1、不同晶體液對腰硬聯合麻醉下應用止血帶行下肢骨科手術患者循環和代謝的影響        【摘要】    【關鍵詞】  止血帶;腰硬聯合麻醉;血流動力學;血氣分析;乳酸鹽        【關鍵詞】 止血帶;腰硬聯合麻醉;血流動力學;血氣分析;乳酸鹽    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    肢體矯形手術通常需要應用止血帶以獲得清晰、無血視野。大量文獻報道了止血帶充/放氣過程、肢體缺血時間、缺血范圍、麻醉所引起的循環和代謝改變，然而在應用止血帶過程中使用不同晶體液對循環和代謝的影響還鮮有報道。本研究旨在探討腰硬聯合麻醉（CSEA）下應用止血帶行下肢骨科手術，不同晶體液對循環和代謝的影響，為術中處理及液體選擇提供依據。    1 資料與方法    1.1 一般資料 選擇非腫瘤下肢手術需上止血

14、帶患者30例，男23例，女7例，ASA 級，年齡1763歲，體重5099kg。術前無循環及呼吸系統疾病，肝腎功能無異常。手術種類包括脛、腓骨骨折切開復位內固定術19例，膝韌帶重建術8例，股骨骨折切開復位內固定術2例，跟骨骨折切開復位內固定術1例，全部病例均未用骨水泥等非生物材料。隨機將患者分為醋酸鈉林格液組（A組）和乳酸鈉林格液組（L組），每組15例。    1.2 麻醉方法 麻醉前30min肌注咪唑安定0.05mg/kg。入室后常規監測ECG、SpO2、BP、T，面罩吸氧，氧流量4L/min。在輸液對側上肢行橈動脈穿刺測壓及采集動脈血樣。腰硬聯合麻醉選擇腰34間

15、隙穿刺，脊麻用藥為重比重0.5%羅哌卡因1.62.0ml，硬膜外頭端置管3cm。麻醉平面控制在胸810以下。術中根據麻醉情況經硬膜外導管給予2%利多卡因及0.75%羅哌卡因。在止血帶放氣前15min及放氣后15min避免硬膜外腔給藥。    1.3 補液 A組患者入室后輸入醋酸鈉林格液，速度68ml(kg· h)。脊麻后改輸聚明膠肽注射液10ml(kg·h)防治低血壓，術中輸入醋酸鈉林格液。待止血帶放氣后，快速輸入聚明膠肽。L組以乳酸鈉林格液取代醋酸鈉林格液。    1.4 使用止血帶 麻醉效果確切后，將止血帶縛于

16、大腿根部。切皮前用彈力繃帶自足部開始向近心端加壓重疊纏繞驅血，直至止血帶處，然后充氣。充氣壓力為充氣前患者的收縮壓加100150mmHg，體型較胖者酌情加大充氣壓力，但最高充氣壓力不超過300mmHg。手術主要操作步驟結束或止血帶充氣時程達120min時放氣。放氣過程要緩慢，歷時11.5min。    1.5 觀察指標 (1)分別于止血帶充氣前即刻（T0）、充氣后30min（TI1）、充氣后60min（TI2）、充氣后90min（TI3）以及放氣后1min（TD1）、放氣后3min（TD2）、放氣后5min（TD3）、放氣后10min（TD4）、放氣后30min（

17、TD5）記錄心率（HR）、收縮壓（SBP）、舒張壓（DBP）和平均動脈壓(MAP)。(2)分別于T0、TD3、TD4、TD5各時點采集動脈血，行血氣分析、電解質及乳酸含量測定。    1.6 統計學處理 計量資料以均數±標準差（x±s）表示，采用SPSS13.0統計軟件進行統計學處理，組內采用配對t檢驗，組間采用兩獨立樣本均數t檢驗。P<0.05為差異有顯著性。    2 結果    2.1 兩組患者一般資料及術中情況的比較 兩組性別比、年齡、體重、ASA分級比、止血帶充氣時間、

18、充氣壓力差異均無顯著性（P0.05），見表1。患者麻醉均滿意，術中未訴止血帶疼痛、患肢酸麻、沉重，無不適感。    2.2 血流動力學指標 止血帶充氣30min、60min和90min時，兩組MAP較充氣前均無明顯變化（P>0.05）。充氣90min后，A組HR增加（P<0.05），而L組在充氣各時點HR無明顯變化。兩組在止血帶放氣后各時點HR均較放氣前增加，其中1min、3min時增加明顯（P<0.01），1min時HR增加達高峰。MAP在放氣后1min時下降（P<0.05），3min及其后各時點與充氣前相比無明顯變化（P>0.05

19、），MAP及HR變化組間比較差異無顯著性，見表2。表1 兩組患者一般資料及術中情況的比較表2 兩組患者術中各時點血流動力學指標的比較  注：與T0相比，*P<0.05，* P<0.01    3 討論    應用止血帶期間動脈血壓會逐漸升高，初期因為止血帶充氣前驅血使單側下肢缺血。充氣3045min后，止血帶疼痛即成為MAP升高的主因1，2。研究表明，無髓鞘C纖維與止血帶疼痛傳導有關3，4。Villa H 等發現，不同麻醉方法止血帶疼痛的發生率差別巨大：全麻67%，局部靜脈麻醉18.6%，脊麻2.7%，臂神經叢阻

20、滯2.5%5。提示在椎管內麻醉下行下肢手術，止血帶疼痛發生率較低。本研究兩組均采用CSEA，無一例出現止血帶疼痛，有效避免了止血帶疼痛所致的血壓升高。    止血帶放氣后，體內血液涌入缺血下肢，乳酸、二氧化碳、組胺等隨止血帶放氣進入循環，引起微循環廣泛開放，使回心血量驟然減少，心排血量減少、血壓下降。本研究兩組患者在止血帶放氣后各時間點心率均高于充氣前，只有放氣后1min時MAP下降（P<0.05），3min時即恢復到放氣前水平，與文獻報道略有差異6，考慮與本研究均為擇期手術患者，無術前急性失血，患者基礎狀態和代償力良好、術中容量補充充足，且在止血帶放氣前1

21、5min及放氣后15min控制硬膜外給藥，有利于循環功能代償有關。MAP及HR變化組間比較差異并無顯著性。    止血帶放氣后引起PaCO2升高可能與缺血肢體無氧代謝活動增加，酸性代謝產物聚積有關。再灌注后這些物質進入循環，使PaCO2迅速上升。本研究止血帶放氣后5min，PaCO2明顯升高（P<0.01），放氣后10min， PaCO2基本回到基線水平。PaCO2組間比較無差異。    隨輸液劑進入體內的乳酸鹽在體液中是以陰離子形式存在，不會致成酸中毒。由于乳酸鈉林格液的電解質組成近似于細胞外液，可大量快速輸入用于補充細胞外液欠缺。大量輸入乳酸鈉林格液，由于該輸液劑本身的pH低于7.0，所以對細胞外液會致成一定程度酸堿紊亂及高乳酸血癥7。    動脈血pH值和BE值在止血帶放氣后即明