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关键词：麻醉，硬膜外；芬太尼；曲马多
摘 要：目的： 观察硬膜外利多卡因加芬太尼、曲马多对上腹部手术的麻醉效应。方法： 按美国麻醉学会(ASA)五级分类法，67例Ⅰ～Ⅱ级胆道手术患者随机分为三组：芬太尼组(F组)、曲马多组(T组)及利多卡因组(L)组。每组硬膜外首剂量均为1.6%利多卡因20 ml，F组含芬太尼0.1mg，T组含曲马多100 mg。于首剂量麻醉期间对镇痛效应、肌松度、内脏牵拉反应予分级评定，同时连续监测血流动力学和血氧饱和度。结果： 三组麻醉镇痛效应相同(P>0.05)，肌松以F组较差(P<0.01)，抑制内脏牵拉反应则F组和T组效果好(P<0.01)，且F组和T组血压下降的病例数比L组少(P<0.05)。结论： 硬膜外腔应用曲马多强化麻醉是临床上可行的一种方法。
分类号： R 614.42 文献标识码： A
文章编号： 1000-2200(2000)01-0032-02
Anesthetic effects of epidural lidocaine with fentanyl or tramal
ZHANG Yun-chun,LUO Yan-zhi,CAO Xian-hua
(Department of Anesthesiology,Affiliated Hospital of Bengbu Medical College,Anhui 233004,China)
Abstract： Objective： To observe anesthetic effects of epidural lidocaine with fentanyl or tramal during abdominal surgery.Methods ： Sixty-seven patients with chronic cholecystolithiasis(ASA Ⅰ～Ⅱ ) were divided at random into 3 groups.Fentanyl(F) group:Patients received 0.1 mg of fentanyl in 20 ml of 1.6% lidocaine;Tramal(T) group:100 mg tramal in 20 ml of 1.6% lidocaine;Lidocaine(L) group:20 ml of 1.6% lidocaine alone as a control.The potency of anagesia,the muscle relaxation and visceral traction reaction were graded during the time of anesthesia after the first dose.Hemodynamic and oxygen saturation were monitored continuously at the same time.Results ： (1)There was no significant difference in the potency of analgesia among these 3 group(P> 0.05).(2)The muscle relaxation in L and T group was better than that in F group(P< 0.01).(3)Visceral traction reaction were dipressed more significantly in F and T group(P< 0.01).(4)The incidences of hypotension in F and T group were less than that of L group during operation(P< 0.05).Conclusions ： The epidural lidocaine-tramal is a favourable method 8 anesthesia in clinical operation.
Key words ： anesthesia,epidural;fentanyl;tramal▲
芬太尼、曲马多用于椎管内镇痛已多年。硬膜外腔用芬太尼混合局麻药用于下腹部手术的报道[1] 反应良好；但用于上腹部手术尚未见报道。笔者选用硬膜外芬太尼或曲马多混合利多卡因麻醉用于上腹部手术，旨在评价其麻醉效应及可行性。
1 资料与方法
1.1 一般资料 1998年9月～1999年2月共有67例ASA Ⅰ～Ⅱ级胆道手术患者，一般临床情况(见表1)各项指标均具可比性(P>0.05)。随机分为三组：芬太尼组(F组)、曲马多组(T组)及利多卡因组(L组)。三组硬膜外首剂用药量均为1.6%利多卡因20 ml，其中F组含芬太尼0.1 mg，T组含曲马多100 mg。
表1 三组患者一般临床情况(或n)
| 分 组 | n | 年龄 (岁) | 体重 (kg) | 身高 (cm) | 性别 | 手术 | |||
