腰麻-硬膜外联合麻醉在小儿外科手术及术后镇痛的应用

目的:观察罗哌卡因与布比卡因在小儿腰麻-硬膜外联合麻醉(combined spinal-epidural anesthesia,CSEA)麻醉的效果、术后镇痛效果和不良反应.方法:选择50例行下腹部及以下手术的患儿,年龄为6～14岁,随机分为两组:罗哌卡因Ropivacaine(R)组25例和布比卡因Bupivacaine(B)组25例,全部采用CSEA麻醉.R组注入腰麻药为:10 g*L-1罗哌卡因1.5 ml+注射用水0.5 ml+100 g*L-1葡萄糖1 ml.B组注入腰麻药物为:7.5 g*L-1布比卡因2 ml+100 g*L-1葡萄糖1 ml.两药的终末浓度皆为5 g*L-1.给药剂量按以下公式计算:药量(ml)=年龄(岁)×0. 2+体重(kg)×0.05/2.当手术超过1.5 h,开始向硬膜外腔输注局麻药物:R组为2.5 g*L-1罗哌卡因1 mg*kg-1*h-1,B组为2.5 g*L-1布比卡因1 mg*kg-1*h-1.研究中观察血压、心率、氧饱和度,麻醉平面,VAS评分,下肢运动阻滞的变化.术后两组均进行硬膜外镇痛,各为0.75 g*L-1罗哌卡因100 ml或布比卡因加入曲马朵200 mg和氟哌利多5 mg.硬膜外持续输注3 ml*h-1(6～9岁)或4 ml*h-1(10～14岁),必要时由患儿或其父母自控镇痛每次2 ml,间隔时间为15 min.观察镇痛效果、下肢运动恢复情况及术后24 h患儿恶心、呕吐、下肢麻木、头痛、尿潴留等不良反应.结果:两组麻醉平面无明显差异.术中下肢运动阻滞,R组明显弱于B组,差异有显著性.术后下肢运动阻滞消退明显快于B组,差异有显著性.在观察中两组各有1例发生恶心,术后B组有1例发生尿潴留,两组间差异无显著性.结论:CSEA用于小儿外科手术能达到满意的麻醉和术后镇痛效果.但罗哌卡因的运动阻滞明显弱于布比卡因,这有利于患儿术后早期下地活动及肠功能的恢复.

Application of combined epidural-spinal anesthesia in pediatric surgery and postoperative analgesia

OBJECTIVE: To compare the anesthetic and analgesic efficacy of ropivacaine and bupivacaine and their side reactions in combined spinal-epidural anesthesia (CSEA) and postoperative analgesia in pediatric surgery. METHODS: Fifty children for lower abdominal surgery, aged 6-14 years, were randomly assigned to receive either ropivacaine (Group R, n=25) or bupivacaine (Group B, n=25) for CSEA. Spinal injection for Group R was a mixture of 1.5 ml of 10 g x L(-1) ropivacaine, 0.5 ml distilled water and 1ml of 100 g x L(-1) dextrose. The injection for Group B was the same as that for Group R except 0.5 ml of 7.5 g x L(-1) bupivacaine. The terminal concentrations of anesthetics were 5 g x L(-1) for the two groups. The injection volume was calculated as: ml=(age x 0.2 + weight x 0.5) divided by 2. When operations prolonged to 1.5 h, epidural infusion at the rate of 1 mg x (kg(-1) x h(-1)) started with 2.5 g x L(-1) ropivacaine for Group R and 2.5 g x L(-1) bupivacaine for Group B. The observed variables were the changes in blood pressure, heart rate, SpO(2), block level, visual analogue scores, and motor block. Epidural postoperative analgesia was performed for Group R with 100 ml of 0.75 g x L(-1) ropivacaine to which 100 mg tramadol and 5 mg were added, and for Group B with 100 ml of 0.75 g/L(-1) bupivacaine instead. Backgroup infusion was 3 ml x h(-1) for the children aged 6-9 years or 4 ml x h(-1) for the children aged 10-14 years, bolus was 2 ml controlled by children or their parents when necessary, and locktime was 15 min. The observed variables were the efficacy of postoperative analgesia, recession of motor block of legs, and the incidence of headache, nausea and vomiting, leg numbness, and urinary retention within 24 h after operation. RESULTS: There was no significant difference between the two groups in block level. Motor block was much milder in Group R than that in Group B during operation, and recessed faster after operation. Only one case of nausea occurred in each group, and one case of urinary retention in Group B without statistical significance. CONCLUSION: Either ropivacaine or bupivacaine can be satisfactorily used in CSEA for analgesia during and after operation. However, ropivacaine has a weaker motor block than bupivacaine, which benefits early walking after operation and recovery of bowl movement.