中国临床药理学杂志

目的 观察腰丛及骶旁坐骨神经阻滞复合瑞马唑仑麻醉诱导结合维持对股骨上段骨折老年患者的麻醉效果及安全性。方法 将股骨上段骨折患者按队列法分为对照组和试验组。对照组接受0.4%罗哌卡因25～30 mL腰丛及0.4%罗哌卡因15～20 mL骶旁坐骨神经阻滞+0.4～0.6μg·kg^-1右美托咪定维持麻醉，试验组在对照组的基础上复合0.2～0.4 mg·kg^-1瑞马唑仑麻醉诱导+0.15～0.35 mg·kg^-1·h^-1瑞马唑仑维持麻醉。比较2组患者手术麻醉效果、神经阻滞情况、围术期血流动力学指标[心率(HR)和平均动脉压(MAP)],苏醒质量(苏醒时间、术后2 h Ramsay镇静评分和躁动情况)、术后疼痛情况以及术后谵妄发生情况。结果 对照组和试验组分别纳入49例和53例。对照组和试验组的麻醉效果优良率分别为79.59%和94.35%,在统计学上差异有统计学意义(P<0.05)。试验组T₁₂、L₃L₄L₅经阻滞完善率分别为79.25%、100.00%、100.00%和98.11%,均显著高于对照组的22.45%、91.84%、89.80%和79.59%,在统计学上差异均有统计学意义(均P<0.05)。试验组和对照组的感觉神经阻滞起效时间分别为(5.37±1.22)和(6.18±1.28)min,运动神经阻滞维持时间分别为(201.37±33.97)和(241.36±42.47)min,在统计学上差异均有统计学意义(均P<0.05)。试验组手术开始时(T₁、手术结束时(T₂、手术结束后2 h(T₃的HR分别为(71.64±3.13)、(74.14±3.27)和(77.86±3.54)beat·min^-1,均显著高于对照组的(65.68±3.24)、(67.68±3.21)和(71.25±3.54)beat·min^-1,在统计学上差异均有统计学意义(均P<0.05);试验组T₁T₂T₃MAP分别为(86.54±3.24)、(89.24±3.54)和(92.35±4.21)mmHg,均显著高于对照组的(80.36±3.47)、(83.22±3.51)和(86.22±4.22)mmHg,在统计学上差异均有统计学意义(均P<0.05)。试验组的苏醒时间、躁动发生率均低于对照组，术后2 h Ramsay镇静评分高于对照组(均P<0.05)。试验组T₃术后12 h(T₄、术后24 h(T₅时的VAS评分均显著低于对照组(均P<0.05)。对照组谵妄发生率为12.24%,试验组未发生谵妄，在统计学上差异有统计学意义(P<0.05)。结论 股骨上段骨折的老年患者手术过程中应用腰丛及骶旁坐骨神经阻滞复合瑞马唑仑麻醉诱导+维持麻醉比单一腰丛及骶旁坐骨神经阻滞的麻醉效果更佳，神经阻滞完善率更高，且能维持术中血流稳定，降低术后谵妄发生率。

Objective To observe the anesthesia effect and safety o anesthesia induction+maintenance with lumbar plexus and parasacra sciatic nerve block combined with remimazolam on elderly patients with proximal femoral fractures.Methods Patients with proximal femoral fractures were divided into control group and treatment group according to cohort method.The control group received 0.4%ropivacaine (25-30 mL) lumbar plexus and 0.4%ropivacaine (15-20 mL) parasacral sciatic nerve block+0.4-0.6μg·kg^-1dexmedetomidine maintenance anesthesia,while the treatment group was combined with 0.2-0.4 mg·kg^-1remimazolam anesthesia induction+0.15-0.35 mg·kg^-1·h^-1remimazolam maintenance anesthesia on the basis of the control group.The surgical anesthesia effect,nerve block status,perioperative hemodynamic indexes[heart rate (HR) and mean arterial pressure (MAP)],recovery quality (recovery time,Ramsay sedation score and restlessness at 2 hours after surgery),postoperative pain status and occurrence of postoperative delirium were compared between two groups of patients.Results Fourty-nine cases in control group and 53 cases in treatment group were finally included.The excellent and good rate of anesthesia effect in control group and treatment group were 79.59%and 94.35%(allP<0.05).The perfection rates of T₁₂,L₃L_4and L_5nerve blocks in treatment group were 79.25%,100.00%,100.00%and 98.11%,which were higher than 22.45%,91.84%,89.80%and 79.59%in control group (allP<0.05).The onset time of sensory nerve block in treatment group with (5.37±1.22) min was shorter than (6.18±1.28) min in control group,and the maintenance time of motor nerve block with (201.37±33.97) min was shorter than (241.36±42.47) min in control group (allP<0.05).The HR values at the beginning (T₁,the end (T₂ and 2 h after the end (T₃ of surgery in treatment group with (71.64±3.13),(74.14±3.27) and (77.86±3.54) beat·min^-1were higher than(65.68±3.24),(67.68±3.21) and (71.25±3.54) beat·min^-1in control group (allP<0.05).MAP values at T₁T_2and T_3in treatment group were (86.54±3.24),(89.24±3.54) and (92.35±4.21) mmHg,which were higher than (80.36±3.47),(83.22±3.51) and (86.22±4.22) mmHg in control group (allP<0.05).The recovery time and incidence rate of restlessness in treatment group were lower than those in control group,and the Ramsay sedation score at 2 h after surgery was higher than that in control group (allP<0.05).The VAS scores of the treatment group T₃12 h (T₄ and 24 h (T₅ after surgery were all lower than those of the control group(allP<0.05).The incidence rate of delirium in control group was 12.24%,and there was no delirium in treatment group (P<0.05).Conclusion The application of lumbar plexus and parasacral sciatic nerve block combined with remimazolam anesthesia induction+maintenance anesthesia in elderly patients with proximal femoral fractures has a better anesthesia effect than lumbar plexus and sacral sciatic nerve block alone and the former one has higher nerve block perfection rate and can maintain intraoperative blood flow stability and reduce the incidence rate of postoperative delirium.