全麻复合骶管阻滞对小儿上腹部手术应激反应的影响
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摘要
前言
关于全麻复合局部麻醉用于抑制围术期应激反应的研究表明：硬膜外麻醉、脊麻和区域麻醉能阻断伤害性刺激的向心性传导，有抑制应激反应效应。骶管阻滞用于小儿麻醉时，因其操作简便、安全、成功率高等优点，便于临床应用。Murat等研究发现骶管阻滞可降低小儿下腹部手术中血浆皮质醇水平，认为骶管阻滞可以抑制术中的内分泌反应。
本文通过观察围术期血浆促肾上腺皮质激素(ACTH)、皮质醇(COR)、C反应蛋白(CRP)、白介素-6(IL-6)含量及血压和脉搏的变化，评价全麻复合0.3％罗哌卡因骶管阻滞对小儿上腹部手术围术期应激反应的影响。
方法
选择16例ASAⅠ～Ⅱ级，年龄在0.58～9.0岁，体重≦25kg的患儿，行择期先天性胆总管囊肿切除、胆肠ROUX-Y吻合手术，且无内分泌系统、神经系统及免疫系统合并症者为研究对象。用掷硬币法将患儿随机分成2组，实验组接受0.3％罗哌卡因骶管阻滞复合全麻8例；对照组单纯全麻下完成手术8例。
术前肌注阿托品0.015mg/kg，入手术室后记录基础血压、脉搏。静注异丙酚2mg/kg、维库溴铵0.1mg/kg诱导；吸入1.0％～2.0％异氟醚维持麻醉。实验组气管插管后，用0.3％罗哌卡因1.25ml/kg行骶管阻滞，肛门松弛为骶管阻滞起效标志，全麻清醒后用针刺法测定骶管阻滞平面。记录两组术后患儿疼痛客观评分(OPS)，根据患儿清醒状态时哭叫、呻吟、面部表情、体位、手触摸痛区等评定术后患儿疼痛。OPS＞4认为存在疼痛。实验组纪录
能管用药量和阻滞平面。麻醉开始前。手术开始后5分为0分、术
终时及术后 24小时抽取静脉血 5 ITl，置于 EDTA抗凝的试管中，离
心后取血浆。用化学发光酶免疫检测法检测血浆ACTH人OR＊L
－6；用免疫速率散射比浊法检测血浆CRP。
定量资料用均数。标准差kd）表示，组间比较用t检验，组
内比较用配对t检验；定性资料用百分率表示，组间比较用X’检
验，p＜0．05为差异有统计学意义。
结 果
两组患儿的年龄、体重、身高、手术时间、麻醉时间的组间比较
无显著差异；两组患儿术中出血量、尿量、输血量、输液量无显著差
异。实验组患儿骰管罗呢卡因实际用药量为17．7。7．Zrnl，阻滞
平面平均为胸5（1。3节段人对照组患儿MAP于切皮后5分钟
和术毕时上升一＜0．05厂而实验组 MAP有所下降，60分钟时有
统计学意义。对照组手术后心率与麻醉前相比上升一＜0．05厂
组间大显著性差异。手术开始后两组 ACTH均明显增加一＜0．
05人术毕24小时恢复，但组间无显著性差异。两组COR于术毕
及术后 24 ／J’时显著上升k＜0．05X组间无显著性差异。两组几
一6于木毕时和术后 24 ／J’时上升（p＜0．05）。术中两组 CRP与麻
醉前相比几乎无变化，术后 24 ／J’时明显增加h＜0．of厂对照组
高于实验组，但无统计学意义；两组间IL－6、和CRP无显著性差
异。麻醉结束时骰管组患儿 OPS＜4的百分率高于对照组师＜0．
05）。
讨 论
本研究ACTH的结果进一步证实小儿麻醉手术期的应激反应
出现的迅速而强烈。从ACTH的变化反映了小儿的应激反应比成
人变化幅度大，与成人的变化趋势相似。围术期COR的变化反映
·2·
了手术损伤及细胞因子对下丘脑一垂体一肾上腺轴的影响，表明
在手术后COR比ACTH能更好地反映应激反应的程度。
本研究结果表明，全麻复合0．3％罗咙卡因能管阻滞不能抑
制小儿上腹部手术中ACTH人OR＊L－6人RP的升高。本研究中
的手术创伤较大，手术刺激引起强烈的下丘脑一垂体／肾上腺皮
质反应。ACTH和COR在术中测量值均达到测量值的上限，分别
为 1250Pg／all和 50卜g／dl。通过 IL－6的变化，可见与 COR的变
化趋势基本一致；而CRP的升高晚于IL－6，提示细胞因子等体液
因素在上腹部手术中参与引发应激反应。用能管阻滞无法抑制由
非感知性刺激引发的应激反应。如何能有效地抑制由非感知性刺
激引发的应激反应尚待研究。
结 论
一、复合麻醉下小儿上腹部手术围术期存在强烈的应激反应。
二、全麻复合0．3％罗明卡因能管阻滞不能抑制小儿上腹部
手术引起的强烈应激反应。
Background
Studies on suppressing perioperative stress responses with general anesthesia combined with local anesthesia have demonstrated that epi-dural anesthesia, spinal anesthesia and regional anesthesia can suppress stress responses by blocking afferent neurological impulses from insults. Caudal block is easy and safe performance in clinic application to pediatric anesthesia. Murat has demonstrated that caudal block can eliminate the level of plasma Cortisol during pediatric lower abdominal surgery and considered that caudal block can depress the endocrine responses during the lower abdominal surgery.
In order to assess the effect of caudal block on stress responses to upper abdominal surgery in children, we have measured the perioperative changes of plasma ACTH, COR, IL -6, CRP values, average artery blood pressure and heart rate.
Methods
