本文關鍵詞： 硬膜外腔 壓力 椎管內(nèi)麻醉 囊泡 高齡患者 壓力囊泡 硬膜外腔　出處：《山東大學》2016年博士論文　論文類型：學位論文

【摘要】：椎管內(nèi)麻醉是目前廣泛應用于臨床的麻醉方式之一…,將麻醉藥物注入椎管內(nèi)腔隙如蛛網(wǎng)膜下腔或硬膜外腔,從而阻斷脊神經(jīng)的沖動傳導,使其所支配的相應區(qū)域產(chǎn)生麻醉作用。根據(jù)藥物注入腔隙的不同,椎管內(nèi)麻醉主要分為硬膜外腔阻滯,硬膜外-腰麻聯(lián)合阻滯和蛛網(wǎng)膜下腔阻滯。椎管內(nèi)麻醉的優(yōu)點包括：抑制手術(shù)引起的應激反應優(yōu)于全麻；可用于術(shù)后鎮(zhèn)痛,且鎮(zhèn)痛效果優(yōu)于靜脈鎮(zhèn)痛,全身副作用輕；麻醉后下肢血管擴張,血流加速,降低深靜脈血栓的發(fā)生率；同時促進腸蠕動,有利于恢復腸道功能。硬膜外麻醉是指通過局部麻醉藥的彌散,使脊神經(jīng)根阻滯,產(chǎn)生鎮(zhèn)痛效果,并且可根據(jù)手術(shù)部位,選擇不同的穿刺點,并且可根據(jù)手術(shù)需要,通過硬膜外導管推注局麻藥滿足不同手術(shù)時間的需要。硬腰聯(lián)合麻醉是結(jié)合硬膜外麻醉和蛛網(wǎng)膜下腔麻醉各自的特點,既有起效快,阻滯完善的優(yōu)點,又可通過硬膜外導管注入局麻藥延長麻醉時間。目前最常用的為硬膜外麻醉和硬腰聯(lián)合麻醉,硬膜外穿刺技術(shù)是實施成功的椎管內(nèi)麻醉的關鍵技術(shù),如果硬膜外穿刺操作不當或判斷失誤,可引起組織或神經(jīng)的損傷；損傷血管引起硬膜外血腫；硬膜外穿刺針誤入蛛網(wǎng)膜下腔等并發(fā)癥,產(chǎn)生嚴重的后果,甚至威脅患者的生命。自19世紀末發(fā)明椎管內(nèi)麻醉以來,判斷硬膜外穿刺成功的方法主要是靠麻醉醫(yī)生的主觀判斷,穿透黃韌帶的落空感,推動玻璃注射器阻力消失法(見圖1)及氣泡壓縮試驗等,而沒有專屬判斷工具和指標,穿刺傳統(tǒng)的判斷方法存在誤判的可能,主要與操作者的主觀因素以及硬膜外腔結(jié)構(gòu)、穿刺間隙及椎體鈣化等客觀因素有關。因此為了減少椎管內(nèi)麻醉并發(fā)癥,除提高操作者硬膜外穿刺技術(shù)外,有必要研究一個客觀的硬膜外穿刺成功判斷裝置。本研究旨在觀察國家新型專利-壓力囊泡指示器在硬膜外穿刺中的可行性和指示的準確性。在本研究中的壓力囊泡指示器也是利用以往教科書中的正壓氣囊試驗(如圖2)的原理,由一個壓力囊泡來持續(xù)測定針尖處的阻力。壓力囊泡指示裝置是在普通注射器(5m1)距針筒前端1cm處的側(cè)壁上開孔(如圖3),開孔處覆蓋有彈性橡膠薄膜。穿刺時用壓力囊泡指示器抽取生理鹽水5ml,接硬膜外穿刺針尾端,當進針深度超過皮下軟組織,到達韌帶或筋膜等致密組織時,推動注射器針栓2.Oml,由于針尖受到致密組織的阻力,針筒內(nèi)壓力增加,薄膜會向外膨脹,凸起形成一個直徑約1.5cm的液體壓力囊泡(如圖4)。手離開針栓(繼續(xù)穿刺進針)時,由于注射器針筒與針栓之間設計有適當?shù)哪Σ磷枇?可阻止囊泡內(nèi)壓力迫使針栓自動后退,故壓力囊泡仍可保持膨脹狀態(tài)。此時雙手持針繼續(xù)穿刺(見圖5),當穿刺針突破黃韌帶的瞬間,針尖處壓力突然下降,阻力降低,囊泡內(nèi)的液體快速流出,囊泡迅速癟掉,為穿刺成功提供了一個可視信號。此裝置能自動持續(xù)監(jiān)測穿刺過程,用明確、迅速、可靠的客觀指標提示穿刺針已到達合適的穿刺深度。擺脫了硬膜外穿刺一直靠人的主觀判斷的現(xiàn)狀,實現(xiàn)操作工具專業(yè)化和判斷指標客觀化；同時提高操作安全性,減少人為誤判的風險。臨床教學中,學生操作時,老師沒有了“手感”,難以判斷學生的穿刺深度,使用壓力囊泡指示器眾人都可以看到囊泡的變化,適合于臨床帶教。壓力囊泡指示器首次采用可視信號自動監(jiān)測技術(shù),降低了對操作經(jīng)驗的依賴,使穿刺操作難度下降；提高了操作安全性,減少人為誤判的風險,降低了醫(yī)療事故隱患。硬膜外穿刺過程中麻醉醫(yī)生可以不間斷的雙手操作,為硬膜外麻醉領域帶來了革命性的技術(shù)進步。隨著生活水平的提高,高齡患者日益增多,有研究證實椎管內(nèi)麻醉雖然對老年患者的循環(huán)功能有一定影響,但麻醉經(jīng)過相對平穩(wěn),對合并心腦血管疾病的老年患者更為適合,減低術(shù)后血栓形成和心血管并發(fā)癥的發(fā)生率,并會大大降低全麻藥物引起的術(shù)后認知功能障礙(POCD)的發(fā)生率,而且還可避免氣管插管全麻引起的術(shù)后并發(fā)癥吸入性入肺炎及肺不張的發(fā)生率。但老年患者血管壁大多硬化而失去彈性,脆性增大,應盡量保證穿刺輕柔,減少損傷出血機率,提高穿刺的成功率。由于老年患者的棘上韌帶、棘間韌帶鈣化而失去彈性,椎間隙變窄,脊柱后凸或側(cè)彎,造成穿刺困難,因此老年患者多采用側(cè)入路穿刺路徑,本研究第二部分中就是觀察壓力囊泡指示器在老年患者側(cè)入路硬膜外穿刺中的應用效果。第一部分壓力囊泡指示性裝置在臨床椎管內(nèi)麻醉操作中的可行性及應用效果目的測定硬膜外腔隙的壓力；測定壓力囊泡指示器的工作壓力；觀察壓力囊泡指示性裝置在臨床椎管內(nèi)麻醉操作中的可行性及應用效果。方法1.120名病人,年齡18-60歲,硬膜外穿刺間隙T10-L3,無硬膜外穿刺禁忌癥,心肺功能無異常,常規(guī)進行硬膜外穿刺,穿刺針針尾通過三通連接壓力傳感器,測量硬膜外腔的壓力。2.隨機抽取120個壓力囊泡指示器,每個壓力囊泡指示器抽取5m1生理鹽水,前端連接壓力傳感器,推動注射器針栓2.Oml,使囊泡鼓起,囊泡大小維持5秒鐘不變,此時記錄囊泡壓力為囊泡的工作壓力。3.擬施行椎管內(nèi)麻醉的病人400例,隨機分為兩組(n=200),壓力囊泡組(P組)和傳統(tǒng)方法組(C組),無硬膜外穿刺禁忌癥,患者均采取正中入路硬膜外穿刺,硬膜外穿刺針末端連接壓力囊泡指示器,P組當針尖穿過皮膚及皮下疏松組織后,推動壓力囊泡指示器的針栓,使壓力囊泡充盈,緩慢進針,當針尖到達硬膜外腔的瞬間,由于囊泡和硬膜外腔的壓力差,囊泡會迅速癟掉,提示穿刺針已到達硬膜外腔,觀察并記錄壓力囊泡指示器指示穿刺成功情況,并與傳統(tǒng)判斷方法比較。C組使用傳統(tǒng)的判斷方式進行硬膜外穿刺。比較兩組的硬膜外穿刺操作時間、并發(fā)癥發(fā)生率及穿刺成功率,并觀察麻醉效果。結(jié)果1.硬膜外腔隙壓力測定結(jié)果：患者硬膜外腔隙壓力為(9.8±4.3)mmHg.2例患者穿刺時注射器有回血,注入局麻藥后麻醉效果不滿意,剔除壓力測定研究,并采取相應措施處理。2.囊泡壓力測定結(jié)果：推注2m1液體使囊泡鼓起,囊泡工作壓力為(72±4)mmHg.3.囊泡指示器應用效果：P組囊泡指示成功200例,確認硬膜外穿刺成功200例,符合率100%。其中囊泡迅速指示者197例,延遲指示者3例,改變進針方向重新穿刺,均迅速指示。C組穿刺成功196例,1例在傳統(tǒng)方法判斷穿刺成功后,置入硬膜外導管失敗,3例出現(xiàn)誤穿入蛛網(wǎng)膜下腔。結(jié)論1.本研究測定的硬膜外腔隙是一低正壓結(jié)構(gòu),范圍接近于中心靜脈壓,臨床的負壓現(xiàn)象可能僅出現(xiàn)在硬膜外穿刺針頂開硬脊膜的瞬間。2.在椎管內(nèi)麻醉硬膜外穿刺操作中,當穿刺針突破黃韌帶進入硬膜外腔時,壓力囊泡和硬膜外腔之間的壓力差使壓力囊泡迅速癟掉,此時再用傳統(tǒng)判斷方法驗證,兩種判斷方法的吻合率為100%。與傳統(tǒng)方法相比,縮短操作時間,降低了穿刺并發(fā)癥。3.壓力囊泡指示器在硬膜外穿刺過程中,操作簡便,通過持續(xù)觀察針尖處阻力的變化,為穿刺及時提供“剎車信號”,可作為椎管內(nèi)麻醉穿刺的輔助判斷工具,提高穿刺成功率和安全性,具有臨床應用價值。