手術(shù)患者全身麻醉前后留置導(dǎo)尿的耐受性對(duì)比研究

金偉魏　陳衛(wèi)英　蔣暉　蔣芳　徐建芳

(復(fù)旦大學(xué)附屬中山醫(yī)院青浦分院手術(shù)室，*護(hù)理部，#麻醉科，上?！?01700)

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·論著·

手術(shù)患者全身麻醉前后留置導(dǎo)尿的耐受性對(duì)比研究

金偉魏陳衛(wèi)英*蔣暉#蔣芳徐建芳*

(復(fù)旦大學(xué)附屬中山醫(yī)院青浦分院手術(shù)室，*護(hù)理部，#麻醉科，上海201700)

摘要目的：比較手術(shù)患者全身麻醉前、后留置導(dǎo)尿的耐受性。方法： 將300例全身麻醉下行腹腔鏡膽囊手術(shù)的患者隨機(jī)分為A組和B組，各150例。A組患者在全身麻醉前10 min、B組患者在全身麻醉氣管插管后，用一次性16號(hào)導(dǎo)尿包嚴(yán)格按標(biāo)準(zhǔn)導(dǎo)尿術(shù)進(jìn)行操作。分別記錄全身麻醉前、氣管拔管后5 min患者的心率、平均動(dòng)脈壓，并評(píng)定躁動(dòng)程度。結(jié)果：A組中、重度躁動(dòng)發(fā)生率低于B組；A組全身麻醉前平均心率高于B組，氣管拔管后5 min平均動(dòng)脈壓、平均心率低于B組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論：全身麻醉前留置尿管能夠顯著提高手術(shù)患者留置導(dǎo)尿的耐受性。

關(guān)鍵詞導(dǎo)尿；全身麻醉；時(shí)機(jī)

留置導(dǎo)尿是普外科腹部手術(shù)患者全身麻醉的常規(guī)準(zhǔn)備工作之一。在全身麻醉前導(dǎo)尿，患者因意識(shí)清醒、情緒緊張等因素而易出現(xiàn)疼痛等不適感；在全身麻醉后導(dǎo)尿，患者蘇醒時(shí)常常不能耐受導(dǎo)尿管，易出現(xiàn)一系列尿路刺激反應(yīng)。為了探索全身麻醉下手術(shù)患者的導(dǎo)尿時(shí)機(jī)，本研究比較了全身麻醉手術(shù)患者手術(shù)前后留置導(dǎo)尿的效果。

1資料與方法

1.1一般資料選擇2014年1月—12月于復(fù)旦大學(xué)附屬中山醫(yī)院青浦分院肝膽外科在全身麻醉下行腹腔鏡膽囊手術(shù)的患者300例。患者均意識(shí)清晰，無泌尿系統(tǒng)疾病，無精神病史和神經(jīng)系統(tǒng)疾病，能夠配合醫(yī)護(hù)人員。300例中男性132例，女性168例；年齡26～78歲，平均(45.6±10.3)歲。將300例隨機(jī)分成A組和B組，各150例。2組患者在性別、年齡、疾病、手術(shù)方式方面的差異均無統(tǒng)計(jì)學(xué)意義(P<0.05)，具有可比性。

1.2方法所有患者入手術(shù)室后進(jìn)行心理護(hù)理，患者情緒穩(wěn)定后，在麻醉前且未導(dǎo)尿時(shí)記錄麻醉前患者的心率、平均動(dòng)脈壓。A組在全身麻醉前10 min、患者意識(shí)清醒狀態(tài)下，使用一次性16號(hào)導(dǎo)尿包嚴(yán)格按標(biāo)準(zhǔn)導(dǎo)尿術(shù)進(jìn)行導(dǎo)尿。B組在全身麻醉氣管插管后，進(jìn)行導(dǎo)尿，方法同A組。分別記錄氣管拔管后5 min患者的心率、平均動(dòng)脈壓，并評(píng)定躁動(dòng)程度。無躁動(dòng)：安靜、合作，肢體無躁動(dòng)；輕度躁動(dòng)：吸痰等刺激時(shí)肢體有躁動(dòng)，用語言安慰可改善；中度躁動(dòng)：無刺激時(shí)也有躁動(dòng)，試圖拔除氣管插管、導(dǎo)尿管、輸液管等，需醫(yī)護(hù)人員制動(dòng)；重度躁動(dòng)：激烈掙扎，需多人按住。

2結(jié)果

A組患者中、重度躁動(dòng)發(fā)生率低于B組；A組全身麻醉前平均心率高于B組，氣管拔管后5 min平均動(dòng)脈壓、心率低于B組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表1~2。