16 children aged 0. 58 ~9. 0 year, ASA I ~ II ,weight <25kg , undergoing elective upper abdominal surgery were assigned in this study. The children were known without endocrine and neurological abnormalities and were randomly allocated to receive either general
anesthesia ( control group, n = 8) or general anesthesia combined with caudal block ( caudal group, n = 8 ) .
Atropin 0. 015mg/kg was administration in intra - muscular as pre - medication. Anesthesia was induct with Propofol 2mg/kg and Vecuroniu0.1mg/kg and maintained with 1. 0% ~ 2. 0% Isoflurane according to clinical criteria. In caudal group caudal blocks was performed by same qualified anesthetist with 0. 3% Ropivacaine 1. 25ml/ kg after the induction of anesthesia. Anus relaxation was considered the onset sign of caudal block. Dermatomal analgesia levels were observed using pinprick after awake of general anesthesia. The patients' pain/discomfort were evaluated after anesthesia using OPS system. Post - operative pain/discomfort scales of awake children were evaluated by crying, groan, facial expression, posture and touch painful are-a. The pain score > 4 were considered in pain /discomfort and recorded the dose and the dermatomal levels of the caudal block. Blood samples were obtained and collected in pre - chilled tubes containing EDTA before induction of anesthesia, 5 min, 60 min after skin incision , at the
end of surgery and 24 h after surgery. After centrifugation plasma samples were kept - 20℃ until assayed. Plasma ACTH, COR, IL - 6 , CRP level was determined using the chemiluminescent enzyme immnoassay.
The quantitative data were expressed as the x ±sD of each group. The paired student ' t test and unpaired student ' t test was performed to compared data within group and between the groups, x2 test was used for comparisons of the incidence of OPS <4. P <0. 05 was considered statistically significant.
Results
The children in the caudal group and control group were similar in age, weight, high and type of surgical procedures. There were no differences between the two groups in duration of surgery and anesthesia. The dose of 0. 3% Ropivacaine was 17. 7 ±7. 2ml in caudal block. The dermatomal anesthesia levels of the caudal block were at T5 in average. The MAP in the caudal group decreased at 60min after skin incision, whereas the MAP in control group increased significantly from baseline values at 5min after skin incision and the end of surgery. There were no significant differences between two groups in heart rate. The means of ACTH concentrations increased significantly from baseline values at 5min after skin incision and returned to baseline values at 24h after surgery in both groups. The COR and IL - 6 values were increased significantly from baseline at the end of surgery and 24h after the surgery in both groups. The CRP values were increased significantly from baseline at 24h after the surgery in both groups.
