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股骨颈骨折是老年人群高发的骨折类型,及时进行髋关节置换术是该病治疗的关键,但由于老年人群身体各项机能退化且可能合并多种慢性疾患,对麻醉的耐受性下降、麻醉风险上升[1]。高龄股骨颈骨折病人具体麻醉方案的选择可能对其最终治疗结局产生重大影响,静脉全身麻醉是目前临床应用最多的麻醉方式,已成功用于众多中大型手术中,但麻醉药物经静脉作用于全身各个组织脏器、加上个体对麻药反应性的差异,可能存在麻醉深度调节不当、镇痛不足等问题[2-3]。蛛网膜下腔麻醉是最典型的椎管内麻醉方式,配伍羟考酮等镇痛药物适用于各种腹部以下手术的麻醉需求[4]。何种麻醉方式更适用于高龄股骨颈骨折病人目前尚无定论。我们探讨上述2种麻醉方案对老年股骨颈骨折病人循环稳定性、全身应激反应的影响,并评价其术后镇痛作用及使用安全性,以期为后续同类病人麻醉方式的选择提供借鉴。现作报道。
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T0时,2组病人HR、MAP、SpO2差异均无统计学意义(P>0.05)。T1、T2时,2组病人HR和MAP均较T0时明显降低(P < 0.01);O组T1时HR、MAP均高于C组(P < 0.05和P < 0.01),T2时MAP明显高于C组(P < 0.01)(见表 1)。
分组 n T0 T1 T2 F P MS组内 HR/(次/分) C组 21 74.38±9.11 63.29±8.23** 65.71±9.54** 8.86 <0.01 80.579 O组 19 74.76±8.94 70.12±8.65 71.20±9.43 1.38 >0.05 81.224 t — 0.13 2.56 1.83 — — — P — >0.05 <0.05 >0.05 — — — MAP/mmHg C组 21 105.48±19.62 82.66±10.91** 84.23±9.37** 17.30 <0.01 197.257 O组 19 104.91±17.54 98.64±9.12 95.73±12.46 2.30 >0.05 180.026 t — 0.10 5.00 3.32 — — — P — >0.05 <0.01 <0.01 — — — SpO2/% C组 21 99.01±0.34 99.01±0.34 99.15±0.49 0.87 >0.05 0.157 O组 19 99.26±0.49 99.12±0.55 99.30±0.61 0.56 >0.05 0.305 t — 1.89 0.60 0.86 — — — P — >0.05 >0.05 >0.05 — — — q检验:与T0比较**P < 0.01 表 1 2组病人不同时点血流动力学参数比较(x±s)
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T0时,2组病人血清Cor、NE、AngⅡ水平差异均无统计学意义(P>0.05)。T1、T2时,2组血清Cor、NE、AngⅡ水平均较T0时明显升高,而O组T1、T2时血清Cor、NE、AngⅡ水平均明显低于C组(P < 0.01)(见表 2)。
分组 n T0 T1 T2 F P MS组内 Cor/(nmol/L) C组 21 328.19±40.58 561.23±79.54** 598.35±81.23** 104.53 <0.01 4 308.420 O组 19 326.77±43.21 429.74±50.61** 478.51±68.92**# 37.27 <0.01 3 059.481 t — 0.11 6.16 5.00 — — — P — >0.05 <0.01 <0.01 — — — NE/(pmol/L) C组 21 910.77±123.47 1 493.72±250.18** 1 704.38±286.21**## 66.65 <0.01 53 250.346 O组 19 904.53±99.37 1 124.71±148.32** 1 206.37±154.28** 24.96 <0.01 18 558.513 t — 0.17 5.60 6.74 — — — P — >0.05 <0.01 <0.01 — — — AngⅡ/(pg/mL) C组 21 43.29±6.18 60.37±8.54** 68.22±9.17**## 52.43 <0.01 65.071 O组 19 42.78±5.96 50.31±6.59** 57.64±8.23**## 21.45 <0.01 48.894 t — 0.27 4.14 3.82 — — — P — >0.05 <0.01 <0.01 — — — q检验:与T0比较** P < 0.01;与T1比较# P < 0.05,## P < 0.01 表 2 2组病人不同时间点应激指标比较(x±s)
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术前2组病人VAS评分差异无统计学意义(P>0.05);术后6 h,2组病人的VAS评分均较术前明显降低(P < 0.01),且O组VAS评分明显低于C组(P < 0.01)(见表 3)。
分组 n 术前 术后6 h t P C组 21 7.21±0.96 3.72±0.51 14.71 <0.01 O组 19 7.15±0.92 1.98±0.34 22.98 <0.01 t — 0.20 12.55 — — P — >0.05 <0.01 — — 表 3 2组病人手术前后VAS评分比较(x±s;分)
Table 3. Information of ground motions
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O组病人恶心呕吐发生率低于C组(P < 0.05),2组肺部感染、切口感染、下肢静脉血栓发生率差异均无统计学意义(P>0.05)(见表 4)。
