【作者】 崔静静；

【导师】 徐贯杰；

【作者基本信息】 河北医科大学 ， 麻醉学， 2012， 硕士

【摘要】 目的：老年人硬膜外腔解剖结构的改变，如老年人骨质增生、椎间盘突出、椎间孔闭锁、黄韧带和后纵韧带钙化、关节退化变性等导致的椎管狭窄；高血压，血管硬化，硬脊膜的通透性改变等降低局麻药的吸收，局麻药容易在硬膜外腔广泛扩散导致阻滞平面增宽。本研究目的通过硬膜外腔造影技术观察局麻药在老年患者硬膜外腔的扩散情况，探讨硬膜外麻醉的用药特点。方法：本研究经河北医科大学第三医院伦理委员会批准。选择ASAⅠ-Ⅲ患者60例，根据年龄分为老年组（65-74岁）和青年组（25-34岁）。患者均取左侧卧位，L2～L3间隙穿刺，头侧置管3cm。回吸阴性以每分钟5毫升速度注入2%氯普鲁卡因5m（l5%盐酸氯普鲁卡因用灭菌注射用水稀释成10ml,取5%盐酸氯普鲁卡因2ml与3ml造影剂（非离子型碘海醇300mgI/ml）混合配成2%氯普鲁卡因）。以穿刺点为中心，患者左侧卧位躺在影像板上，球管与影像板的距离调整到101cm,调整焦距。5分钟后应用移动式数字摄影X线系统照相，观察2%氯普鲁卡因在硬膜外腔的扩散显影情况，记录含造影剂的2%氯普鲁卡因在硬膜外腔的显影长度及其扩散的相应椎体数，计算每个节段所需要局麻药的毫升数。用针刺法和酒精棉球测试皮肤痛觉、温度觉的阻滞平面。结果：1一般情况比较,两组患者性别、体重、身高比较无统计学差异（P>0.05）。2老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为13.0±2.8cm;青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为9.0±2.1cm。两组比较，含碘海醇的2%氯普鲁卡因在老年组硬膜外腔的显影长度明显大于青年组（P<0.05）。3老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为5.3±1.2个节段；青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为3.3±0.8个节段。两组比较,含碘海醇的2%氯普鲁卡因在老年人硬膜外腔扩散的椎体数明显大于青年组（P<0.05）。4老年组中阻滞每个神经节段所需的局麻药容量为1.0±0.2ml;青年组中阻滞每个神经节段所需的局麻药容量为1.6±0.4ml。两组比较，老年组阻滞每个脊神经节段所需要的局麻药容量明显少于青年组（P<0.05）。5老年组中温度觉阻滞平面为6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；青年组中温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段。两组比较，老年组的温度觉阻滞平面、痛觉阻滞平面明显高于青年组（P<0.05）。6老年组内温度觉阻滞平面6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为5.3±1.2个节段。温度觉、痛觉阻滞平面与2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。老年患者的痛觉与温度觉阻滞平面比较无统计学差异（P>0.05）。7青年组内温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为3.3±0.2个节段。温度觉、痛觉阻滞平面与含碘海醇的2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。青年患者的痛觉与温度觉阻滞平面比较有统计学差异（P<0.05）。结论：1相同容量的局麻药在老年人硬膜外腔的扩散范围明显大于青年人，老年人硬膜外麻醉用药量宜减少。2老年人阻滞一个神经节段所需氯普鲁卡因的量为1.0（0.8-1.2）ml/节段；青壮年阻滞一个神经节段所需氯普鲁卡因的量为1.6（1.2-2.0）ml/节段。更多还原

