局麻药加地塞米松行浅颈丛阻滞麻醉的临床观察
摘要:目的 观察甲状腺腺瘤切除术采用局麻药加地塞米松行浅颈丛阻滞麻醉的临床效果。 方法 40例甲状腺腺瘤切除术患者随机分成两组，Ⅰ组局麻药加地塞米松10mg，Ⅱ组局麻药不加任何药，均行双侧颈浅丛阻滞，术中有牵拉不适辅助强化麻(氟哌啶2.5mg+芬太尼0.05mg静脉滴注)，仍无法缓解辅助静脉全麻(异丙酚200mg加芬太尼0.1mg混合液泵注)。观察麻醉前后血压、心率的变化，术毕评定麻醉效果。 结果 麻醉后两组血压、心率较麻醉前比均差异有显著性(P<0.05或P<0.01)，但从升高数值上看，全组40例血压、心率变化均在正常值范围内;Ⅰ组麻醉效果明显优于Ⅱ组，Ⅰ组中无1例需辅助静脉全麻。 结论 浅颈丛阻滞应用于甲状腺腺瘤切除术，发生心血管副反应程度低，加用地塞米松，可增强麻醉效果，患者能清醒配合手术，提高了麻醉和手术的安全性。
关键词:局麻药;地塞米松;浅颈丛阻滞;甲状腺腺瘤
Clinical observation on the effect of superficial cervical plexus blocking anesthesia plus local anesthetics for surgical treatment of patients with thyroid adenoma.LIN Xiao-fang，ZHUJian-zhong，ZHONG Yu-xia.(Department of Anesthesia of Hainan Provincial Land Reclamation Bureau Hospital，Haikou570311，Hainan，P.R.China)
Abstract:Objective To observe the clinical effect of superficial cervical plexus blocking anesthesia with local anesthesia plus dexamethasone in surgical treatment of patients with thyroid adenoma. Methods Forty thyroid adenoma patients were randomly di-vided into Group I and Group II.Local anesthesia plus10mg of dexamethasone was used for surgical treatment of patients in Group I，while local anesthesia along was used in Group II without use of dexamethasone.Superficial cervical plexus blocking anesthesia on both sides were performed during the operation and intensified anesthesia was applied on those feeling uncomfortable due to traction during the operation(2.5mg of doperidol-2plus0.05mg of stag and fentanyl were given intravenously).General anesthesia was used on those without relieving during operation(the mixture of200mg of propofol and0.1mg of fentanyl was used by pumping injec-tion)The variations of blood pressure and heart rate were observed before and after the operation and anesthetic results were assessed completion of surgical treatment. Results Significant differences in blood pressure and heart rate before and after the operation were observed in the two groups(P<0.05and P<0.01).Itwas noticed that the values of blood pressure and heart rate of the40patients were in the normal range.The anesthesia results in Group I was obviously superior to Group II and no general anesthesia was required for patients in Group I. Conclusion The extent of occurrence of adversary reactions in cardiovascular was low by applying superficial cervical plexus blocking anesthesia in surgical treatment of patients with thyroid adenoma，the anesthetic effect can be strengthened by addition of dexamethasone and the safety of operational and anesthesia can be enhanced as the patients was clear dur-ing operation and cooperate with the doctor.
