关于全麻与硬膜外复合时对全胃切除术麻醉质量价格比的影响

关于全麻与硬膜外复合时对全胃切除术麻醉质量/价格比的影响

【关键词】硬膜外阻滞

关键词: 麻醉，全身;硬膜外阻滞;麻醉质量;费用效益分析

摘要:目的评估胸段硬膜外阻滞复合全麻用于全胃切除手术时的麻醉质量/价格比. 方法 38例择期行全胃切除手术患者，ASA I～II级，被随机分为单纯全麻组（GA组）和胸段硬膜外阻滞复合全麻组（CGA组），每组19例，分别接受气管插管全麻和胸段硬膜外阻滞复合气管插管全麻.记录麻醉诱导期、手术期及苏醒期血压、心率的变化;记录术后拔管时间、是否合作或主诉刀口疼痛及术后恢复记忆时间;计算两组间可变项目费用. 结果①两组患者均无术中知晓，所有患者回到病房后才有记忆;②CGA组患者术中收缩压（16.4±1.8）kPa、心率（77.8±9.7）min-1 的变化与GA组（17.5±2.2）kPa和（84.5±10.4）min-1 比较没有显著差异（P>0.05）;③两组患者诱导插管时及苏醒期的血压、心率变化差异不显著

（P>0.05）;④CGA组患者术毕拔管时间（12±4）min与GA组（10±8）min比

较，差异不显著（P>0.05）;⑤CGA组无一例术后12h内主诉刀口疼痛，而GA组所有患者在术后12h内均主诉刀口疼痛，其中12例在术后2h内安装镇痛泵;⑥CGA

组两组间可变项目费用总计（286.6±10.2）RMB（人民币），与GA组

（618.0±121.9）RMB相比，差异有极显著性（P<0.01）. 结论与单纯全麻相

比，胸段硬膜外阻滞复合全麻用于全胃切除手术时的麻醉质量/价格比明显增加.

Keywords:anesthesia，general;epidural blockade;anesthe-sia efficacy cost benefit analysis

Abstract:AIM To assess the ratio of anesthesia efficacy to cost of combined anesthesia of general anesthesia and thoracic epidural blockade when applied to patients undergoing whole gastrectomy.METHODS 38patients scheduled for elective whole gastrectomy with ASA I～II were randomly pided in-to GA（general anesthesia）group（n=19）and CGA（com-bined general anesthesia）group（n=19），received general anesthesia with general anesthesia and general anesthesia combined with and thoracic epidural blockade.Changes in blood pressure and heart rate during the period of anesthesia induction，operation and awakening were

recorded.The time for extubation and for memory recovering after the opera-tion，and whether the patients were cooperative or com-plained of wound pain，were recorded.The cost of the changeable anesthesia items between the GA group and the CGA group were calculated.RESULTS ①All patients had no memory during the operation until they returned to wards.②No significant difference existed between the chang es of

systolic blood pressure and heart rate during the operation in the CGA group and those in the GA group re-spectively（P>0.05）.③Blood pressure and heart rate re-sponse to intubation and awakening were similar in the two groups（P>0.05）.④No significant d ifference in the time for extubation between CGA group（12±4）min and GA group（10±8）min

（P>0.05）.⑤No patients in the CGA group complained of wound pain

within12h after the opera-tion，while all patients in the GA group complained of wound pain and12patients asked for pain treatment with disposable patient-controlled analgesia pump within2h after the opera-tion.⑥The total cost of changeable anesthesia items was dif-ferent between the CGA group and the GA group（P<0.01）.CONCLUSION Compared with pure general anes-thesia，combined general anesthesia with thoracic epidural blockade could increase the ratio of anesthesia efficacy to cost when applied to patients undergoing whole gastrectomy.

0 引言

随着社会的发展，人们对医疗服务的要求越来越高，既要求提高医疗服务质量，又要求降低医疗费用，这也是目前许多国家政府所追求的目标［1-4］ .一般来说硬膜外麻醉费用相对较低，全身麻醉费用相对较高.但对某些手术来说，如全胃切除术等，全麻可能是唯一可选择的麻醉方法.面对这类手术，如何提高麻醉质量，又不过多增加麻醉费用，一直是许多麻醉工作人员关注的焦点.我们拟将胸段硬膜外阻滞和全麻联合使用，与单纯全麻相比，对麻醉质量/价格比进行评估.

1 对象和方法

1.1 对象 38例拟择期行全胃切除术的患者，ASA I～II级，年龄35～55岁，体质量50～75kg，随机分为单纯全麻组（GA组）和胸段硬膜外阻滞复合全麻组（CGA组），每组19例.

1.2 方法

1.2.1 仪器及材料麻醉前所有患者均选用（英）Penlon麻醉机，麻醉前换钠石灰，检测呼吸环路的密闭性;在30mbar压力下，漏气<200mL min-1 ;（德）Dra ger生产的Vapor9.3安氟醚专用挥发罐;（日本）Colin生命体征监护仪监测其袖带血压、心电图及脉搏血氧饱和度（SpO2 ）;同一批的一次性用品;同一批的一次性硬膜外穿刺包，同一批的药品.

1.2.2 麻醉患者均在麻醉前30min肌注苯巴比妥钠0.2g，东莨菪碱

0.3mg.CGA组患者在全麻诱导前先行硬膜外阻滞:取左侧卧屈膝弓背体位，常规消

毒铺巾后，局麻下穿刺T8～9 棘突间隙，穿刺成功后向头侧置入硬膜外导管;取平卧位向硬膜外腔注入试验量局麻药:20g L-1 盐酸利多卡因5mL;观察5min，若无腰麻征，即可再给予3.75g L-1 盐酸布比卡因7～10mL使麻醉平面达T ～T12 ;1.0