布比卡因或左旋布比卡因对腰麻行髋关节骨折手术老年患者脑氧合的影响：随机对照试验
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Effects of bupivacaine or levobupivacaine on cerebral oxygenation during spinal anesthesia in elderly patients undergoing orthopedic surgery for hip fracture: a randomized controlled trial
背景与目的
布比卡因和左旋布比卡因具有相似的药动学和药效学特征，常用于腰麻。其血流动力学和麻醉特征的潜在差异是否可以决定老年患者发生并发症的不同风险，这一点仍存在争议。本研究的主要目的是比较鞘内注射左旋布比卡因（LB）和布比卡因（B）对髋关节骨折手术老年患者腰麻期间局部脑氧饱和度、认知状态和神经并发症的影响。
方 法
本研究为随机、对照、单盲试验。58名70岁或70岁以上拟于腰麻下行髋关节骨折手术的患者，按1:1的比例分别鞘内注射LB或B，联合芬太尼15μg。主要结果是通过近红外光谱监测术中局部脑缺血时间比例（与基线相比，局部脑氧饱和度降低了20%）。次要结果包括血流动力学参数、感觉和运动阻滞水平、简易便携式精神状态问（SPMSQ）的变化以及神经并发症。
结 果
B组左、右半球平均术中去饱和时间百分比分别为6.1%（SD：17.5）和4.7%（SD：11.9）；LB组左、右半球平均术中去饱和时间百分比分别为4.8%（SD：11.4）和2.4%（SD：8.3），治疗组间无统计学差异。手术开始时，LB的感觉阻滞水平低于B（Th10 vs Th8，P:0.047），15分钟时，LB的运动阻滞水平较低（2.5 vs 3，P:0.009）。术后SPMSQ无明显差异。B组50%的患者出现精神错乱、躁动或定向障碍等神经并发症，LB组21.4%，P=0.05。B组左、右半球平均术中去饱和时间百分比分别为6.1%（标准差：17.5）和4.7%（标准差：11.9）；LB组左、右半球平均术中去饱和时间百分比分别为4.8%（标准差：11.4）和2.4%（标准差：8.3）。治疗组间无统计学差异。手术开始时，LB组的感觉阻滞平面低于B组（Th10 vs Th8，P:0.047），15分钟时，LB组的运动阻滞平面较低（2.5 vs 3，P:0.009）。术后SPMSQ无明显差异。B组50%的患者出现精神错乱、躁动或定向障碍等神经并发症，LB组21.4%的患者出现以上症状，P=0.05。
结 论
两组的局部脑氧饱和度和血流动力学参数无统计学差异。布比卡因和左旋布比卡因在感觉和运动阻滞方面存在差异。虽然SPMSQ测量的认知损害方面没有观察到治疗组之间的差异，但医生报告的神经并发症更多见于布比卡因。
原始文献摘要
Vives R,Fernandez-Galinski D,Gordo F,et al.Effects of bupivacaine or levobupivacaine on cerebral oxygenation during spinal anesthesia in elderly patients undergoing orthopedic surgery for hip fracture: a randomized controlled trial[J]BMC Anesthesiology,2019 Jan 31;19(1):17. doi: 10.1186/s12871-019-0682-1.
BACKGROUND: Bupivacaine and levobupivacaine have similar pharmacokinetic and pharmacodynamic characteristics, and are used regularly in spinal anesthesia. Whether potential differences in their hemodynamic and anesthetic profiles could determine a differential risk of complications in elderly subjects, is controversial. The main objective was to compare the effects of intrathecally administered levobupivacaine (LB) versus bupivacaine (B), on regional cerebral O2 saturation during spinal anesthesia, cognitive status and neurological complications in elderly patients undergoing surgery for hip fracture.
METHODS: This was a randomized, controlled, single blind study. 58 patients aged 70 or older undergoing surgery for hip fracture with spinal anesthesia were allocated with a 1:1 ratio to receive LB or B, combined with fentanyl 15 μg, by intrathecal route. The primary outcome was the proportion of intraoperative time with regional cerebral desaturation (>/=20% reduction in regional cerebral oxygen saturation from baseline), monitored by near -infrared spectroscopy. Secondary endpoints included hemodynamic parameters, level of sensory and motor block, changes in Short Portable Mental Status Questionnaire (SPMSQ), and neurological complications.
RESULTS: The mean percentage of intraoperative time with desaturation in the B group was 6.1% (SD: 17.5) and 4.7% (SD: 11.9) in the left and right hemisphere respectively; in the LB group the mean was 4.8% (SD: 11.4) in the left hemisphere and 2.4% (SD: 8.3) in the right one. No statistically significant differences were found between treatment groups. The level of sensory block at the start of surgery was lower for LB than for B (Th10 vs Th8, p:0.047) and motor block at 15 min was lower for LB (2.5 vs 3, p:0.009). No differences in postoperative SPMSQ were observed. Neurological complications such as confusional state, agitation or disorientation were reported in 50% of patients in the B group and 21.4% of patients in the LB group, p = 0.05.
CONCLUSIONS: No statistically significant differences in regional cerebral oxygen saturation or hemodynamic parameters were observed between both treatment groups. Bupivacaine and levobupivacaine differed in sensory and motor block achieved. While no differences were observed in cognitive impairment measured by the SPMSQ between treatment groups neurological complications reported by the physician were more frequent with bupivacaine.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：何幼芹 审校：王贵龙