| 男 | 女 | 胆囊 切除术 | 胆道其 它手术 | ||||||
| L | 20 | 46.20±15.20 | 53.30±7.73 | 164.00±8.29 | 11 | 9 | 8 | 12 | |
| F | 22 | 41.30±13.10 | 50.50±7.51 | 162.00±6.72 | 11 | 11 | 10 | 12 | |
| T | 25 | 43.82±?8.67 | 50.84±6.66 | 159.56±6.55 | 11 | 14 | 14 | 11 | |
| F | — | 0.82 | 0.92 | 2.17 | 0.55△ | 1.21△ | |||
| P | — | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | |||
摘 要：目的： 观察硬膜外利多卡因加芬太尼、曲马多对上腹部手术的麻醉效应。方法： 按美国麻醉学会(ASA)五级分类法，67例Ⅰ～Ⅱ级胆道手术患者随机分为三组：芬太尼组(F组)、曲马多组(T组)及利多卡因组(L)组。每组硬膜外首剂量均为1.6%利多卡因20 ml，F组含芬太尼0.1mg，T组含曲马多100 mg。于首剂量麻醉期间对镇痛效应、肌松度、内脏牵拉反应予分级评定，同时连续监测血流动力学和血氧饱和度。结果： 三组麻醉镇痛效应相同(P>0.05)，肌松以F组较差(P<0.01)，抑制内脏牵拉反应则F组和T组效果好(P<0.01)，且F组和T组血压下降的病例数比L组少(P<0.05)。结论： 硬膜外腔应用曲马多强化麻醉是临床上可行的一种方法。
分类号： R 614.42 文献标识码： A
文章编号： 1000-2200(2000)01-0032-02
Anesthetic effects of epidural lidocaine with fentanyl or tramal
ZHANG Yun-chun,LUO Yan-zhi,CAO Xian-hua
(Department of Anesthesiology,Affiliated Hospital of Bengbu Medical College,Anhui 233004,China)
Abstract： Objective： To observe anesthetic effects of epidural lidocaine with fentanyl or tramal during abdominal surgery.Methods ： Sixty-seven patients with chronic cholecystolithiasis(ASA Ⅰ～Ⅱ ) were divided at random into 3 groups.Fentanyl(F) group:Patients received 0.1 mg of fentanyl in 20 ml of 1.6% lidocaine;Tramal(T) group:100 mg tramal in 20 ml of 1.6% lidocaine;Lidocaine(L) group:20 ml of 1.6% lidocaine alone as a control.The potency of anagesia,the muscle relaxation and visceral traction reaction were graded during the time of anesthesia after the first dose.Hemodynamic and oxygen saturation were monitored continuously at the same time.Results ： (1)There was no significant difference in the potency of analgesia among these 3 group(P> 0.05).(2)The muscle relaxation in L and T group was better than that in F group(P< 0.01).(3)Visceral traction reaction were dipressed more significantly in F and T group(P< 0.01).(4)The incidences of hypotension in F and T group were less than that of L group during operation(P< 0.05).Conclusions ： The epidural lidocaine-tramal is a favourable method 8 anesthesia in clinical operation.
Key words ： anesthesia,epidural;fentanyl;tramal▲
芬太尼、曲马多用于椎管内镇痛已多年。硬膜外腔用芬太尼混合局麻药用于下腹部手术的报道[1] 反应良好；但用于上腹部手术尚未见报道。笔者选用硬膜外芬太尼或曲马多混合利多卡因麻醉用于上腹部手术，旨在评价其麻醉效应及可行性。