There are no significant differences between two groups in ACTH, COR, IL -6 and CRP values . The percent of OPS <4 at end of the surgery in caudal groups was higher than the control groups.
Conclusion
In the present study, it is shown that there are exces
关于全麻复合局部麻醉用于抑制围术期应激反应的研究表明：硬膜外麻醉、脊麻和区域麻醉能阻断伤害性刺激的向心性传导，有抑制应激反应效应。骶管阻滞用于小儿麻醉时，因其操作简便、安全、成功率高等优点，便于临床应用。Murat等研究发现骶管阻滞可降低小儿下腹部手术中血浆皮质醇水平，认为骶管阻滞可以抑制术中的内分泌反应。
本文通过观察围术期血浆促肾上腺皮质激素(ACTH)、皮质醇(COR)、C反应蛋白(CRP)、白介素-6(IL-6)含量及血压和脉搏的变化，评价全麻复合0.3％罗哌卡因骶管阻滞对小儿上腹部手术围术期应激反应的影响。
方法
选择16例ASAⅠ～Ⅱ级，年龄在0.58～9.0岁，体重≦25kg的患儿，行择期先天性胆总管囊肿切除、胆肠ROUX-Y吻合手术，且无内分泌系统、神经系统及免疫系统合并症者为研究对象。用掷硬币法将患儿随机分成2组，实验组接受0.3％罗哌卡因骶管阻滞复合全麻8例；对照组单纯全麻下完成手术8例。
术前肌注阿托品0.015mg/kg，入手术室后记录基础血压、脉搏。静注异丙酚2mg/kg、维库溴铵0.1mg/kg诱导；吸入1.0％～2.0％异氟醚维持麻醉。实验组气管插管后，用0.3％罗哌卡因1.25ml/kg行骶管阻滞，肛门松弛为骶管阻滞起效标志，全麻清醒后用针刺法测定骶管阻滞平面。记录两组术后患儿疼痛客观评分(OPS)，根据患儿清醒状态时哭叫、呻吟、面部表情、体位、手触摸痛区等评定术后患儿疼痛。OPS＞4认为存在疼痛。实验组纪录
能管用药量和阻滞平面。麻醉开始前。手术开始后5分为0分、术
终时及术后 24小时抽取静脉血 5 ITl，置于 EDTA抗凝的试管中，离
心后取血浆。用化学发光酶免疫检测法检测血浆ACTH人OR＊L
－6；用免疫速率散射比浊法检测血浆CRP。
定量资料用均数。标准差kd）表示，组间比较用t检验，组
内比较用配对t检验；定性资料用百分率表示，组间比较用X’检
验，p＜0．05为差异有统计学意义。
结 果
两组患儿的年龄、体重、身高、手术时间、麻醉时间的组间比较
无显著差异；两组患儿术中出血量、尿量、输血量、输液量无显著差
异。实验组患儿骰管罗呢卡因实际用药量为17．7。7．Zrnl，阻滞
平面平均为胸5（1。3节段人对照组患儿MAP于切皮后5分钟
和术毕时上升一＜0．05厂而实验组 MAP有所下降，60分钟时有
统计学意义。对照组手术后心率与麻醉前相比上升一＜0．05厂
组间大显著性差异。手术开始后两组 ACTH均明显增加一＜0．
05人术毕24小时恢复，但组间无显著性差异。两组COR于术毕
及术后 24 ／J’时显著上升k＜0．05X组间无显著性差异。两组几
一6于木毕时和术后 24 ／J’时上升（p＜0．05）。术中两组 CRP与麻
醉前相比几乎无变化，术后 24 ／J’时明显增加h＜0．of厂对照组
高于实验组，但无统计学意义；两组间IL－6、和CRP无显著性差
异。麻醉结束时骰管组患儿 OPS＜4的百分率高于对照组师＜0．
05）。
讨 论
本研究ACTH的结果进一步证实小儿麻醉手术期的应激反应
出现的迅速而强烈。从ACTH的变化反映了小儿的应激反应比成
人变化幅度大，与成人的变化趋势相似。围术期COR的变化反映
·2·
了手术损伤及细胞因子对下丘脑一垂体一肾上腺轴的影响，表明
在手术后COR比ACTH能更好地反映应激反应的程度。
本研究结果表明，全麻复合0．3％罗咙卡因能管阻滞不能抑
制小儿上腹部手术中ACTH人OR＊L－6人RP的升高。本研究中
的手术创伤较大，手术刺激引起强烈的下丘脑一垂体／肾上腺皮
质反应。ACTH和COR在术中测量值均达到测量值的上限，分别
为 1250Pg／all和 50卜g／dl。通过 IL－6的变化，可见与 COR的变
化趋势基本一致；而CRP的升高晚于IL－6，提示细胞因子等体液
因素在上腹部手术中参与引发应激反应。用能管阻滞无法抑制由
非感知性刺激引发的应激反应。如何能有效地抑制由非感知性刺
激引发的应激反应尚待研究。
结 论
一、复合麻醉下小儿上腹部手术围术期存在强烈的应激反应。
二、全麻复合0．3％罗明卡因能管阻滞不能抑制小儿上腹部
手术引起的强烈应激反应。
Background
Studies on suppressing perioperative stress responses with general anesthesia combined with local anesthesia have demonstrated that epi-dural anesthesia, spinal anesthesia and regional anesthesia can suppress stress responses by blocking afferent neurological impulses from insults. Caudal block is easy and safe performance in clinic application to pediatric anesthesia. Murat has demonstrated that caudal block can eliminate the level of plasma Cortisol during pediatric lower abdominal surgery and considered that caudal block can depress the endocrine responses during the lower abdominal surgery.
In order to assess the effect of caudal block on stress responses to upper abdominal surgery in children, we have measured the perioperative changes of plasma ACTH, COR, IL -6, CRP values, average artery blood pressure and heart rate.
Methods
