超声辅助定位可提高老年患者椎管内麻醉一次穿刺成功率  

Ultrasound imaging increases first-attempt success rate of neuraxial block in elderly patients

作　　者：耿姣[1] 陈宣伶 王雪冬[1] 郭向阳[1] 李民[1] 

机构地区：[1]北京大学第三医院麻醉科,100191

出　　处：《中华医学杂志》2016年第43期3459-3463,共5页National Medical Journal of China

摘　　要：目的探讨穿刺前应用超声辅助定位能否提高老年患者椎管内麻醉的一次穿刺成功率。方法选取2015年9月至2016年2月在北京大学第三医院采用椎管内麻醉实施下肢手术的老年患者200例，应用RandA 1.0随机分组软件随机分为传统解剖定位组（解剖组）和超声定位组（超声组），每组各100例。超声组应用低频（2-5 MHz）凸阵超声探头采用旁矢状倾斜位和横向水平间隙位扫查腰椎管后定位穿刺点。两组穿刺均采用旁正中穿刺入路。主要观察指标包括一次穿刺成功率，即通过1个皮肤穿刺点到达蛛网膜下腔的比例。次要观察指标包括穿刺次数、调整穿刺针方向的次数、硬膜外穿刺针的深度、定位时间、穿刺时间、操作时间、总时间、操作过程中的不良反应以及术后相关并发症。结果共191例患者由住院医师成功完成腰硬联合麻醉，有9例穿刺失败（解剖组7例，超声组2例）。解剖组一次穿刺成功率为37.6%，超声组一次穿刺成功率为68.4%，差异有统计学意义（χ^2=18.112, P〈0.01）。解剖组皮肤穿刺次数和调整穿刺针方向的次数分别为2（1，3）、5（3，10）次，超声组分别为1（1，2）、3（0，5）次，差异均有统计学意义（Z=-4.132、-4.077,均P〈0.01）。超声组定位时间、穿刺时间、操作时间、总时间分别为2.8（2.6，3.1）、2.5（1.8，4.1）、7.8（6.5，8.9）、10.6（9.5，11.9） min，解剖组分别为0.4（0.3，0.4）、4.1（2.2，6.3）、8.8（7.5，11.4）、9.2（7.8，11.9） min，差异均有统计学意义（Z=-11.931、-4.025、-3.550、-3.290,均P〈0.01）。旁矢状倾斜位置超声图像质量优于横向水平间隙位置的图像。结论应用超声对拟行腰部椎管内麻醉的老年患者进行穿刺前定位，可以有效提高一次穿刺成功率，缩短穿刺时间。穿刺前超声扫查定位的优势弥补了总时间的延长。ObjectiveTo verify whether preprocedural ultrasound of the lumbar spine could improve first-attempt success rate （defined as a successful neuraxial anesthesia with only one skin puncture） of neuraxial block in elderly patients. MethodsFrom septemble 2015 to February 2016, 200 elderly patients undergoing lower-limb surgery with neuraxial block at the Peking Universty Third Hospital were enrolled in this study.RandA 1.0 software was used to randomize patients into two groups： conventional surface landmark-guided group （group LM） and ultrasound-assisted group （group US）. Ultrasound scanning of the lumbar spine was performed to determine the suitable insertion point of US group, using a low-frequency （2-5 MHz） curved-array probe in both paramedian sagittal oblique plane and transverse median plane.Spinal anesthesia was done via the paramedian approach.The primary outcome was the rate of successful access to subarchnoid space on the first needle insertion attempt.Secondary outcomes included the following： number of needle insertion attempts, number of needle redirection times, actual epidural needle insertion depth, time taken to eastablish landmarks, time taken to perform the spinal anesthesia （the duration between local infiltration and bupivacaine injection）, procedure time （the duration from sterilizing the back to converting into supine position）, total time （the sum of the time to establish landmarks and the procedure time）, adverse events during the procedure and anesthesia related complications.ResultsA total of 191 patients successfully received combined spinal-epidural anesthesia by resident anesthesiologists, 9 patients （7 patients in group LM vs 2 patients in group US） failed.The first-attempt success rate in group LM was 37.6%, while the first-attempt success rate in group US was 68.4%, the difference between the two groups was significant （χ^2=18.112, P〈0.01）. In group LM, the number of needle insertion attempts and needle redirection attempts were 2（1, 3）

关 键 词：老年人 麻醉 硬膜外 麻醉 脊椎 超声检查 

分 类 号：R614[医药卫生—麻醉学]