本文選題：骶管　切入點(diǎn)：硬膜外阻滯　出處：《廣西醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的探討經(jīng)骶管連續(xù)硬膜外阻滯用于小兒腹部和會(huì)陰部手術(shù)后鎮(zhèn)痛的安全性及有效性。方法選擇行擇期腹部、會(huì)陰部手術(shù)的患兒84例,分為三組,每組各28例,C組:靜吸復(fù)合全身麻醉組;S組:全身麻醉+單次骶管阻滯;E組:全身麻醉+經(jīng)骶管連續(xù)硬膜外阻滯+PCEA。三組患兒均在手術(shù)室外靜注咪達(dá)唑侖0.1mg/kg,待安靜后推入手術(shù)室,常規(guī)連接心電監(jiān)護(hù)儀。麻醉誘導(dǎo):三組均采用靜脈麻醉快速誘導(dǎo)方法,S組全麻誘導(dǎo)后予0.25%羅哌卡因0.8ml/kg進(jìn)行單次骶管阻滯,E組全麻誘導(dǎo)后經(jīng)骶裂孔穿刺置入硬膜外導(dǎo)管,對(duì)于腹部手術(shù)將導(dǎo)管頭端置入L2~L3水平,肛門或直腸手術(shù)導(dǎo)管頭端置入至超過(guò)L5~S1水平,尿道手術(shù)導(dǎo)管頭端置入S2~S3水平。導(dǎo)管置入成功后注射1%利多卡因2ml作為試驗(yàn)劑量,5min后若無(wú)蛛網(wǎng)膜下腔阻滯跡象、生命征穩(wěn)定,再注入0.25%羅哌卡因(總量0.8ml/kg,注入總量的1/3~1/4)。麻醉維持:三組術(shù)中均采用靜吸復(fù)合維持麻醉,按需要適時(shí)追加鎮(zhèn)痛藥物,E組術(shù)中每隔1h從硬膜外導(dǎo)管追加一次羅哌卡因(每次追加總量的1/3~1/4)。術(shù)畢將患兒送麻醉后復(fù)蘇室(PACU)。E組于拔除氣管導(dǎo)管后啟動(dòng)硬膜外鎮(zhèn)痛泵(PCEA),鎮(zhèn)痛泵藥物濃度為0.1%羅哌卡因+1μg/ml芬太尼,總量150ml,持續(xù)泵入0.1ml·kg-1·h-1,PCA劑量、負(fù)荷量0ml/h,使用48h后撤除硬膜外鎮(zhèn)痛泵。觀察指標(biāo):記錄患兒的一般情況、手術(shù)種類、手術(shù)時(shí)間、用藥時(shí)間、術(shù)后禁食時(shí)間及術(shù)后住院時(shí)間;記錄術(shù)后1h、4h、8h、12h、24h、36h、48h、72h的心率(HR)、FLACC疼痛評(píng)分、Ramsay鎮(zhèn)靜評(píng)分;記錄手術(shù)結(jié)束至術(shù)后72h內(nèi)鎮(zhèn)痛、鎮(zhèn)靜藥物的追加使用情況;記錄術(shù)后第二天家長(zhǎng)疼痛評(píng)估PPPM量表評(píng)分;記錄術(shù)后發(fā)熱、嘔吐、呼吸抑制、皮膚瘙癢、尿潴留、局麻藥中毒等不良反應(yīng)以及神經(jīng)損傷、穿刺部位局部或椎管內(nèi)感染等并發(fā)癥的發(fā)生情況。結(jié)果最終入選觀察者共為72例,其中C組23例,S組24例,E組25例。(1)三組患兒一般情況、手術(shù)種類、手術(shù)時(shí)間、用藥時(shí)間、術(shù)后禁食時(shí)間、術(shù)后住院時(shí)間比較無(wú)顯著差異(P0.05)。(2)術(shù)后48hPPPM量表評(píng)分比較,S組和E組高于C組,E組高于S組(P0.05)。(3)術(shù)后各時(shí)點(diǎn)FLACC疼痛評(píng)分比較,S組和E組明顯低于C組,E組明顯低于S組(P0.05);三組患兒術(shù)后鎮(zhèn)靜評(píng)分比較無(wú)顯著差異(P0.05)。(4)E組術(shù)后72h內(nèi)追加其他鎮(zhèn)痛藥物的人數(shù)和次數(shù)明顯少于S組和C組(P0.05);C組術(shù)后0~4h之間有4例患兒追加鎮(zhèn)痛藥物,S組和E組沒(méi)有患兒追加鎮(zhèn)痛藥物,S組術(shù)后24~48h時(shí)段追加鎮(zhèn)痛藥物人數(shù)明顯少于S組和C組(P0.05);三組術(shù)后72h內(nèi)追加鎮(zhèn)靜藥的人數(shù)和次數(shù)以及術(shù)后嘔吐、發(fā)熱的發(fā)生率的比較無(wú)顯著差異(P0.05);三組術(shù)后72h內(nèi)均未發(fā)生呼吸抑制、皮膚瘙癢、尿潴留、局麻藥中毒,也無(wú)患兒發(fā)生神經(jīng)損傷、穿刺部位局部或椎管內(nèi)感染等并發(fā)癥。結(jié)論(1)經(jīng)骶管連續(xù)硬膜外阻滯能為小兒腹部、會(huì)陰部手術(shù)后提供持續(xù)有效的鎮(zhèn)痛,是一種安全有效的術(shù)后鎮(zhèn)痛方式。0.1%羅哌卡因+1μg/ml芬太尼經(jīng)骶管連續(xù)硬膜外阻滯用于小兒腹部、會(huì)陰部手術(shù)后鎮(zhèn)痛可取得滿意效果。(2)單次骶管阻滯可為小兒腹部、會(huì)陰部手術(shù)后4~6h內(nèi)提供較好的鎮(zhèn)痛效果。