【Abstract】 Objective:The anatomic changes of epidural space with oldpeople,included bone hyperplasia, ligament calcification, degenerative joint,These lead to spinal canal stenosis.High blood pressure, vascularsclerosis,permeability reduce of endorhachis reduce the absorption of localanesthetics.Local anesthetics was easy to widely spread in the epiduralspace,lead to high block plane.The purpose of the research, through theepidural canvity imaging technology,observed the diffusion of localanesthetics in elderly patients’s epidural space, investigated the characteristicsof epidural anesthesia medication.Methods：The study protocol was approved by Ethics Committee ofHebei Medical University Third Hospital. Written informed consent wasobtained from each patient after a detailed explanation of the protocol.Sixtypatients (ASA physical status Ⅰ to Ⅲ) were enrolled in this study.All patientsenrolled in this study were divided into two groups on the basis of age:(Ⅰ) the elderlygroup (65~74yr of age,13female and15male patients)(Ⅱ)the young group (25~34yr of age,12female and17male patients).They wereplaced in the left lateral position on a horizontal operating table. Epiduralpuncture was performed aseptically by an attending anesthetist at the L2-L3level of the lumbar intervertebral space using a reusable16G winged Tuohyneedle by a paramedian approach with the loss of resistance(LOR) to air using0.3ml.On entering the epidural space,the bevel of the needle was pointedcephalad.The epidural catheter was advanced3cm in the cephalad directioninto the epidural space.After confirming negative aspiration of cerebrospinalfluid and blood,5ml of2%chloroprocaine with3ml Omnipaque was injectedat the rate of5ml.min-1(5%chloroprocaine was diluted with sterilizationinjection water into10ml. Take2ml of (5%chloroprocaine and3ml of iohexol(nonionic300mgI/ml) made up with5ml of2%chloroprocaine) in theleft lateral position. Five minutes after injection of the anesthetic,the spreadwas studied by taking X-rays after both injections in the left lateral position.The spread of contrast medium were recorded by epidurograms after5mlinjection of2%chloroprocaine through the epidural catheter. Five minutesafter the anesthetics injection,assessment of the spread of hypesthesia to coldand pain on both sides of the body according to a dermatomal chart,usingcotton soaked in rubbing alcohol and pinprick,was performed by an individualblinded to determine the sensory blockade.The extent of the hypesthesia wascalculated as the average dermatome of both side.Results:1No statistically significant differences were found between the elderlygroup and the young group on sex, weight, height（P>0.05）.2The total radiographic length of2%chloroprocaine in epidural canvitywere13.0±2.8cm in the elderly group. The total radiographic length of2%chloroprocaine were9.0±2.1cm in the young group.The total radiographiclength of2%chloroprocaine was significantly greater in the elderly groupthan in the young group.(P<0.05).3The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments in the elderly group.The spread segments of2%chloroprocaine in epidural canvity were3.3±0.8segments in the younggroup.The spread segments of2%chloroprocaine was significantly greater inthe elderly group than in the young group.(P<0.05).4The dose of one spinal segment were1.0±0.2ml in the elderly group,The dose of one spinal segment were1.6±0.4ml in the young group. The doseof one spinal segment was statistically lesser in the elderly group than in theyoung group (P<0.05).5In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes. In the young group, thenumber of spinal segments with hypesthesia for prinprick were3.3±0.4 dermatomes, the number of spinal segments with hypesthesia for coldnesswere2.8±0.3dermatomes. the number of spinal segments with hypesthesia forprinprick and the number of spinal segments with hypesthesia for coldnesswas significantly greater in the elderly group than in the younggroup(p<0.05).6In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes.The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments.There were nosignificant differences between the number of spinal segments withhypesthesia for coldness and prinprick (p>0.05). There were no significantdifferences between the number of spinal segments with hypesthesia forprinprick and the spread segments of2%chloroprocaine(p>0.05). There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05).7In the young group, the number of spinal segments with hypesthesiafor prinprick were2.8±0.3dermatomes, the number of spinal segments withhypesthesia for coldness were3.3±0.4dermatomes, the spread segmentsofof2%chloroprocaine in epidural canvity were3.3±0.2segments. There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05). There were no significant differences between the number of spinalsegments with hypesthesia for prinprick and the spread segments of2%chloroprocaine (p>0.05). The number of spinal segments with hypesthesiafor coldness was significantly wider than the number of spinal segments withhypesthesia for prinprick in the young group(p<0.05).Conclusion:1The spread of local anesthetics in epidural space was significantlygreater in the elderly group than in the young group with the same volum ofanesthetic solution，the dosage of epidural anesthesia should reduce in the elderly patients.2The dose of one spinal segment were1.0±0.2ml in the elderly patientsgroup, The dose of one spinal segment were1.6±0.4ml in the young paients.更多还原