不同剂量右美托咪定对老年胫腓骨骨折术后凝血功能影响及术后恢复的影响因素

王文玺

doi:10.13898/j.cnki.issn.1000-2200.2021.11.010

不同剂量右美托咪定对老年胫腓骨骨折术后凝血功能影响及术后恢复的影响因素

王文玺

Effect of different doses of dexmedetomidine on the coagulation function in elderly patients with tibiofibular fracture, and analysis of the influencing factors of postoperative recovery

WANG Wen-xi

摘要

摘要:
目的探讨不同剂量右美托咪定对老年胫腓骨骨折术后凝血功能影响，分析术后恢复的影响因素。
方法选择171例行切开复位内固定术治疗的老年胫腓骨骨折病人，依据随机数字表法分为A组、B组和C组，各57例，A组采用连续硬脊膜外腔阻滞麻醉，B组采用连续硬脊膜外腔阻滞麻醉联合0.5 μg·kg^-1·h^-1右美托咪定静脉输注麻醉，C组采用连续硬脊膜外腔阻滞麻醉联合1.0 μg·kg^-1·h^-1右美托咪定静脉输注内麻醉，比较3组凝血功能、应激反应指标变化，并分析术后恢复的影响因素。
结果所有病人均成功麻醉，并顺利完成手术。3组病人镇痛时间、麻醉满意度、血流动力学改变度、术后下肢功能恢复度差异无统计学意义（P>0.05）；3组愈合、延迟愈合和不愈合比例差异具有统计学意义（P < 0.01）；术后2个月踝关节功能评分按A、B、C组呈递升现象（P < 0.01）；3组病人术前活化部分凝血酶时间（APTT）、凝血酶原时间（PT）、凝血酶时间（TT）和血浆纤维蛋白原定量（Fib）、超氧化物歧化酶（SOD）、丙二醛（MDA）、去甲肾上腺素（NE）、皮质醇（COR）差异均无统计学意义（P>0.05），术后A组和B组APTT、PT、TT、MDA、NE、COR水平均升高（P < 0.05），Fib、SOD水平均降低（P < 0.05），C组无变化（P>0.05）；SOD与APTT、PT、TT均呈正相关关系（P < 0.05~P < 0.01），与Fib呈负相关关系（P < 0.01）；MDA、NE、COR与APTT、PT、TT均呈负相关关系（P < 0.05~P < 0.01），与Fib呈正相关关关系（P < 0.05~P < 0.01）。单因素及logistic回归分析显示骨折分型、手术前后凝血指标（APTT、PT、TT和Fib）差值、手术前后应激反应指标（SOD、MDA、NE、COR）差值均为影响术后恢复的危险因素（P < 0.05~P < 0.01）。
结论麻醉后应激反应影响老年胫腓骨骨折术后凝血功能，二者共同影响骨折愈合。右美托咪定抑制应激反应、改善术后凝血功能的效果与给药剂量相关，与低剂量0.5 μg·kg^-1·h^-1相比，高剂量1.0 μg·kg^-1·h^-1效果更佳。

Abstract:
ObjectiveTo explore the effects of different doses of dexmedetomidine on coagulation function in elderly patients with tibiofibular fractures, and analyze the influencing factors of postoperativem recovery.
MethodsOne hundred and seventy-one sacral fractures patients treated with open reduction internal fixation were randomly divided into the group A, group B and group C(57 cases in each group).The group A was treated with continuous epidural anesthesia, the group B was treated with continuous epidural anesthesia combined with 0.5 μg·kg·^-1·h^-1 dexmedetomidine intravenous infusion, and the group C was treated with continuous epidural anesthesia combined with 1.0 μg·kg·^-1·h^-1 dexmedetomidine intravenous infusion.The changes of coagulation function and stress response index among three groups were compared, and the influencing factors of postoperative recovery were analyzed.
ResultsAll patients were anesthetized successfully, and the operations were successfully completed.The differences of the analgesia time, anesthesia satisfaction, hemodynamic change and postoperative lower limb function recovery among three groups were not statistically significant(P>0.05).The differences of the ratios of healing, delayed healing and non-healing were statistically significant(P < 0.01).After 2 months of operation, the ankle function scores in group A, group B and group C showed the progressive phenomenon(P < 0.01).The differences of the APTT, PT, TT, Fib, SOD, MDA, NE and COR among three groups before operation were not statistically significant(P>0.05).After operation, the levels of APTT, PT, TT, MDA, NE and COR in group A and group B increased(P < 0.05), the levels of Fib and SOD in A and B groups decreased, and there was no change in group C(P>0.05).The level of SOD was positively correlated with the levels of APTT, PT and TT(P < 0.05 to P < 0.01), and negatively correlated with Fib(P < 0.01).The levels of MDA, NE and COR were negatively correlated with the levels of APTT, PT, TT(P < 0.05 to P < 0.01), and positively correlated with Fib(P < 0.05 to P < 0.01).The results of univariate and logistic regression analysis showed that fracture type, difference of coagulation index(APTT, PT, TT and Fib) between before and after operation, and difference of stress response index(SOD, MDA, NE, COR) between before and after operation were the risk factors affecting postoperative recovery(P < 0.05 to P < 0.01).
ConclusionsThe post-anesthesia stress response affects the coagulation function in elderly patients with tibiofibular fractures, which together affect fracture healing.The inhibitory effects of dexmedetomidine on stress response and postoperative coagulation function are correlated with dose.Compared with low dose of 0.5 μg·kg·^-1·h^-1, the effects of high dose of 1.0 μg·kg·^-1·h^-1 is better.

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