Key words:Local anesthesia;Dexamethasone;Superficial cervical plexus blocking anesthesia;Thyroid adenoma
甲状腺腺瘤切除术要求患者能意识清醒配合手术，多采用颈丛阻滞麻醉，但其引起的心血管副反应不容忽视，且术中牵拉甲状腺上、下极时患者常出现难以忍受的不适。我们采用局麻药加地塞米松行浅颈丛阻滞的麻醉方法，取得较好的效果，现报道如下。
1 资料与方法
1.1 临床资料 ASAⅠ～Ⅱ级甲状腺腺瘤切除术患者40例，无内分泌、心脑血管疾患，随机分成Ⅰ级(观察组)和Ⅱ级(对照组)，每组20例，两组性别、年龄、体重差异无显著性。
1.2 方法 术前常规肌肉注射苯巴比妥钠0.1g、东莨菪碱0.3mg。以0.55ml/kg配制0.3%布比卡因药液，Ⅰ组加地塞米松10mg，Ⅱ组不加任何药，两组均行双侧颈浅丛阻滞。阻滞后20min术始，术中有牵拉不适者辅助强化麻(氟哌啶2.5mg+芬太尼0.05mg静脉注射)，仍无法缓解辅助静脉全麻(异丙酚200mg+芬太尼0.1mg混合液泵注)。全部病例于入手术室安静后(麻醉前)、颈丛阻滞后5min(A)、10min(B)、20min(C)分别测定血压、心率的变化，术毕评定麻醉效果。全部资料进行统计学处理，计量资料以均数±标准差表示(x±s)，组间比较采用配对t检验，计数资料采用卡方检验，P<0.05为差异有显著性。1.3 麻醉效果评级 优:术中无牵拉不适;良:术中有轻微牵拉不适，辅助强化麻可缓解;差:术中牵拉不适明显，辅助强化麻缓解不明显，需辅助静脉全麻。
2 结果
2.1 两组患者麻醉前血压、心率差异无显著性(P>0.05)。颈丛阻滞后两组血压、心率较麻醉前比差异均有显著性(P<0.05或P<0.01)，Ⅱ组较Ⅰ组上升明显(P<0.05)，但从升高数值上看，全组40例的血压、心率变化均在正常值范围内(表1)。
2.2 Ⅰ组麻醉效果明显优于Ⅱ组(P<0.01)，Ⅰ组中无1例需辅助静脉全麻(表2)。
表1 颈丛阻滞前后血压、心率的变化(x±s，n=20)(略)
注:与麻醉前比，※P<0.05，※※P<0.01;与Ⅱ组比，△P<0.05。
表2 两组麻醉效果比较(略)
注:与Ⅱ组比， △△ P<0.01。
3 讨论
颈丛阻滞后出现血压升高、心率增快等心血管副反应的原因很可能为颈动脉窦及迷走神经被阻滞所致，且可能与它们受到不同程度的阻滞有关 [1，2] 。有报道 [3] ，深颈丛阻滞由于其阻滞部位更接近颈动脉窦和迷走神经，其引起心血管副反应的发生率及程度明显高于浅颈丛阻滞。本文两组均行浅颈丛阻滞，阻滞后血压、心率与麻醉前比较虽有统计学上差异显著性，但从升高数值上看，全组40例血压、心率的变化均在正常值范围内，无1例需用心血管药物治疗，说明浅颈丛组滞后出现心血管副反应程度低。
甲状腺腺瘤切除术中分离甲状腺上、下极时牵拉肌肉，由于颈部肌肉组织由深颈从支配 [4] ，浅颈丛阻滞麻醉不能很好地阻滞支配颈肌的神经而出现牵拉反应，影响麻醉效果。本文观察到，Ⅱ组术中牵拉反射明显，多需辅助静脉全麻，而Ⅰ组在局麻药中加入地塞米松，阻滞效果佳，牵拉反射不明显，患者均能清醒配合手术完成，说明地塞米松有增强麻醉效果的作用，原因可能为 [5，6] :①地塞米松能提高机体痛阈，降低或减轻机体对创伤的应激反应。②地塞米松强化和加固了局麻药与神经轴索的结合，从而增强和延长了其神经阻滞作用。③地塞米松可抑制创伤部位氧化酶活性和前列腺素合成，而发挥其镇痛作用。我们还观察到，阻滞后Ⅱ组的血压、心率较Ⅰ组上升明显，这是否与地塞米松能降低血液中的甲状腺激素 [7] 有关尚有待于进一步研究。
因此，甲状腺腺瘤切除术采用浅颈丛阻滞麻醉，发生心血管副反应程度低，麻醉安全性提高，加用地塞米松，可增强麻醉效果，患者能清醒配合手术完成，提高手术安全性，值得推广使用。
参考文献:
[1]刘文东.颈丛阻滞后血压升高原因探讨[J].临床麻醉学，1990，6(3):183.
[2]费立国，杭燕南，孙大金.颈丛阻滞后心血管反应原因及处理[J].医学理论与实施，1996，9(3):99.
[3]沈玲，李永庆，路红社.深、浅颈丛神经阻滞对心血管反应的比较研究[J].重庆医学，2003，32(5):635～636.
[4]刘俊杰，赵俊.现代麻醉学[M].北京:人民出版杜，1987，597.
