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硬膜外麻醉单用利多卡因有无快速耐药的观察

时间:2010-08-24 11:30:45  来源:  作者:

Observation of with or without Celerity drug Resistance During Epidural Anesthesia with Pure Lidocaine<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

刘肖平  柳  冰
曹建平  缪小勇
黄佰乾  王明红
中国人民解放军第四五五医院麻醉科, 上海  200052
Xiaoping Liu, Bing Liu,  Jianping Cao,  Xiaoyong Miao, Baiqian Huang and Minghong Wang
Department of Anesthesiology, 455th Hospital of PLA, Shanghai, 200052

ABSTRACT

Objective:  Observation of with or without celerity drug resistance during epidural anesthesia with simple lidocaine  
Methods:  2365 ASA
- patients, 16~88 years old, were assigned to one of two groups. Group L were initially receieved (15.79±3.02)ml of 1.6% lidocaine and then followed by 3-8ml epidurally at 45min intervalsGroup LD initially receieved (17.08±4.42)ml of 1.6% lidocaine and 0.2% dicaine and then followed by 3-8ml epidurally at 60min intervals. epidural anesthesia with lidocaine group(Group L, n=2035); epidural anesthesia lidocaine and dicaine combination group (Group LD, n=330). During laparotomy operation, patient number of BP and HR instancy decreased as low as over 25% (i.e. severe draw visceral reflex) respectively than that before operation, and the percentage per group with draw visceral reflex were recorded.
Results:  Group L result of clinical observation showed that adequate muscle relaxation and analgesia can be achieved by epidural lidocaine.  Group LD has 12(3.64%) patients incidence severe draw visceral reflex during Laparotomy; but Group L, draw visceral reflex incidence was 5.7%
P0.05. Other comparisons were not significantly different.
Conclusion:  Effects of adequate muscle relaxation and analgesia can be achieved by epidural lidocaine and dicaine combined not much better than that single lidocaine during laparotomy; absence celerity drug resistance of epidural anesthesia with pure lidocaine.
Key words: Lidocaine; Epidural anesthesia; Celerity drug resistance
Corresponding author: Xiaoping Liu;
xiaopingliu1713@sohu.com

腹部手术的硬膜外麻醉局麻药大多数采用利多卡因(L组),或利多卡因和丁卡因混合液(LD组)。然而,临床上对用这两种局麻药液仍有不同看法。诸如单用利多卡因者认为它可控性强且效果并不差,而用利多卡因和丁卡因混合液者则认为其肌松好。为此,本文进行了比较研究,现将有关数据分析如下。

                    一、临床资料
  1. 一般情况 2419例ASAⅠ~Ⅲ级,拟行连续硬膜外麻醉(简称连硬)的患者中,6例连硬穿剌未成功,占0.25%;25例连硬导管误入静脉,占1.04%;29例改全麻(包括导管进入椎间孔、脱出或误入静脉等致阻滞不全、肌松不佳或完全无效者),占1.20%;2例全脊麻,占0.08%,经对症处理,均于90分钟内平稳恢复。连硬总失败率为2.24%(54/2419)。

  2. 麻醉情况 连硬成功的2365例中,男748例,女1617例。年龄16~88岁。麻醉前用药为阿托品0.5mg或东莨菪碱0.3mg、苯巴比妥钠0.1或安定10mg。
  本组麻醉均由高年资住院医师和主治医师实施,连硬取T7~10间隙穿刺头向置管3.5cm。L组局麻药多采用1.6%利多卡因, LD组多采用1.6%利多卡因和0.2%丁卡因混合液,如无禁忌加1∶20~40万肾上腺素。阻滞范围T2~4~T12~L3。常规面罩给氧2~4L/min,保持SpO2≥96%。麻醉期间均常规持续监测SpO2、HR、BP及ECG等。
                       二、结  果
  各组情况见表1~5。每分钟平均局麻药用量,L组为0.374ml,LD组为0.311ml,而L组中68例手术长达3小时以上[(236.75±78.01)分钟,(57.1±15.0),体重(60.6±9.9)kg,初量(16.72±3.59)ml,追加量(27.97±12.39)ml]者的分钟平均局麻药用量仅为0.188ml

  本文剖腹胆系手术在30分钟内完成者占
10.62%(251/2365)1小时内完成者1436例占60.72%,2小时内完成者2108例占89.13%。进腹后手术操作致心率在30秒内急剧减慢≥牵拉前的  25%~52%者有90例占3.81%;38例(1.61%)出现恶心呕吐及躁动等牵拉反应,经立即暂停手术操作,同时静脉滴注阿托品或/和血管加压药及加快输液[1-5],或经追加局麻药或再联用氟芬半量等辅助处理后好转[1]。未见其他严重并发症,无麻醉死亡病例。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 
                       
三、讨 论
  
从表1可见,当进腹探查、拉钩压拉和纱布填塞时致心率减慢25%52%,或出现恶心呕吐、躁动等牵拉反应,以及因阻滞不全、肌松不佳而改全麻者,在L组与LD组之间并无显著差异(P>0.05P>0.9)提示L组连硬的肌松等效果并不比LD组差。另外,≥65岁者,其体重、手术时间、局麻药初量和追加量,以及内脏牵拉反应的例数等,在L组与LD组之间也未见有统计学差异(4),此结果均提示L组与LD组的连硬效果相仿。就每分钟平均局麻药用量而论,L组为0.374ml, LD组为0.311ml, 而L组68例手术长达3小时以上[(236.75±78.01)分钟]的分钟平均局麻药用量仅为0.188ml,均可提示在L组并未见快速耐药现象。且利多卡因作用快,阻滞完善,麻醉中可充分利用连硬导管随时按需追加维持量,故认为单用利多卡因可控性更强。相比之下,利多卡因和丁卡因混合液的毒性要更大些。另外,在体重相仿的情况下(表2、5),老年人(≥65岁)连硬的局麻药初量要小于青壮年(≤41岁),两者之间有统计学差异。且年龄相仿(表3),体重轻(≤48kg)者局麻药初量要小于体重重(≥80kg)的,两者有非常显著地统计学差异。在这两点上,无论是单用利多卡因,还是利多卡因和丁卡因联用,此结果也相似。

    此外,手术时间短(≤30分钟)而连硬麻醉仍在高峰期者(尤其在关腹前追加了利多卡因和丁卡因混合液),须待改为呼吸空气并观察10分钟以上,若SpO2≥术前基础值,HR及BP稳定,方可送回病房, 以防不测。从这一点来看,似乎采用单纯利多卡因连硬更合适些。

参 考 文 献
1. 刘肖平. 小切口胆道手术中胆心反射的临床观察. 临床麻醉学杂志 1998,14(5): 320.
2. 刘肖平, 王舟琪. 血管加压药与椎管内麻醉期循环稳定. 上海市麻醉学会2000年年会知识更新讲座汇编.上海,2000,12:73-76.
3.   Morgan P. The role of vasopressors in the management of hypotension induced by spinal and epidural anaesthesia. Can J Anaesth, 1994,41(5): 404.
4.  Brooker RF, Butterworth JF, Kitzman DW, et al. Treatment of hypotension afterhyperbaric tetracaine spinal anesthesia. Anesthesiology, 1997,86:797.

5
. 刘肖平. 小剂量多巴酚丁胺或新福林防治胆道手术中循环波动的效应.中国麻醉与镇痛,2002,4(2) :117-118.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

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