第二部分壓力囊泡指示器在高齡患者側(cè)入路硬膜外穿刺中的應用研究目的探討壓力囊泡指示器在高齡患者側(cè)入路硬膜外穿刺中的應用,以提高高齡患者硬膜外穿刺的成功率,降低麻醉并發(fā)癥,提高麻醉質(zhì)量。方法1.選擇ASA Ⅱ～Ⅲ級的高齡患者(75-92歲)120例,擬行下肢骨科手術(shù),術(shù)前腰椎平片示所有患者均有不同程度的腰椎鈣化。2.所有患者常規(guī)消毒鋪單,采用側(cè)入路硬膜外穿刺,P組患者當穿刺針穿過皮膚及皮下疏松組織后,推注注射器,使囊泡充盈,穿刺過程中持續(xù)觀察壓力囊泡的變化,若穿刺過程中針尖遇到骨質(zhì),則應將硬膜外穿刺針退至皮下,重新調(diào)整穿刺針方向,當囊泡迅速癟掉后,證明穿刺針到達硬膜外腔隙,再用傳統(tǒng)方法進行判斷,并計算指示成功率。結(jié)果：在120例高齡患者中均有3例因硬膜外穿刺困難改為氣管插管全麻,剔除該實驗。P組其余117例患者采用壓力囊泡指示器均順利完成硬膜外穿刺的指示,壓力囊泡正確指示率100%。結(jié)論：壓力囊泡指示器在穿刺針進入硬膜外腔時,由于囊泡內(nèi)壓力與硬膜外腔的壓力差,囊泡迅速癟掉,準確提示穿刺針到達硬膜外腔。此指示裝置結(jié)構(gòu)簡單,成本低,使用簡便。而且適用于高齡患者側(cè)入路硬膜外穿刺,提高了穿刺成功率和安全性。
[Abstract]:Intraspinal anesthesia is one of the most widely used clinical anesthetic methods at present. The anesthetic injection, spinal cavity gap such as subarachnoid or epidural cavity, thereby blocking the nerve impulse conduction, the corresponding region of its control. According to the anesthetic effect of different anesthesia drugs injected into space, mainly divided into epidural spinal and epidural spinal anesthesia combined anesthesia and subarachnoid space subarachnoid block. Advantages of spinal anesthesia include: stress response inhibition is superior to general anesthesia induced by operation; can be used for postoperative analgesia, and better analgesic effect than intravenous analgesia, systemic side effects of light; lower extremity vascular dilatation after anesthesia, blood flow speed, reduce the incidence of deep venous thrombosis; and promote peristalsis, is conducive to the recovery of intestinal function. Epidural anesthesia is through the dispersion of local anesthetics, block the spinal nerve root, have analgesic effect, and according to the operation site, choose different puncture points, and according to the need of surgery, Through an epidural catheter infusion of local anesthetics to meet the needs of different operation time. Combined spinal epidural anesthesia combined with epidural anesthesia and subarachnoid anesthesia with their own characteristics, both the advantages of rapid onset of complete block, but also through the epidural catheter injection of local anesthetics to extend the anesthesia time. The most commonly used for epidural anesthesia and the combined spinal epidural anesthesia, epidural puncture technique is the key to the successful implementation of the spinal anesthesia epidural puncture, if improper operation or judgment, can cause tissue or nerve injury; vascular injury caused by epidural hematoma; epidural puncture needle into the subarachnoid space and other complications, have serious consequences even threaten the life of patients. Since the end of nineteenth Century the invention of spinal anesthesia, the judgment method of epidural puncture success mainly depends on the subjective judgment of the anesthesiologist, empty into the Yellow ligament, Push the glass syringe resistance disappearance method (see Figure 1) and bubble compression test, but not the exclusive judgment tools and indicators, determine the existence of the traditional method of puncture misjudgment, the subjective factors and the operator and epidural cavity structure, the objective factors and vertebral puncture gap calcification. So in order to reduce the complications of spinal anesthesia. In addition to improve the epidural puncture technique, it is necessary to study an objective epidural