[5]Dahl JB，Kehlet H.Non-storoidal anti-inflammatory drugs:rationale for use in sovorc postooperative pain[J].Br J Anaosth，1991，66:123.
[6]张元信，刘宝义，胡双贵，等.地塞米松对延长小儿臂丛阻滞时间及术后镇痛的疗效观察[J].中华医学杂志，1998，78:164.
[7]王忠义，黄惠荣.地塞米松局部注射治疗57例甲亢疗效观察[J].宁夏医学杂志，18(2):102～103.
作者单位:海南农垦总局医院，海南海口 570311., http://www.100md.com(林小芳 朱坚忠 钟玉霞)
关键词:局麻药;地塞米松;浅颈丛阻滞;甲状腺腺瘤
Clinical observation on the effect of superficial cervical plexus blocking anesthesia plus local anesthetics for surgical treatment of patients with thyroid adenoma.LIN Xiao-fang，ZHUJian-zhong，ZHONG Yu-xia.(Department of Anesthesia of Hainan Provincial Land Reclamation Bureau Hospital，Haikou570311，Hainan，P.R.China)
Abstract:Objective To observe the clinical effect of superficial cervical plexus blocking anesthesia with local anesthesia plus dexamethasone in surgical treatment of patients with thyroid adenoma. Methods Forty thyroid adenoma patients were randomly di-vided into Group I and Group II.Local anesthesia plus10mg of dexamethasone was used for surgical treatment of patients in Group I，while local anesthesia along was used in Group II without use of dexamethasone.Superficial cervical plexus blocking anesthesia on both sides were performed during the operation and intensified anesthesia was applied on those feeling uncomfortable due to traction during the operation(2.5mg of doperidol-2plus0.05mg of stag and fentanyl were given intravenously).General anesthesia was used on those without relieving during operation(the mixture of200mg of propofol and0.1mg of fentanyl was used by pumping injec-tion)The variations of blood pressure and heart rate were observed before and after the operation and anesthetic results were assessed completion of surgical treatment. Results Significant differences in blood pressure and heart rate before and after the operation were observed in the two groups(P<0.05and P<0.01).Itwas noticed that the values of blood pressure and heart rate of the40patients were in the normal range.The anesthesia results in Group I was obviously superior to Group II and no general anesthesia was required for patients in Group I. Conclusion The extent of occurrence of adversary reactions in cardiovascular was low by applying superficial cervical plexus blocking anesthesia in surgical treatment of patients with thyroid adenoma，the anesthetic effect can be strengthened by addition of dexamethasone and the safety of operational and anesthesia can be enhanced as the patients was clear dur-ing operation and cooperate with the doctor.
