行全髋置换术的老年患者血流动力学及肾上腺皮质功能影响

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摘要目的探讨依托咪酯持续输注联合腰骶丛麻醉在老年患者全髋置换术中应用的安全性和可行性。方法选择2018年1~12月于上海第一人民医院宝山分院行全髋关节置换术的老年患者102例，采用随机数字表法分为丙泊酚诱导+七氟醚持续吸入维持组（A组）和依托咪酯诱导+持续输注维持组（B组），两组在全麻诱导前均行腰骶丛阻滞。记录苏醒时间和去氧肾上腺素使用情况等；记录麻醉诱导前（T1），麻醉诱导后（T2），手术开始时（T3），扩髓腔前（T4），股骨头假体安放后（T5）及手术结束时（T6）的心率（HR）、平均动脉压（MAP）、每搏输出量（SV）、外周血管阻力（SVR）；测定开放静脉时（t0），术毕（t1），术后24 h（t2），及术后48 h（t3）血中皮质醇（COR）和促肾上腺皮质激素（ACTH）的浓度；记录围术期不良反应发生情况。结果 92例患者纳入该研究，A组45例，B组47例。两组患者在手术时间、术毕喉罩拔除时间和术中出血量比较，差异无统计学意义（P > 0.05）；B组苏醒时间长于A组（P < 0.01），B组去氧肾上腺素的使用人次及使用量少于A组（P < 0.01）。术中各时间点两组患者HR、SV比较差异无统计学意义（P > 0.05），T2~T5时点，B组MAP、SVR高于A组（P < 0.01）；与T1时点比较，A组MAP、SV、SVR在T2~T5时点下降（P < 0.05），B组MAP在T5时点下降（P < 0.01）。t1时点B组患者血中COR含量低于A组（P < 0.01），ACTH含量高于A组（P < 0.01）；与t0时点比较，B组在t1时间点COR降低（P < 0.01），ACTH升高（P < 0.01），A组在t1~t3各时间点COR和ACTH差异均无统计学意义（P > 0.05）。B组注射痛、术后躁动和恶心呕吐的发生率低于A组（P < 0.05），但肌阵挛的发生率高于A组（P < 0.05）。结论老年全髋置换术患者在腰骶丛阻滞基础上，依托咪酯诱导和维持麻醉对血流动力学影响较小，肾上腺皮质功能抑制短暂，有利于麻醉安全。

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	巩文怡1 徐冰1 邹锋2 岳小芳2 范坤2

关键词 ：依托咪酯, 血流动力学, 持续输注, 关节成形术, 肾上腺皮质激素

Abstract：To investigate the safety and feasibility of Etomidate administered by continuous infusion combined with lumbosacral plexus block in elderly patients undergoing total hip arthroplasty. Methods From January to December 2018, 102 elderly patients undergoing total hip arthroplasty in Baoshan Branch of Shanghai First People′s Hospital were randomly divided into the following groups: Propofol induction + Sevoflurane maintenance inhalation group (group A), Etomidate induction + maintenance infusion group (group B). Lumbosacral plexus block was performed in both groups before induction of general anesthesia. The recovery time, the use of deoxyepinephrine, etc. were recorded. Heart rate (HR), mean arterial pressure (MAP), stroke volume (SV), and systemic vascular resistance (SVR) were measured and recorded before anesthesia induction (T1), after anesthesia induction (T2), at the beginning of operation (T3), before reaming cavity (T4), after femoral head prosthesis placement (T5), and at the end of operation (T6). The concentration of cortisol (COR) and adrenocorticotropic hormone (ACTH) were measured before anesthesia (t0), at the end of operation (t1), 24 h after operation (t2), 48 h after operation (t3). The occurrence of adverse reactions was recorded. Results There were 92 patients were enrolled in the study: 45 patients in group A and 47 patients in group B. There was no significant difference between the two groups in operative time, removal time of laryngeal mask after operation and bleeding volume (P > 0.05). The recovery time of group B was significantly longer than that of group A (P < 0.01). The number and total amount of deoxyepinephrine used in group A were significantly higher than those in group B (P < 0.01). There was no significant difference in HR and SV between the two groups at different time points during operation (P > 0.05). MAP and SVR were significantly higher in group B than in group A at T2-T5 (P < 0.01). MAP, SV and SVR in group A decreased at T2-T5 compared with T1 (P < 0.05), while MAP in group B decreased at T5 (P < 0.01). At t1, COR in group B was lower than that in group A (P < 0.01), and ACTH was higher than that in group A (P < 0.01). In group B, COR decreased at t1 compared with t0 (P < 0.01) and ACTH increased at t1 compared with t0 (P < 0.01). There was no significant difference in COR and ACTH in group A at t1-t3 (P > 0.05). The incidence of injection pain, post-operative restlessness and nausea and vomiting in group B were lower than that in group A (P < 0.05), but the incidence of myoclonus was higher than that in group A (P < 0.05). Conclusion Etomidate induction and maintenance has little effect on hemodynamics in elderly patients undergoing total hip arthroplasty on the basis of lumbosacral plexus block, the inhibition of Etomidate on adrenocortical function is transient. It is advantageous to anesthesia safety.

Key words： Etomidate Hemodynamics Continues infusion Arthroplasty Adrenal cortex hormones

基金资助:国家自然科学基金青年科学基金项目（31400953）。
上海市宝山区科学技术委员会科技创新专项资金项目（16-E-5）。

通讯作者: 范坤（1985-），男，硕士；研究方向：超声引导下神经阻滞。

作者简介: 巩文怡（1977-），女，硕士，副主任医师；研究方向：静脉麻醉药。

引用本文:

巩文怡1 徐冰1 邹锋2 岳小芳2 范坤2. 行全髋置换术的老年患者血流动力学及肾上腺皮质功能影响[J]. 中国医药导报, 2019, 16(31): 98-102.
GONG Wenyi1 XU Bing1 ZOU Feng2 YUE Xiaofang2 FAN Kun2. Effect of Etomidate continuous infusion on perioperative hemodynamics and adrenocortical function in elderly patients undergoing total hip arthroplasty combined with lumbosacral plexus block. 中国医药导报, 2019, 16(31): 98-102.

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