分组 n 恶心呕吐 肺部感染 切口感染 下肢静脉血栓 C组 21 9 4 2 4 O组 19 2 0 1 0 χ2 — 5.23 2.18△ 0.01△ 2.18△ P — <0.05 >0.05 >0.05 >0.05 △示校正χ2值 表 4 2组病人术后并发症发生情况比较(n)
羟考酮联合蛛网膜下腔麻醉用于高龄病人股骨颈骨折手术的有效性和安全性
Effectiveness and safety of oxycodone combined with intraspinal anesthesia for femoral neck fracture surgery in elderly patients
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摘要:
目的分析羟考酮联合蛛网膜下腔麻醉用于高龄病人股骨颈骨折手术的有效性及安全性。 方法股骨颈骨折病人40例,按照麻醉方案分为全身麻醉组(C组)21例和羟考酮联合蛛网膜下腔麻醉组(O组)19例。分别于麻醉前(T0)、麻醉后1 h(T1)、缝合时(T3)比较2组病人血流动力学参数[心率(HR)、平均动脉压(MAP)、血氧饱和度]、应激指标[皮质醇(Cor)、去甲肾上腺素(NE)、血管紧张素Ⅱ(AngⅡ)],比较2组病人手术前后视觉模拟评分(VAS),并记录术后并发症发生情况。 结果T0时,2组病人HR、MAP、血氧饱和度差异均无统计学意义(P>0.05);T1、T2时,2组HR和MAP均较T0时明显降低(P < 0.01),而O组T1时HR、MAP和T2时MAP均高于C组(P < 0.05~P < 0.01)。T0时,2组病人血清Cor、NE、AngⅡ水平差异均无统计学意义(P>0.05);T1、T2时,2组血清Cor、NE、AngⅡ水平均较T0时明显升高,而O组T1、T2时血清Cor、NE、AngⅡ水平均明显低于C组(P < 0.01)。术前2组病人VAS评分差异无统计学意义(P>0.05);术后6 h,2组病人VAS评分均较术前明显降低(P < 0.01),且O组VAS评分明显低于C组(P < 0.01)。O组病人恶心呕吐发生率低于C组(P < 0.05),2组肺部感染、切口感染、下肢静脉血栓发生率差异均无统计学意义(P>0.05)。 结论与常规静脉全身麻醉相比,高龄病人行股骨颈骨折手术时采用羟考酮联合蛛网膜下腔麻醉在减少循环波动及全身应激损伤、增强术后镇痛作用、减少术后并发症方面均更具优势。 Abstract:ObjectiveTo analyze the effectiveness and safety of oxycodone combined with intraspinal anesthesia for femoral neck fracture surgery in elderly patients. MethodsForty patients with femoral neck fracture were divided into the general anesthesia group(group C, n=21), and oxycodone combined with subarachnoid anesthesia group(group O, n=19) according to the anesthesia program.The hemodynamic parameters[heart rate(HR), mean arterial pressure(MAP), blood oxygen saturation(SpO2)], stress indexes[cortisol(Cor), norepinephrine(NE) and angiotensin Ⅱ(Ang Ⅱ)] before anesthesia(T0), after anesthesia(T1) and during suture(T3) were compared between two groups.The visual analogue score(VAS) before and after operation were compared between two groups, and the occurrence of complications were recorded. ResultsAt T0, there was no statistical significance in the levels of HR, MAP and SpO2 between two groups(P>0.05).At T1 and T2, the levels of HR and MAP in two groups were significantly lower than those at T0(P < 0.01), while the levels of HR and MAP at T1 and MAP level at T1 in group O were higher than those in group C(P < 0.05 to P < 0.01).At T0, there was no statistical significance in the levels of Cor, NE and Ang Ⅱ between two groups(P>0.05).At T1 and T2, the serum levels of Cor, NE and Ang Ⅱ in two groups significantly increased compared with at T0, while the levels of Cor, NE and Ang Ⅱ in group O at T1 and T2 were significantly lower than those in group C(P < 0.01).There was no statistical significance in VAS score between two groups before operation(P>0.05).After 6 h of surgery, the VAS scores