16 children aged 0. 58 ~9. 0 year, ASA I ~ II ,weight <25kg , undergoing elective upper abdominal surgery were assigned in this study. The children were known without endocrine and neurological abnormalities and were randomly allocated to receive either general
anesthesia ( control group, n = 8) or general anesthesia combined with caudal block ( caudal group, n = 8 ) .
Atropin 0. 015mg/kg was administration in intra - muscular as pre - medication. Anesthesia was induct with Propofol 2mg/kg and Vecuroniu0.1mg/kg and maintained with 1. 0% ~ 2. 0% Isoflurane according to clinical criteria. In caudal group caudal blocks was performed by same qualified anesthetist with 0. 3% Ropivacaine 1. 25ml/ kg after the induction of anesthesia. Anus relaxation was considered the onset sign of caudal block. Dermatomal analgesia levels were observed using pinprick after awake of general anesthesia. The patients' pain/discomfort were evaluated after anesthesia using OPS system. Post - operative pain/discomfort scales of awake children were evaluated by crying, groan, facial expression, posture and touch painful are-a. The pain score > 4 were considered in pain /discomfort and recorded the dose and the dermatomal levels of the caudal block. Blood samples were obtained and collected in pre - chilled tubes containing EDTA before induction of anesthesia, 5 min, 60 min after skin incision , at the
end of surgery and 24 h after surgery. After centrifugation plasma samples were kept - 20℃ until assayed. Plasma ACTH, COR, IL - 6 , CRP level was determined using the chemiluminescent enzyme immnoassay.
The quantitative data were expressed as the x ±sD of each group. The paired student ' t test and unpaired student ' t test was performed to compared data within group and between the groups, x2 test was used for comparisons of the incidence of OPS <4. P <0. 05 was considered statistically significant.
Results
The children in the caudal group and control group were similar in age, weight, high and type of surgical procedures. There were no differences between the two groups in duration of surgery and anesthesia. The dose of 0. 3% Ropivacaine was 17. 7 ±7. 2ml in caudal block. The dermatomal anesthesia levels of the caudal block were at T5 in average. The MAP in the caudal group decreased at 60min after skin incision, whereas the MAP in control group increased significantly from baseline values at 5min after skin incision and the end of surgery. There were no significant differences between two groups in heart rate. The means of ACTH concentrations increased significantly from baseline values at 5min after skin incision and returned to baseline values at 24h after surgery in both groups. The COR and IL - 6 values were increased significantly from baseline at the end of surgery and 24h after the surgery in both groups. The CRP values were increased significantly from baseline at 24h after the surgery in both groups.