puncture device. The purpose of this study is to observe the accuracy and feasibility of national patent - indicating the pressure bladder indicator in epidural puncture in. In this study the pressure bladder indicator is using the old textbooks in positive pressure the airbag test (Figure 2) the principle, by a pressure of the vesicles to continuous measurement of tip resistance. The pressure bladder indicator is the common syringe needle distance (5m1) The front side wall of the barrel opening on the 1cm (Figure 3), the hole is covered with elastic rubber film. Puncture with the pressure bladder indicator extraction of saline 5ml after epidural puncture needle end, when the depth of the needle than subcutaneous soft tissue, ligaments and fascia to dense tissue, push the syringe the needle pin 2.Oml, due to the tip by dense tissue resistance, the needle cylinder pressure increases, the film expands outward, the liquid pressure capsule of a diameter of about 1.5cm are formed on the bubble (Figure 4). Left hand needle pin (to puncture needle), due to friction between the appropriate design of the syringe barrel with the needle bolt, can prevent the vesicle pressure forced the pintle back automatically, so the pressure can still maintain a vesicle expanded state. At this time the hands holding the needle to puncture (see Figure 5), when the needle break ligamentum moment, tip pressure suddenly dropped, the resistance decreased, the vesicles within the liquid quickly Quick outflow of vesicles rapidly deflated, for a successful puncture of a video signal. The device can automatically and continuously monitoring the puncture process, with a clear, rapid, reliable objective index has reached the depth of puncture needle tip appropriate. To get rid of the epidural puncture has been relying on the subjective judgment of the situation, to achieve the operating tool professional and andobjective; at the same time improve the safety, reduce the risk of human error. In the clinical teaching, students' operation, the teacher did not "feel", it is difficult to determine the puncture depth of the students, the use of the pressure bladder indicator and everyone can see changes in the vesicles, suitable for clinical teaching. The pressure bladder indicator for the first time using visual signal automatic monitoring technology, reduce the dependence on the operation experience, the difficulty of the puncture operation decreased; improve operation safety, reduce the risk of human error, reduce the medical. The risks. Epidural puncture during anesthesia doctors can uninterrupted operation for epidural anesthesia with both hands, the field has brought revolutionary technological progress. With the improvement of living standards, more and more elderly patients, although studies have shown that spinal anesthesia has a certain effect on the circulatory function of elderly patients after anesthesia, but relatively stable, the elderly for patients with cardiovascular and cerebrovascular diseases is more suitable for thrombosis and cardiovascular complications, reduce the incidence of postoperative, and will greatly reduce the general anesthesia drug induced postoperative cognitive dysfunction (POCD) incidence rate, but also can avoid the complications of tracheal intubation anesthesia inhalation in the incidence of pneumonia and atelectasis. But most of elderly patients