超声引导神经阻滞麻醉用于老年脊髓灰质炎后遗症疝手术1例

2018-03-29 佚名 人民军医

患者女,78岁。

【一般资料】

患者女,78岁。

【主诉】

查体发现双侧腹股沟区鸽蛋大小可复性包块3年入院

【初步诊断

诊断为双侧腹股沟疝。

【辅助检查】

患者因脊髓灰质炎后遗症胸腰段椎体后突畸形明显,胸椎及腰椎多发压缩性骨折,心肺功能差,CT检查提示慢性支气管炎伴双下肺感染,血气分析示氧分压69.9mmHg,评估心功能III级。

【治疗】

考虑行腰-硬联合麻醉穿刺操作困难,全身麻醉术中管理风险大且术后并发症多,最终选择行超声引导髂腹股沟髂腹下神经阻滞联合右美托咪定静脉泵注麻醉下双侧腹股沟疝无张力修补术。入室后开放静脉通道,常规输注钠钾镁钙葡萄糖注射液500ml;麻醉前30min静脉注入咪达唑仑0.5mg及舒芬太尼2μg,而后恒速泵入右美托咪定0.3μg/(kg`h)。监测血压105/65mmHg、血脉氧饱和度(SpO2)0.98、心率(HR)74/min;面罩给氧,流量2L/min。患者取平卧位,采用台式彩色多普勒超声诊断仪进行操作,将超声探头长轴放置于靠近髂前上棘位置,探头一段指向脐部。超声下可见3层低回声腹壁肌肉组织,由上至下分别是腹外斜肌、腹内斜肌和腹横肌;在腹内斜肌和腹横肌之间找到2个楠圆形结构组织,内部呈低回声影,外部有高回声影包绕,即为髂腹股沟神经(IIN)和髂腹下神经(IHN);找到靶向神经后测量3个距离(髂前上棘到IIN、IIN到IHN及皮肤到IIN和IHN的距离)。对穿刺点位置进行常规消毒,穿刺针采取与探头长轴方向垂直进针,当针尖至腹内斜肌和腹横肌的间隙神经周围时,回抽无血后注入0.375%罗哌卡因+1%利多卡因混合液15mL。20min后开始手术,麻醉效果满意。手术开始时患者血压98/58mmHg,SpO21.00,HR65/min;术中患者生命体平稳,无疼痛应激反应,镇静-躁动评分(SAS评分)2~3分,易唤醒,可正常交流。一侧腹股沟疝手术结束后,同法行另一侧髂腹股沟髂腹下神经阻滞麻醉,效果满意。手术时间80min,手术结束前30min停止输注右美托咪定。术毕人麻醉恢复室观察40min后送回病房。给予舒芬太尼40μg+氟比洛芬酯100mg+托烷司琼10mg+甲氧氯普胺20mg术后镇痛,总量150ml,泵速3ml/h。术后随访患者无不适,生命体征平稳,镇痛良好。2天后结束镇痛,5天后痊愈出院。

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    2018-03-31 huirong
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