There are no significant differences between two groups in ACTH, COR, IL -6 and CRP values . The percent of OPS <4 at end of the surgery in caudal groups was higher than the control groups.
Conclusion
In the present study, it is shown that there are exces
引文
1. Gregory GA. Pediatric Anesthesia, 2nd eds , New York: Churchill livingstone , 1989,1.
2．张秉钧．小儿麻醉进展．中华麻醉杂志，1998，18：254．
3. Wolf AR, et al. Effect of extradural analgesia on stress responses to abdominal surgery in infants. British Journal of Anaesthesia, 1993, 70: 654-660.
4．钱燕宁．手术应激反应新概念-神经免疫内分泌学说．国外医学，麻醉学与复苏分册，1995，16：193．
5. Murat I, et al. Effect of lumbar epidural anaesthesia on plasma cortisol levels in children. Can J Anaesth , 1988, 35:20-24.
6. Naito Y, et al. Responses of Plasma Adernocortropic Hormone, Cortisol, and Cytokines during and after Upper Abdominal Surgery. Anesthesiology, 1992, 77: 426-431.
7. Crozier TA, et al. Effect of anaesthesia on the cytokione responses to abdominal surgery. British Journal of Anesthesia, 1994, 72: 280-285.
8. Ivani G, et al. Ropivacaine_Colonidine Combination for caudal blockade in children. Acta Anase Scan, 2000, 44:446-449.
9. Ivani G, et al. Comparision of ropivacaine with bupivacaine for paediatric caudal block. British of Journal of Anesthesia, 1998, 76: 247-48.
10. Ala_Kokko TJ, et al. Pharmacokinetics of 0.2% ropivacaine and 0.2% bupivacaine following caudal blocks in children. Acta anaesthesiol Scand, 2000,44:1099-1102.
11. Hannallah RS, etal. Comparison of caudal and llioingnal/iliohypogastric nerve block for control of post - orchipexy pain in pediatric
ambulatory surgery. Anesthesiology, 1987, 66:832-4.
12．傅诚章．糖皮质激素与麻醉手术应激研究进展．国外医学，麻醉学与复苏分册，1995，16：205．
13．徐道妙．围麻醉期应激反应及调控．国外医学，麻醉与复苏分册，1995，16：207．
14．胡同增 等译．实用小儿麻醉学．北京：人民卫生出版社，1995，140，199，410．
15．洪溪 等．肠道手术和骨科手术围术期IL-6及相关因素的变化．中华麻醉杂志，2000，20：329-331．
16．胡智勇．白介素6与手术．国外医学，麻醉学与复苏分册，1995，16：161．
17．王军等．不同全麻方法对腹部手术患者静脉血IL-6水平的影响．中华麻醉杂志，1999，19：750-751．
18．张红斌 等．麻醉方法对上腹部手术围术期血清IL-6，Cor及T细胞亚群的影响．中华麻醉杂志，2000，20：220-222．
19．杨瑞．硬膜外加浅全麻的应用．国外医学，麻醉学与复苏分册，1997，18：92-96．
20．刘俊杰 赵俊主编．现代麻醉学．第2版，北京：人民卫生出版社，1996，130，990．
21. Takasaki M, et al . Dosage of Lidocaine for Caudal Anesthesia in Infant And Children . Anesthesiology, 1977, 47:527-529.
22. Gaitini LA, et al. Effect of caudal block on the plasma adrenaline and noradrenaline concentrations in pediatrc patients undergoing ilioinguinal herniorrhaphy. Eur J Anaesthesiol, 1999 , 16:92-7.
23. Gaitini LA, et al . Dose the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children ? Anesth Analg,2000, 90:1029-33.
2．张秉钧．小儿麻醉进展．中华麻醉杂志，1998，18：254．
3. Wolf AR, et al. Effect of extradural analgesia on stress responses to abdominal surgery in infants. British Journal of Anaesthesia, 1993, 70: 654-660.
4．钱燕宁．手术应激反应新概念-神经免疫内分泌学说．国外医学，麻醉学与复苏分册，1995，16：193．
5. Murat I, et al. Effect of lumbar epidural anaesthesia on plasma cortisol levels in children. Can J Anaesth , 1988, 35:20-24.
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