with vascular wall sclerosis and loss of elasticity, brittleness increases, should try to ensure the puncture is gentle, reduce the damage probability of bleeding, improve the power due to the old puncture. In patients with spine ligament, interspinal ligament calcification and loss of elasticity, intervertebral space narrowing, kyphosis or scoliosis caused by puncture is difficult, therefore, in elderly patients with lateral approach puncture path, the second part of this study is to observe the pressure bladder indicator into the application effect of the road in the epidural puncture in elderly patients the first part of the pressure side. Vesicles indicative to the feasibility and application effect of anesthesia device operation in clinical determination of spinal epidural space pressure; Determination of the pressure bladder indicator work pressure; observe the pressure vesicles indicative of anesthesia device feasibility and application effect of operation in clinical intraspinal. Methods 1.120 patients, age 18-60 old, epidural puncture gap T10-L3, no contraindication of epidural puncture, heart and lung function abnormalities, routine epidural puncture, puncture needle tail through the three connecting pressure sensor, The measurement of epidural pressure.2. were randomly selected from 120 pressure bladder indicator, each pressure bladder indicator extraction 5m1 saline, is connected to the front end of the pressure sensor, push the syringe needle pin 2.Oml, the vesicles swelled, vesicle size for 5 seconds at constant pressure for recording vesicle vesicle working pressure.3. to effect of spinal anesthesia in 400 patients, were randomly divided into two groups (n=200), pressure vesicle group (P group) and the traditional group (C group), no contraindication of epidural puncture, patients were treated by midline epidural puncture, epidural puncture needle is connected at the end of the pressure bladder indicator, P group when the needle through the skin and subcutaneous tissue loose, push the needle bolt pressure bladder indicator, so that the pressure of vesicle filling, slowly into the needle, when the needle tip reaches the epidural moment, because vesicles and epidural pressure difference, vesicles will quickly deflated, suggesting that the needle has To the epidural cavity, observe and record the pressure bladder indicator of successful puncture, and compared with the traditional method to determine the.C group used to judge the traditional way of epidural puncture. Epidural puncture operation time between the two groups, the complication rate and the success rate of puncture, and to observe the effect of anesthesia. Results 1. epidural pressure results: Patients with epidural pressure (9.8 + 4.3) mmHg.2 patients puncture syringe back to the blood, injecting local anesthetics after anesthesia is not satisfactory, determination of eliminate pressure, and take appropriate measures to deal with.2. vesicle pressure determination results: injection of 2M1 liquid to vesicle vesicle muster, working pressure (72 + 4) mmHg.3. vesicles indicator application effect: group P vesicles 200 cases of successful instructions, confirm the epidural puncture was successful in 200 cases, the coincidence rate of 100%. vesicles immediately instructed in 197 cases, 3 cases of delayed instructions, change The needle direction to puncture, quickly