Key words:Local anesthesia;Dexamethasone;Superficial cervical plexus blocking anesthesia;Thyroid adenoma
甲状腺腺瘤切除术要求患者能意识清醒配合手术，多采用颈丛阻滞麻醉，但其引起的心血管副反应不容忽视，且术中牵拉甲状腺上、下极时患者常出现难以忍受的不适。我们采用局麻药加地塞米松行浅颈丛阻滞的麻醉方法，取得较好的效果，现报道如下。
1 资料与方法
1.1 临床资料 ASAⅠ～Ⅱ级甲状腺腺瘤切除术患者40例，无内分泌、心脑血管疾患，随机分成Ⅰ级(观察组)和Ⅱ级(对照组)，每组20例，两组性别、年龄、体重差异无显著性。
1.2 方法 术前常规肌肉注射苯巴比妥钠0.1g、东莨菪碱0.3mg。以0.55ml/kg配制0.3%布比卡因药液，Ⅰ组加地塞米松10mg，Ⅱ组不加任何药，两组均行双侧颈浅丛阻滞。阻滞后20min术始，术中有牵拉不适者辅助强化麻(氟哌啶2.5mg+芬太尼0.05mg静脉注射)，仍无法缓解辅助静脉全麻(异丙酚200mg+芬太尼0.1mg混合液泵注)。全部病例于入手术室安静后(麻醉前)、颈丛阻滞后5min(A)、10min(B)、20min(C)分别测定血压、心率的变化，术毕评定麻醉效果。全部资料进行统计学处理，计量资料以均数±标准差表示(x±s)，组间比较采用配对t检验，计数资料采用卡方检验，P<0.05为差异有显著性。1.3 麻醉效果评级 优:术中无牵拉不适;良:术中有轻微牵拉不适，辅助强化麻可缓解;差:术中牵拉不适明显，辅助强化麻缓解不明显，需辅助静脉全麻。
2 结果
2.1 两组患者麻醉前血压、心率差异无显著性(P>0.05)。颈丛阻滞后两组血压、心率较麻醉前比差异均有显著性(P<0.05或P<0.01)，Ⅱ组较Ⅰ组上升明显(P<0.05)，但从升高数值上看，全组40例的血压、心率变化均在正常值范围内(表1)。
2.2 Ⅰ组麻醉效果明显优于Ⅱ组(P<0.01)，Ⅰ组中无1例需辅助静脉全麻(表2)。
表1 颈丛阻滞前后血压、心率的变化(x±s，n=20)(略)
注:与麻醉前比，※P<0.05，※※P<0.01;与Ⅱ组比，△P<0.05。
表2 两组麻醉效果比较(略)
注:与Ⅱ组比， △△ P<0.01。
3 讨论
颈丛阻滞后出现血压升高、心率增快等心血管副反应的原因很可能为颈动脉窦及迷走神经被阻滞所致，且可能与它们受到不同程度的阻滞有关 [1，2] 。有报道 [3] ，深颈丛阻滞由于其阻滞部位更接近颈动脉窦和迷走神经，其引起心血管副反应的发生率及程度明显高于浅颈丛阻滞。本文两组均行浅颈丛阻滞，阻滞后血压、心率与麻醉前比较虽有统计学上差异显著性，但从升高数值上看，全组40例血压、心率的变化均在正常值范围内，无1例需用心血管药物治疗，说明浅颈丛组滞后出现心血管副反应程度低。
甲状腺腺瘤切除术中分离甲状腺上、下极时牵拉肌肉，由于颈部肌肉组织由深颈从支配 [4] ，浅颈丛阻滞麻醉不能很好地阻滞支配颈肌的神经而出现牵拉反应，影响麻醉效果。本文观察到，Ⅱ组术中牵拉反射明显，多需辅助静脉全麻，而Ⅰ组在局麻药中加入地塞米松，阻滞效果佳，牵拉反射不明显，患者均能清醒配合手术完成，说明地塞米松有增强麻醉效果的作用，原因可能为 [5，6] :①地塞米松能提高机体痛阈，降低或减轻机体对创伤的应激反应。②地塞米松强化和加固了局麻药与神经轴索的结合，从而增强和延长了其神经阻滞作用。③地塞米松可抑制创伤部位氧化酶活性和前列腺素合成，而发挥其镇痛作用。我们还观察到，阻滞后Ⅱ组的血压、心率较Ⅰ组上升明显，这是否与地塞米松能降低血液中的甲状腺激素 [7] 有关尚有待于进一步研究。
因此，甲状腺腺瘤切除术采用浅颈丛阻滞麻醉，发生心血管副反应程度低，麻醉安全性提高，加用地塞米松，可增强麻醉效果，患者能清醒配合手术完成，提高手术安全性，值得推广使用。
参考文献:
[1]刘文东.颈丛阻滞后血压升高原因探讨[J].临床麻醉学，1990，6(3):183.
[2]费立国，杭燕南，孙大金.颈丛阻滞后心血管反应原因及处理[J].医学理论与实施，1996，9(3):99.
[3]沈玲，李永庆，路红社.深、浅颈丛神经阻滞对心血管反应的比较研究[J].重庆医学，2003，32(5):635～636.
[4]刘俊杰，赵俊.现代麻醉学[M].北京:人民出版杜，1987，597.
[5]Dahl JB，Kehlet H.Non-storoidal anti-inflammatory drugs:rationale for use in sovorc postooperative pain[J].Br J Anaosth，1991，66:123.
[6]张元信，刘宝义，胡双贵，等.地塞米松对延长小儿臂丛阻滞时间及术后镇痛的疗效观察[J].中华医学杂志，1998，78:164.
[7]王忠义，黄惠荣.地塞米松局部注射治疗57例甲亢疗效观察[J].宁夏医学杂志，18(2):102～103.
作者单位:海南农垦总局医院，海南海口 570311., http://www.100md.com(林小芳 朱坚忠 钟玉霞)