全麻与腰硬联合麻醉在腹腔镜疝修补术中不同气腹阶段应激反应的变化

目的:评价全麻与腰硬联合麻醉在腹腔镜疝修补术中气腹不同阶段应激反应的变化。方法:选择拟行腹腔镜疝修补术的40例患者,20~60岁,ASA分级Ⅰ或Ⅱ级,体重55~80 kg,采用随机数字表法将患者随机平均分为两组,Ⅰ组采用全凭静脉麻醉,靶控输注异丙酚(血浆靶浓度2~3μg/ml),间断推注芬太尼维持麻醉,根据血压(BP)、心率(HR)变化调整药物浓度,维持血液动力学平稳。Ⅱ组选择L2~3间隙硬膜外穿刺成功后置入腰麻针注入0.5%等比重布比卡因15 mg,靶控输注异丙酚1~1.5μg/ml维持镇静。分别于麻醉前(T0)、气腹前5 min(T1)、气腹后15 min(T2)、气腹后30 min(T3)监测BP与HR,于各时点抽取桡动脉血行血气分析,同时抽取桡动脉血测定血浆皮质醇(plasma cortisol,Cor)、去甲肾上腺素(norepinephrine,NE)、肾上腺素(epinephrine,E)的浓度,记录患者术后清醒时间。结果:与T0相比,Ⅰ组T2时HR、平均动脉压(mean arterial pressure,MAP)升高,T2、T3时血浆NE、E浓度,T3时Cor浓度升高(P<0.05);Ⅱ组T1、T2时HR升高,T1时MAP下降,T3时Cor浓度升高(P<0.05),T1、T2时pH(potential of hydrogen)下降,二氧化碳分压(PaCO2)升高。与Ⅰ组相比,Ⅱ组T2、T3血浆NE、E浓度降低(P<0.05),T3时Cor浓度降低(P<0.05),T1时HR升高,T1、T2时MAP、pH下降,T1、T2时PaCO2升高(P<0.05),Ⅱ组术后患者清醒时间短(P<0.05)。结论:腹腔镜疝修补术中应用腰硬联合麻醉可更好地控制应激反应,缩短术后恢复时间。

Changes in stress response at different periods of pneumoperitoneum during general anesthesia and combined epidural spinal anesthesia in laparoscopic hernia repair

Objective：To evaluate the changes in stress response at different periods of pneumoperitoneum during general anesthesia and combined epidural spinal anesthesia in laparoscopic hernia repair. Methods：Forty ASA Ⅰ or Ⅱ patients,aged 20-60 years, weighted 55-80 kg,undergoing laparoscopic hernia repair,were randomly divided into 2 groups （n = 20 each）. In group I , anesthesia was maintained with TCI （target controlled infusion） of propofol （target plasma concentration 2-3μg/ml）, and intermittent injected fentanyl. The concentrations of propofol were adjusted according to the changes of blood pressure （BP） and heart rate （HR） to maintain hemodynamics stable. In group Ⅱ , to take the L2-3 lumbar puncture gap anesthesia, puncture needle was punctured into the sub- arachnoid space to inject the infusion of 0. 5% bupivaeaine solution 15 rag, anesthesia was maintained with TCI of propofol 1- 1.5μg/ml. Before anesthesia （T0 ） ,5 min before pneumoperitoneum （T1）, 15 and 30 min of pneumoperitoneum （T2, T3 ）, HR and BP were monitored and artery blood samples were taken for blood gas anai~sis ; blood samples were taken for determination of plasma cortisol （ Cor）, norepinephrine （NE） ＇and epinephrine （ E ） concentrations. Postoperative awake time was recorded. Results： HR, mean arterial pressure （MAP） at T2 and NE,E concentrations at T2, T3, and Cor concentrations at T3 were significantly higher than those at To in group I ;HR at T1 ,T2 and Cot concentrations at T3 ,PCO2 at T1 ,T2 were significantly higher than those at To in group Ⅱ ,but MAP at T1 and potential of hydrogen （pH） at T1 , T2 were significantly lower than those at To in group Ⅱ. MAP and pH at T1, T2, NE, E concen- trations at T2 , T3 and Cor concentrations at T3 were significantly lower in group Ⅱ than in group [ （ P 〈 0.05 ）, HR at Tj and PaCO2 at T1-2 were significantly higher in group Ⅱ than in group I （ P 〈 0.05 ） , recovery was faster in group I1 than in group I （ P 〈 0.