biāo)術(shù)中也明顯下降，但術(shù)后3天內(nèi)均反跳明

2、顯高于術(shù)前。結(jié)論：硬膜外阻滯能更好地抑制應(yīng)激反應(yīng)，其對(duì)血流變學(xué)的影響更有利于預(yù)防術(shù)后下肢靜脈炎和靜脈血栓的形成。關(guān)鍵詞全身麻醉硬膜外麻醉血液流變學(xué)The Clinic Research on Effects of Different Anesthetic Techniques on Haemorheology in Patients Undergoing Total Hip ReplacementYin Meihua, Zhang Jing, Chai Changhua. Department of Anesthesiology， The peoples Hospital of Liaonin

3、g Province , Shenyang 110016Objective: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 , scheduled for elective total hip replacement were divided randomly into two groups.

4、Group （n8），5ml，2 lidocaine was given epidurally before induction of anaesthesia, and every 50min 68ml was added after induction. The group was not given epidural anesthisisa, and the general anaesthesia method of both groups was similar in induction and maintenance. In 24 houurs after operation, 0.5

5、 bupivacaine was given epidurally in group and pethidineim.in group 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 postoper

6、ative day in group , but were higher than that in group . 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 w

7、ordsGeneral anaesthesiaEpidural anaesthsiaHaemorehology下肢骨科手術(shù)，特別是全髖置換術(shù)和股骨頭置換手術(shù)后，深靜脈炎和深靜脈血栓的發(fā)生率較高14。血液流變學(xué)的改變是引起這一并發(fā)癥的一個(gè)相關(guān)因素。本研究對(duì)比觀察單純?nèi)榕c硬膜外阻滯加全麻對(duì)全髖置換術(shù)患者的血液流變學(xué)的影響。1材料與方法11病例選擇選ASA級(jí)行全髖置換手術(shù)患者16例，隨機(jī)分為兩組，每組8例，年齡5075歲，每組均為男3例、女5例，無嚴(yán)重心血管疾病及血液系統(tǒng)疾病，術(shù)前血常規(guī)檢查正常。12麻醉方法術(shù)前30min肌注哌替啶50mg、異丙嗪25mg、東莨菪堿0.3mg。兩組全麻誘導(dǎo)均用芬太

8、尼22.5gkg、硫噴妥鈉68mgkg、維庫(kù)溴銨60gkg、氣管插管后麻醉維持用0.81.0異氟醚、5060氧化亞氮、氧氣。取樣期間保持血流動(dòng)力學(xué)穩(wěn)定。硬膜外加全麻組（組）在麻醉誘導(dǎo)前先于L12間隙行硬膜外穿刺置管，用2利多卡因阻滯，麻醉效果確切后，再行全麻誘導(dǎo)。術(shù)中每隔50min1h追加2利多卡因68ml。兩組取樣期間均輸注平衡鹽液，第2次取樣前輸液量控制在500ml以內(nèi)，第3次取血樣前輸液量控制在1 5002 000ml以內(nèi)，不輸血及其他液體。組術(shù)后間斷肌注哌替啶鎮(zhèn)痛，組留置硬膜外導(dǎo)管48h，用0.5布比卡因鎮(zhèn)痛。13樣本采集分別于誘導(dǎo)前、患者清醒未吸氧時(shí)、誘導(dǎo)后30min、切皮以前、誘導(dǎo)

9、后90min各取橈動(dòng)脈血10ml，其中1ml作血?dú)夥治鲇?，其?ml用于測(cè)血液流變學(xué)的各項(xiàng)指標(biāo)。另外，術(shù)后第3天再采血1次，測(cè)血流變學(xué)指標(biāo)。14統(tǒng)計(jì)學(xué)處理資料以Xs表示，用配對(duì)t檢驗(yàn)進(jìn)行顯著性檢驗(yàn)，P0.05和P0.01視為差異具有顯著意義和極顯著意義。2結(jié)果21兩組患者年齡、性別、體重及第3次取樣前失血和輸液量均無顯著差異。22全血及血漿粘度的變化：兩組麻醉后30min、90min及術(shù)后3天時(shí)，各切變率下的全血粘度均下降，硬膜外加全麻組（組）在30min時(shí)下降幅度（均為P0.01）比全麻組（組）大（P0.05）。血液還原粘度兩組麻醉后也下降。在90min時(shí)組下降幅度（12.2，P0.01）比