[Abstract]:Objective to investigate the sacral epidural anesthesia in pediatric abdominal and perineal analgesia after operation safety and effectiveness. Methods for elective abdominal perineal surgery patients 84 cases were divided into three groups, 28 cases in each group, group C: general anesthesia group; group S: whole body anesthesia + single sacral anesthesia; group E: general anesthesia + through sacral epidural block +PCEA. three groups of children were in operation outside the intravenous injection of midazolam 0.1mg/kg, quietly pushed into the operation room, connected conventional ECG monitor. Anesthesia induction: three groups were treated with rapid intravenous anesthesia induction method, induced by S group after general anesthesia with 0.25% ropivacaine 0.8ml/kg single sacral block group E after induction of anesthesia with sacral hiatus epidural catheter was puncture for abdominal surgery, the tip of catheter placement L2~L3, anal or rectal surgery catheter tip placement to exceed the level of L5~S1, urethral surgery The end of the catheter placement of S2~S3 catheter. After successful injection of 1% lidocaine 2ml as test dose, 5min without subarachnoid block signs, vital signs are stable, and then injected 0.25% ropivacaine (total 0.8ml/kg, total injection 1/3~1/4). Anesthesia: three groups of patients with anesthesia, according to the needs of timely additional analgesic drugs, patients in group E every 1H catheter from epidural ropivacaine and another (each additional 1/3~1/4 of the total). After operation, the children sent post anesthesia recovery room (PACU).E group started to epidural analgesia pump after extubation (PCEA), the drug concentration of 0.1% ropivacaine for analgesia pump +1 g/ml fentanyl, total 150ml, 0.1ml and kg-1 continued to pump into the H-1, the dose of PCA, load 0ml/h, the removal of epidural analgesia pump after using 48h. Observation index: generally, record the children's type of surgery, operative time, postoperative medication time. 紱侀鏃墮棿鍙?qiáng)鏈悗浣忛櫌鏃堕棧?

本文編號(hào)：1602277