Fuchs C
Kreiskrankenhaus Bad Salzungen, Klinik für Anaesthesie und Intensivtherapie, Bad Liebenstein.
Anaesthesist. 1992 Oct;41(10):634-8.
Being advanced in years is not in itself a high risk in anaesthesia; however, altered pharmacokinetics and pharmacodynamics, mental dysfunction and the administration of anaesthetics complicate the postoperative period. In order to examine the problem of sedation in elderly patients, we studied the effects and side effects of continuous peridural anaesthesia for abdominal surgery. METHODS. On the day before surgery we inserted a peridural catheter (Perifix 400, Braun, Melsungen, FRG) between T-12 and L-4 in 52 patients in a sitting position (mean age 69.3 +/- 10.9 years) using the loss-of-resistance technique. If no signs of spinal anaesthesia became apparent, the exact position of the catheter was determined using 9 or 10 ml bupivacaine 0.5%. Next day, after premedication with atropine, pethidine or midazolam, 20-25 ml bupivacaine 0.5% was instilled through the peridural catheter. During surgery patients were sedated using a small dose of propofol. We also insufflated oxygen (2 l/min). Blood pressure, heart rate, and blood gases were monitored and electrocardiography and pulse oximetry performed. As postoperative pain therapy, we administered morphine through the peridural catheter at intervals of 8 h. For statistical evaluation we used Wilcoxon's test. RESULTS. An adequate degree of analgesia was found between T-4 and T-7 and abdominal muscle relaxation was satisfactory. Heart rate decreased by 10.3% after the administration of local anaesthetics. After surgery had begun, blood pressure decreased over a period of 30 min (systolic by 20.5% and diastolic by 14.2%) but it remained constant at this level during the rest of the operation (see Fig. 1). Neither of these side effects was significant. Oxygen saturation and blood gases were normal. During the operation, a mean dose of 325 mg propofol/h was necessary to maintain sedation. After surgery all patients were awake, suffered no pain and had complete amnesia with regard to the operation. The postoperative peridural dosage of 5 mg morphine (three times in 24 h) was very effective. Because some patients vomited we used between 50 and 100 mg tramadol (four times in 24 h) instead of morphine. Early mobilization of patients was possible and there were no pulmonary complications such as pneumonia. CONCLUSIONS. If carried out by an experienced physician, continuous peridural anaesthesia can be an alternative method in abdominal surgery for elderly patients. We see advantages in the minimal disturbance of pulmonary and mental function, in the minimal amount of sedation required and in the successful postoperative pain therapy.
高龄本身并非麻醉的高风险因素；然而，药代动力学和药效学的改变、精神功能障碍以及麻醉药物的使用使术后情况变得复杂。为了研究老年患者的镇静问题，我们研究了连续硬膜外麻醉用于腹部手术的效果和副作用。方法。手术前一天，我们采用阻力消失法，在52例患者（平均年龄69.3±10.9岁）坐位时于胸12至腰4间隙置入硬膜外导管（Perifix 400，德国布劳恩公司，梅尔松根）。若未出现蛛网膜下腔麻醉征象，则用9或10毫升0.5%布比卡因确定导管的确切位置。次日，在给予阿托品、哌替啶或咪达唑仑进行术前用药后，通过硬膜外导管注入20 - 25毫升0.5%布比卡因。手术期间，使用小剂量丙泊酚使患者镇静。我们还持续吹入氧气（2升/分钟）。监测血压、心率和血气，并进行心电图和脉搏血氧饱和度监测。作为术后疼痛治疗，我们每隔8小时通过硬膜外导管给予吗啡。采用威尔科克森检验进行统计学评估。结果。在胸4至胸7水平发现有足够的镇痛效果，腹部肌肉松弛良好。给予局部麻醉药后心率下降了10.3%。手术开始后，血压在30分钟内下降（收缩压下降20.5%，舒张压下降14.2%），但在手术剩余时间内保持稳定（见图1）。这些副作用均不显著。血氧饱和度和血气正常。手术期间，维持镇静平均每小时需要325毫克丙泊酚。术后所有患者均清醒，无疼痛，对手术完全失忆。术后硬膜外给予5毫克吗啡（24小时内3次）非常有效。由于部分患者呕吐，我们使用50至100毫克曲马多（24小时内4次）替代吗啡。患者能够早期活动，未出现诸如肺炎等肺部并发症。结论。如果由经验丰富的医生实施，连续硬膜外麻醉可作为老年患者腹部手术的一种替代方法。我们认为其优点在于对肺和精神功能的干扰最小、所需镇静剂量最小以及术后疼痛治疗成功。