10、組（5.3，P0.05）大。術(shù)后3天組還原粘度恢復(fù)正常，組反跳明顯高于術(shù)前。23紅細(xì)胞比積、剛性指數(shù)及聚集性的變化：兩組麻醉后紅細(xì)胞比積均有下降，但組下降幅度?。?0min時(shí)組下降5.2，組下降11.2）。紅細(xì)胞剛性指數(shù)兩組均無明顯變化，紅細(xì)胞聚集指數(shù)兩組均下降。24血小板聚集率和纖維蛋白原的變化：兩組的血小板聚集率在麻醉后90min時(shí)和術(shù)后下降。纖維蛋白原濃度兩組麻醉后均有下降，組術(shù)后恢復(fù)到術(shù)前水平，組術(shù)后明顯高于術(shù)前(表1、2）。表1全麻組圍麻醉期血液流變學(xué)參數(shù)的變化（s）麻醉前麻醉后30min麻醉后90min術(shù)后35天全血粘度切變率（mPas）230Ls3.330.312.990.49*

11、2.380.83*2.750.58*46Ls4.520.733.810.57*3.620.99*3.660.71*5.75Ls5.711.825.381.67*5.261.26*5.201.33*血漿粘度（mPas）1.280.061.260.101.240.031.350.12*紅細(xì)胞比積（）35.62.6031.62.99*31.33.45*26.46.65*紅細(xì)胞剛性指數(shù)0.9120.020.8950.050.8980.080.9080.09紅細(xì)胞聚集指數(shù)1.8190.321.6870.35*1.4600.95*1.7940.32血液還原粘度9.650.599.120.49*9.160.

12、59*10.521.17*血小板聚集率（）68.921.466.417.4*64.911.8*58.112.8*血漿纖維蛋白原（gL）3.961.113.391.13*3.270.95*5.812.20*與麻醉前比較*P0.05*P0.01 表2硬膜外加全麻組圍麻醉期血液流變學(xué)參數(shù)的變化（s）麻醉前麻醉后30min麻醉后90min術(shù)后35天全血粘度切變率（mPas）230Ls3.720.343.280.16*2.870.38*2.690.46*46Ls4.870.284.250.58*3.730.53*3.450.81*575Ls8.031.407.602.18*5.790.91*4.961.

13、03*血漿粘度（mPas）1.440.171.380.16*1.370.14*1.430.21紅細(xì)胞比積（）38.82.8336.83.56*34.94.46*31.24.85*紅細(xì)胞剛性指數(shù)0.8180.120.7830.150.7960.110.7800.14紅細(xì)胞聚集指數(shù)2.4680.532.1750.48*1.9190.32*1.8090.37*血液還原粘度9.640.998.930.69*8.460.98*9.490.96血小板聚集率（）56.69.256.411.447.37.7*48.17.2*血漿纖維蛋白原（gL）3.981.143.660.88*3.110.93*4.012.

14、62與麻醉前比較*P0.05*P0.01 25兩組術(shù)后均無明顯疼痛感覺。3討論血液流變學(xué)的各項(xiàng)參數(shù)測(cè)定受許多因素的影響5，6，本研究在采取相同全麻方式的基礎(chǔ)上，其中一組加用硬膜外阻滯，以比較觀察硬膜外麻醉對(duì)血液流變學(xué)的特殊影響。兩組麻醉后全血粘度及Hct均明顯下降，這與以往報(bào)道一致1，2，認(rèn)為是麻醉后血管擴(kuò)張、組織間液轉(zhuǎn)移到血管所致。Davis等7，8的研究結(jié)果認(rèn)為，傷后應(yīng)激反應(yīng)會(huì)導(dǎo)致血漿粘度和血漿纖維蛋白原升高，全麻組血漿粘度麻醉后無明顯下降，術(shù)后反而高于麻醉前。硬膜外加全麻組麻醉后30min就有明顯下降，術(shù)后恢復(fù)正常。兩組血漿纖維蛋白原術(shù)中均有下降，術(shù)后硬膜外加全麻組恢復(fù)到麻醉前水平，全麻

15、組術(shù)后反而高于術(shù)前。這一結(jié)果不僅是以往研究理論的佐證，也很可能是在兩種不同的麻醉方式下，深靜脈血栓發(fā)生率有所不同的因素之一。本實(shí)驗(yàn)兩組的紅細(xì)胞剛性指數(shù)均無明顯變化，說明麻醉對(duì)紅細(xì)胞的變形性均無影響。術(shù)中兩組紅細(xì)胞聚集指數(shù)均有下降，術(shù)后全麻組恢復(fù)，硬膜外加全麻組則持續(xù)在低水平，這也是后者不易形成血栓的一個(gè)因素?？傊緦?shí)驗(yàn)結(jié)果表明，在全麻基礎(chǔ)上加用硬膜外阻滯會(huì)更充分地抑制應(yīng)激反應(yīng)對(duì)血流變學(xué)的若干影響，這對(duì)于下肢骨科手術(shù)患者的術(shù)后恢復(fù)是有利的。作者單位：110016 沈陽 遼寧省人民醫(yī)院麻醉科參考文獻(xiàn)1Mckenzie PJ, Wishart HY, Gray I. Effects of anae

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