表1　兩組患者的躁動(dòng)情況比較　(n，%)

注：與B組比較，*P<0.05

表2　兩組患者的平均動(dòng)脈壓、心率比較

注：與B組麻醉前比較，*P<0.05；與B組拔管后比較，#P<0.05

3討論

手術(shù)患者麻醉前留置導(dǎo)尿，由于有心理準(zhǔn)備，患者常能配合護(hù)士操作，引起的不適感或疼痛感較輕微；但在手術(shù)室的環(huán)境中，患者術(shù)前的恐懼和緊張情緒、身體的應(yīng)激反應(yīng)、導(dǎo)尿的不適預(yù)期、導(dǎo)尿前的心理應(yīng)激，使血流動(dòng)力學(xué)發(fā)生改變，如心率加快、血壓升高等。由于在清醒狀態(tài)下行尿管置入可導(dǎo)致膀胱痙攣并刺激了恥骨膀胱三角區(qū)而引起尿道疼痛，患者大腦對(duì)這一過程有著明顯的記憶，在清醒后能接受導(dǎo)尿管的存在。本研究結(jié)果顯示，A組患者雖然麻醉前心率高于B組，但在氣管拔管后5 min復(fù)測(cè)心率則較B組顯著下降。

麻醉后留置導(dǎo)尿時(shí)插管不會(huì)使患者感覺疼痛不適，但由于大腦皮層對(duì)留置導(dǎo)尿的過程毫無記憶，導(dǎo)致了麻醉蘇醒期對(duì)尿管存在的不適應(yīng)和不接受；而且感知覺恢復(fù)后，局部的尿道刺激使患者主訴便欲感明顯；此外，由于尿道括約肌可以受主觀的控制，麻醉復(fù)蘇后患者的緊張或疼痛可能引起尿道括約肌痙攣性收縮，進(jìn)一步造成不良的體驗(yàn)，導(dǎo)致血壓升高、心率加快，使患者出現(xiàn)明顯躁動(dòng)。文獻(xiàn)[1]報(bào)道留置導(dǎo)尿在引起麻醉后躁動(dòng)常見原因中占33.77%。本研究顯示，A組患者中、重度躁動(dòng)發(fā)生率明顯少于B組。

綜上所述，麻醉前留置導(dǎo)尿能夠顯著提高手術(shù)患者麻醉蘇醒后對(duì)尿管的耐受性。

參考文獻(xiàn)

[1]劉新.539例全麻蘇醒患者蘇醒期躁動(dòng)原因分析及護(hù)理[J].中華護(hù)理雜志,2007,42(10):886-888.

·經(jīng)驗(yàn)交流·

Indwelling Urethral Catheterization before or after General Anesthesia: A Comparison Study of Tolerance in Surgical Patients

JINWeiweiCHENWeiying*JIANGHui#JIANGFangXUJianfang*TheOperatingRoom,*NursingDepartment,#DepartmentofAnesthesiology,QingpuBranchofZhongshanHospital,FudanUniversity,Shanghai201700,China

AbstractObjective：To compare the tolerance to indwelling urethral catheterization in surgical patients who received the procedure before general anesthesia with that after general anesthesia, and to find out the best timing for indwelling urethral catheterization. Methods:Totally 300 cases undergoing laparoscopic gallbladder operation with general anesthesia were randomly divided into group A and group B,with 150 cases in each group.In group A, Indwelling urethral catheterization was done 10 min before general anesthesia, while in group B it was done after tracheal intubation of general anesthesia. And the procedures in two groups were conducted with No.16 disposable urethral catheterization bag and complied with the standard criteria of catheterization. Heart rate and mean arterial pressure before anesthesia and that in 5 min after tracheal extubation, were recorded respectively, and were evaluated in accordance with the degree of agitation scale. Results: Occurrence rate of moderate and severe agitation in group A was less than that in group B.Heart rate before general anesthesia was higher in group A than that in group B, while mean arterial pressure and heart rate 5 min after tracheal extubation was lower in group A than that in group B. And the differences were statistically significant(P<0.05). Conclusions: To indwell urethral catheters before the general anesthesia could significantly improve the tolerance to urethral catheterization in surgical patients more comfortable.

Key WordsUrethral catheterization；General anesthesia；Timing

通訊作者徐建芳，E-mail：xu.jianfang@zs-hospital.sh.cn

中圖分類號(hào)R472

文獻(xiàn)標(biāo)識(shí)碼A