instructed the.C puncture was successful in 196 cases, 1 cases of puncture success in traditional method after epidural catheter failure occurred in 3 cases of error into the subarachnoid space. Conclusion: 1. this study was to determine the epidural space is a low pressure structure, range close to the central venous pressure, negative clinical phenomena may only appear in the epidural anesthesia epidural puncture needle top opening dural.2. moment in spinal puncture operation, when the puncture needle enters the epidural cavity through the ligamentum flavum, pressure difference between the pressure bladder pressure vesicles and epidural cavity bubble deflated quickly, then the traditional verification at this time judgment method, two methods are compared with the rate of 100%. with the traditional method, shorten operation time, reduce the complications of puncture.3. the pressure bladder indicator in the epidural puncture process, simple operation, through continuous observation of tip resistance Changes in the puncture provide timely brake signal, the auxiliary judgment can be used as a tool of spinal anesthesia puncture, improve the safety and success rate of puncture, has clinical application value. The second part of the pressure bladder indicator in elderly patients. Objective side into the road in the epidural puncture of the pressure bladder indicator into the application of road epidural puncture in elderly patients with side, in order to improve the elderly patients with epidural puncture success rate, reduce the complications of anesthesia, improve the quality of anesthesia in elderly patients. Methods 1. ASA II ~ III level (75-92 years old) in 120 patients undergoing lower extremity surgery, Department of orthopedics, preoperative lumbar radiographs showed that all patients had different degree the lumbar.2. calcification in all patients using the conventional disinfection shop, volar epidural puncture, patients in the P group when the puncture needle through the skin and subcutaneous tissue loose after injection syringe, the vesicle filling, puncture process In the continuous observation of changes in pressure vesicles, if encountered during puncture needle bone, it should be returned to the subcutaneous epidural puncture needle, re adjust the direction of the puncture needle, when the vesicles rapidly deflated after the proof of the needle to the epidural space, use the traditional method to judge, and calculate the success rate. The results indicate in 120 cases of elderly patients in 3 cases with epidural puncture for difficult tracheal intubation, excluding the experimental group.P the remaining 117 cases were treated by the pressure bladder indicator were successfully completed epidural puncture indication of pressure vesicle accurately indicates the rate of 100%. on the pressure bladder indicator in the epidural puncture needle the vesicle cavity, internal pressure and epidural pressure difference, vesicles rapidly deflated, accurate and prompt the needle to the epidural cavity. The indicating device has the advantages of simple structure, low cost, easy to use. It is suitable for the elderly patients with lateral approach Epidural puncture improves the success rate and safety of the puncture.

【學位授予單位】：山東大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R614.4

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