单侧腰麻和连续腰麻-硬膜外联合麻醉用于下肢骨科手术的疗效和安全性的比较
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Comparison of Efficacy and Safety of Unilateral Spinal Anaesthesia with Sequential Combined Spinal Epidural Anaesthesia for Lower Limb Orthopaedic Surgery
背景与目的
骨科麻醉计划需要根据患者对预后的需求进行定制。连续腰麻-硬膜外联合麻醉和单侧单次腰麻，均具有优于传统腰麻，并且具有阻滞时间较长以及低血压发生率较低的优点。本研究比较单侧腰麻和连续腰麻-硬膜外联合麻醉用于下肢骨科手术的安全性和有效性。
方 法
本次前瞻性随机对照研究对60例年龄在18〜65岁的ASA I-III的患者进行约2小时的下肢骨科手术。连续腰麻-硬膜外联合麻醉组接受5mg 0.5％重比重的布比卡因的腰麻，随后硬膜外注入2cc 0.5％等比重布比卡因以达到和维持于T10水平。在单侧单次腰麻组中，单侧腰麻给予10mg 0.5％的重比重布比卡因。记录血液动力学参数，麻醉准备时间和阻滞特征，并使用不配对的Student t检验分析结果。
结 果
两组均未发生阻滞失败，两组的所有病人达到外科麻醉T10感觉水平，运动阻滞Bromage达到3级。单侧单次腰麻的麻醉准备时间较少（p <0.001），连续腰麻-硬膜外联合麻醉患者的低血压发生率（p=0.0059）和麻黄碱使用的剂量均明显减少。单侧单次腰麻患者需要全身麻醉补充。
结 论
我们的研究结果显示，单侧单次腰麻是一种具有成本效益且快速进行的麻醉技术。10 mg布比卡因单侧单次腰麻和5mg腰麻以及硬膜外腔补充的连续腰麻-硬膜外联合麻醉都为下肢骨科手术提供了良好的感觉和运动阻滞，但连续腰麻-硬膜外联合麻醉提供更稳定的血液动力学，具有延长阻滞的优点。因此，在高风险患者中，特别是下肢骨科手术中，连续腰麻-硬膜外联合麻醉优于单侧单次腰麻。
原始文献摘要
Magar JS,Bawdane KD,Patil R,et al.Comparison of Efficacy and Safety of Unilateral Spinal Anaesthesia with Sequential Combined Spinal Epidural Anaesthesia for Lower Limb Orthopaedic Surgery.J Clin Diagn Res.2017 Jul;11(7):UC17-UC20. doi: 10.7860/JCDR/2017/26235.10215.
Introduction: Orthopaedic anaesthesia plan requires customi-zation as per patient’s need for safe outcome. Sequential Combined Spinal Epidural Anaesthesia(Sequential CSEA) and Unilateral Single Shot Spinal anaesthesia(Unilateral SA),both have advantages over conventional spinal anaesthesia that they provide longer lasting block with less hypotension.
Aim: To compare safety and efficacy of unilateral spinal anaesthesia with sequential combined spinal epidural anaesthesia for lower limb orthopaedic surgery.
Materials and Methods: This prospective randomized study was conducted on sixty ASA I-III patients aged 18-65 years undergoing lower limb orthopaedic surgeries of approximately two hours duration. Sequential CSE group received spinal with 5 mg of 0.5 hyperbaric bupivacaine followed by incremental epidural top up of 2 cc of 0.5% isobaric bupivacaine to achieve and maintain T10 level. In unilateral SA group, unilateral spinal anaesthesia was given with 10 mg of 0.5% hyperbaric bupivacaine. Haemodynamic parameter,anaesthesia readiness time and block characteristics were recorded and results were analysed using unpaired Student's t-test.
Results:There was no failure of block,surgical anaesthesia with T10 sensory level and bromage score three motor block was achieved by all patients in both groups. Anaesthesia readiness time was less in unilateral SA(p<0.001) Incidences of hypotension (p-value 0.0059) and mean ephedrine dose were significantly less in sequential CSEA.Five patients of unilateral SA required supplementation with general anaesthesia.
Conclusion:Thus,our study concludes that unilateral SA is a cost-effective and rapidly performed anaesthetic technique. Unilateral SA with 10 mg bupivacaine and sequential CSEA with 5 mg spinal and incremental epidural top up, both provide good quality sensory and motor block for lower limb orthopaedic surgery but sequential CSEA provides significantly more stable haemodynamics with feasibility to prolong block. Thus sequential CSEA should be preferred over unilateral SA in high risk patients especially for major lower limb orthopaedic surgeries
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