1 资料与方法
1.1 一般资料 1998年9月～1999年2月共有67例ASA Ⅰ～Ⅱ级胆道手术患者，一般临床情况(见表1)各项指标均具可比性(P>0.05)。随机分为三组：芬太尼组(F组)、曲马多组(T组)及利多卡因组(L组)。三组硬膜外首剂用药量均为1.6%利多卡因20 ml，其中F组含芬太尼0.1 mg，T组含曲马多100 mg。
表1 三组患者一般临床情况(或n)
| 分组 | n | 肌松度(级) | 内脏牵拉反应(级) | 镇痛效果(级) | 血压 | |||||||||
| 0 | 1 | 2 | 0 | 1 | 2 | 3 | 0 | 1 | 2 | 3 | 正常 | 下降 | ||
| L | 20 | 2 | 6 | 12** | 5 | 8 | 5 | 2 | 0 | 0 | 2 | 18 | 6 | 14 |
| F | 22 | 9 | 10 | 3 | 0 | 3 | 3 | 16△△ | 0 | 0 | 1 | 21 | 14 | 8 |
| T | 25 | 3 | 9 | 13* | 1 | 4 | 8 | 12△△ | 0 | 0 | 2 | 23 | 15 | 10 |
| 合计 | 67 | 14 | 25 | 28 | 6 | 15 | 16 | 30 | 0 | 0 | 5 | 62 | 35 | 32 |
| Hc | 13.08 | 20.59 | 1.44 | 6.03＃ | ||||||||||
| P | <0.005 | <0.005 | >0.05 | <0.05 | ||||||||||
多个样本两两比较的秩和检验：与F组比较*P<0.05，**P<0.05；与L组比较△△P<0.01，＃示χ2 值
3 讨论
芬太尼混合局麻药麻醉用于下腹部手术[1] 被认为有加强麻醉镇痛效应，加快阻滞起效等优点，而本文观察结果并未表明上述优点，三组麻醉镇痛效果并无差异，提示硬膜外芬太尼、曲马多无明显增强上腹部手术的麻醉镇痛效能，与下腹部手术研究结果不同。
Ackerman[4] 双盲研究硬膜外腔0.5%布比卡因加入芬太尼50 μg,证明减少子宫手术操作时的恶心、呕吐，国内也报道[3] 硬膜外腔1.6%利多卡因加入芬太尼100 μg明显减轻阑尾手术的牵拉反应。本研究结果与上述一致。笔者认为对内脏牵拉反应抑制效应可能与芬太尼或曲马多兴奋中枢和脊髓μ受体有关，从而强化了利多卡因镇静效应，曲马多能抑制脑突触体对5-HT和NE的摄取[5] ，这也可参与抑制效应。
Nickel[6] 认为，吗啡、曲马多有提高肌张力的作用，本文结果未发现曲马多有明显肌紧张作用，而芬太尼显示出明显肌紧张作用。Rucci[1] 研究发现0.5%布比卡因加入芬太尼200 μg时，腰段硬膜外腔注入能降低运动神经阻滞，产生肌紧张效应，而加入芬太尼50～100 μg时，未有明显的肌紧张作用，随芬太尼剂量增加，肌紧张有增强的趋势。胸段硬膜外腔注入芬太尼100 μg时，显示肌紧张现象，推测芬太尼肌紧张产生与剂量以及药物向脊髓头端转移的距离密切相关。静注芬太尼引起肌强直临床上早有报道，其原因至今尚未完全清楚。但近年普遍认为与中枢神经系统调节机制有关，提示肌紧张作用可能与硬膜外腔芬太尼快速吸收入血产生中枢效应有关。
新型镇痛药曲马多对血流动力学影响轻微，硬膜外腔用药呈现镇痛后的循环效应，应用曲马多无危害循环之虑[7] 。笔者的观察支持以上观点，本文曲马多和芬太尼循环改变轻微，与文献报道[3] 相符。■
作者简介：张运淳(1964-)，男，安徽五河县人，主治医师，讲师.
参考文献：
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[3]张兆平，张胜兰，卫玉海.芬太尼利多卡因硬膜外阻滞对阑尾牵拉反应的影响[J].临床麻醉学杂志，1993，9(1)∶11.
[4]Ackerman WE,Tewes PA,Hore PJ,et al.Epicural fentanyl signficantly decreases nausea and vomiting during uterine menipulation in a wake patients undergoing caesarean section(abstract)[J].Anesthesiology,1988,69(1)∶679.
[5]张玉想，杨景霞，袁云起，等.曲马多的药理及临床[J].实用麻醉学杂志，1992，5(1)∶28.
[6]Nickel B,Sokoll MD,Paul GP,et al.The effect of flupartine various analgesics and muscle relaxants on skeletal muscle tone in the conscious rat[J].Arzneim Forsch Drug Res,1990,40(8)∶909.
[7]余守章，彭吕宪，罗禄萍，等.曲马多对硬膜外阻滞病人血流动力学影响的观察[J].中华麻醉学杂志，1993，13(1)∶28.
收稿日期：1999-04-01 , 百拇医药