in two groups were significantly lower than those before operation(P < 0.01), and the VAS score in group O was significantly lower than that in group C(P < 0.01).The incidence rates of nausea and vomiting in group O were lower than those in group C(P < 0.05), and there was no statistical significance in the incidence rates of pulmonary infection, incision infection and lower limb venous thrombosis between two groups(P>0.05). ConclusionsCompared with conventional intravenous general anesthesia, the oxycodone combined with subarachnoid anesthesia is more advantageous in reducing circulatory fluctuation and general stress injury, enhancing postoperative analgesia, and reducing postoperative complications in elderly patients with femoral neck fracture surgery. -
Key words:
- femoral neck fracture /
- elderly /
- oxycodone /
- intraspinal anesthesia
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表 1 2组病人不同时点血流动力学参数比较(x±s)
分组 n T0 T1 T2 F P MS组内 HR/(次/分) C组 21 74.38±9.11 63.29±8.23** 65.71±9.54** 8.86 <0.01 80.579 O组 19 74.76±8.94 70.12±8.65 71.20±9.43 1.38 >0.05 81.224 t — 0.13 2.56 1.83 — — — P — >0.05 <0.05 >0.05 — — — MAP/mmHg C组 21 105.48±19.62 82.66±10.91** 84.23±9.37** 17.30 <0.01 197.257 O组 19 104.91±17.54 98.64±9.12 95.73±12.46 2.30 >0.05 180.026 t — 0.10 5.00 3.32 — — — P — >0.05 <0.01 <0.01 — — — SpO2/% C组 21 99.01±0.34 99.01±0.34 99.15±0.49 0.87 >0.05 0.157 O组 19 99.26±0.49 99.12±0.55 99.30±0.61 0.56 >0.05 0.305 t — 1.89 0.60 0.86 — — — P — >0.05 >0.05 >0.05 — — — q检验:与T0比较**P < 0.01 表 2 2组病人不同时间点应激指标比较(x±s)
分组 n T0 T1 T2 F P MS组内 Cor/(nmol/L) C组 21 328.19±40.58 561.23±79.54** 598.35±81.23** 104.53 <0.01 4 308.420 O组 19 326.77±43.21 429.74±50.61** 478.51±68.92**# 37.27 <0.01 3 059.481 t — 0.11 6.16 5.00 — — — P — >0.05 <0.01 <0.01 — — — NE/(pmol/L) C组 21 910.77±123.47 1 493.72±250.18** 1 704.38±286.21**## 66.65 <0.01 53 250.346 O组 19 904.53±99.37 1 124.71±148.32** 1 206.37±154.28** 24.96 <0.01 18 558.513 t — 0.17 5.60 6.74 — — — P — >0.05 <0.01 <0.01 — — — AngⅡ/(pg/mL) C组 21 43.29±6.18 60.37±8.54** 68.22±9.17**## 52.43 <0.01 65.071 O组 19 42.78±5.96 50.31±6.59** 57.64±8.23**## 21.45 <0.01 48.894 t — 0.27 4.14 3.82 — — — P — >0.05 <0.01 <0.01 — — — q检验:与T0比较** P < 0.01;与T1比较# P < 0.05,## P < 0.01 表 3 2组病人手术前后VAS评分比较(x±s;分)
Table 3. Information of ground motions
分组 n 术前 术后6 h t P C组 21 7.21±0.96 3.72±0.51 14.71 <0.01 O组 19 7.15±0.92 1.98±0.34 22.98 <0.01 t — 0.20 12.55 — — P — >0.05 <0.01 — — 表 4 2组病人术后并发症发生情况比较(n)
分组 n 恶心呕吐 肺部感染 切口感染 下肢静脉血栓 C组 21 9 4 2 4 O组 19 2 0 1 0 χ2 — 5.23 2.18△ 0.01△ 2.18△ P — <0.05 >0.05 >0.05 >0.05 △示校正χ2值 -
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