硬膜外麻醉复合针刺促进移植肾早期功能重建

目的：观察针刺对肾移植术中和术后早期泌尿功能的影响。方法：终末期肾衰病人作肾移植手术44例，男女各22例，随机分为四组,分别接受常规剂量硬膜外阻滞，初量12－14mL (硬外I组），小剂量给药硬膜外阻滞，初量为7－8mL（硬外Ⅱ组），针刺复合常规剂量硬膜外阻滞（针硬I组）和针刺复合小剂量硬膜外阻滞（针硬Ⅱ组）。针刺取穴：次体、三阴交、太溪、足三里、均为双侧。诱导30min。每组11例。麻醉平面T6－T8,术中根据手术需要而追加局麻药。麻醉管理：常规鼻导管供氧，监测心电图、SPO2、无创血压和呼吸。术中静脉输液用乳酸林格氏液和5％葡萄糖液，根据血压输液速度。必要时补充胶体液或输血。麻醉前和术中移植肾血管开放时取静脉血，测定血浆儿茶酚胺浓度（采用高压液相色谱法和电化学检测器测定血浆肾上腺素和去甲肾上腺素）。观察移植肾恢复血液循环后的泌尿开始时间、尿流速度和术中尿量。术后连续观察4天循环功能、尿量、输液量、血浆悄素氮、肌酐和血钾等肾功能指标。结果：①硬膜外阻滞的局麻药用药量：硬外I组＞硬外Ⅱ组＞针硬Ⅰ组＞针硬Ⅱ组，分别为28、24、21和14mL。②硬膜外阻滞复合针刺的两组病人于术中移植肾血管开放时动脉平均压高于硬外Ⅱ组。③移植肾开始泌尿时间、术中尿量和尿流速度以两组复合针刺者明显优于单纯硬膜外阻滞。④各组血浆去甲肾上腺素浓度与术前比较无统计学差异。针刺复合硬膜外阻滞的两组病人术中肾血管开放时肾上腺素浓度明显高于术前（P＜0．05），且显著高于单纯硬膜外麻醉的两组病人。⑤术后各组血压、心率除术后24hr针硬I组动脉收缩压高于硬外Ⅱ组外，其余各组各时间点组内和组间比较无统计学差异。⑥硬外Ⅱ组术后第一天尿量明显低于其他三组，术后第二天仍低于硬外I组（P＜0．05）。硬外Ⅱ组术后第一天补液量也低于两组复合针刺组。⑦术后各组病人肌酐水平逐日下降趋势，以针刺复合小剂量硬膜外阻滞组最为明显。尿素氮水平两组复合针刺组下降明显，在针硬Ⅱ组为著。血钾水平术后各组均有所下降，也以复合针刺的两组下降明显。结论：在肾移植的病人硬膜外麻醉复合针刺，能明显减少硬膜外阻滞局麻药的需要量，有助于维持术中循环功能稳定，可改善术中和术后早期肾的功能，可明显提高血浆肾上腺素浓度, 而对去甲肾上腺素影响不大。

Electroacupuncture Facilitates Recovery of the Transplanted-kidney Function

Objective: To explore the effect of electroacupuncture (EA) on the transplanted kidney function during operation and in the early period of post operation. Methods: Forty four adult patients (22 males and 22 females) were randomized to one of the following four groups (with 11 patients in each group): ①routine dose (12～14 mL) epidural block (RDEB), ②small dose (7～8 mL) epidural block (SDEB), ③ EA+RDEB and ④ EA+SDEB. Patients in the two EA group received a 30 minutes' EA stimulation of Ciliao (BL 32), Sanyinjiao (SP 6), Taixi (KI 3) and Zusanli (ST 36) before epidural anesthesia. Additional epidural doses were permitted to maintain a block level of T 6～T 8 whenever necessary during operation. Lactate Linger's solution and 5% dextrose were infused intravenously. Colloids or blood transfusion was used if indicated. The ECG, SPO 2, arterial blood pressure and respiratory rate were monitored continuously. Plasma epinephrine (E) and norepinephrine (NE) were detected before anesthesia and at the time of restoration of renal blood flow to the transplanted kidney. The time for starting urine formation and urine flow rate were recorded. Hemodynamic parameters, urine output, solution input, plasma urea, creatinine and potassium were monitored daily postoperatively for 4 days. Results: ① Mean consumptions of local anesthetic solution were 28, 24, 21 and 14 mL in RDEB, SDEB, EA+RDEB and EA+SDEB groups respectively. ② Hemodynamics was more stable in EA+SDEB group with minimum intravenous solution requirement. ③ Earlier urine formation and more urine output were found in patients of the two EA groups in comparison with RDEB and SDEB groups. ④ There were no statistically significant changes in plasma NE levels between pre and post operation in the 4 groups while plasma E levels in two EA groups were higher than preoperation. ⑤ Hemodynamics was maintained stable in all groups postoperatively. ⑥ Urine output in SDEB was less than those of the other groups in the first 24 hours of postoperation and was still less than that of RDEB group in the following 24 hours after operation. ⑦ Plasma urea, creatinine and potassium decreased faster in two EA groups. Conclusion: Electroacupuncture stimulation can decrease the requirement of epidural anesthetics, increase plasma epinephrine level, stabilize hemodynamics and improve the early renal function of the transplanted kidney under combined anesthesia of EA and epidural administration of small dose of anesthetics.