黃澤漢,陸榮臻,韋忠良

(右江民族醫(yī)學(xué)院附屬醫(yī)院麻醉科,廣西百色 533000)

小劑量羅呱卡因復(fù)合舒芬太尼蛛網(wǎng)膜下腔麻醉用于剖宮產(chǎn)的臨床觀察*

黃澤漢,陸榮臻△,韋忠良

(右江民族醫(yī)學(xué)院附屬醫(yī)院麻醉科,廣西百色 533000)

目的觀察小劑量羅呱卡因復(fù)合舒芬太尼行蛛網(wǎng)膜下腔麻醉用于剖宮產(chǎn)的麻醉效果?方法 將75例美國(guó)麻醉醫(yī)師協(xié)會(huì)(ASA)分級(jí)為Ⅰ～Ⅱ級(jí)的剖宮產(chǎn)患者隨機(jī)分為A?B?C 3組,每組25例?A組:0.75%羅呱卡因15mg(2mL);B組:0.75%羅呱卡因10mg(1.3mL);C組:0.75%羅呱卡因7.5mg+舒芬太尼5μg(0.75%羅呱卡因1.0mL+舒芬太尼0.1mL)?B?C兩組均加10%葡萄糖溶液至2mL?觀察3組給藥后平均動(dòng)脈壓(MAP)和心率變化?麻醉效果?新生兒Apgar評(píng)分?不良反應(yīng)發(fā)生率及麻黃堿用量?結(jié)果麻醉后A?B兩組MAP和心率明顯下降(P0.05),且與C組比較,差異有統(tǒng)計(jì)學(xué)意義(P0.05);麻醉后A?B組間MAP比較,差異有統(tǒng)計(jì)學(xué)意義(P0.05)?麻醉后C組感覺阻滯起效時(shí)間短于A?B組(P0.05);B組感覺阻滯維持時(shí)間短于 A?C組(P0.05),而 A?C組間比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);B組感覺阻滯最高平面高于 A?C組(P0.05),而A?C組間比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);C組運(yùn)動(dòng)神經(jīng)阻滯持續(xù)時(shí)間短于A?B組(P0.05);C組Bromage評(píng)分低于A?B組(P0.05)?C組術(shù)后尿潴留?惡心?嘔吐發(fā)生率,以及麻黃堿用量明顯低于A?B組 (P0.05)?3組患者所產(chǎn)新生兒Apgar評(píng)分比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)?結(jié)論小劑量羅呱卡因復(fù)合舒芬太尼麻醉效果確切?對(duì)患者呼吸?血流動(dòng)力學(xué)的影響輕微?不良反應(yīng)少,是剖宮產(chǎn)手術(shù)較理想的麻醉方法?

舒芬太尼;蛛網(wǎng)膜下腔;麻醉;剖宮產(chǎn)術(shù);羅呱卡因

剖宮產(chǎn)患者是麻醉醫(yī)師面臨的一個(gè)特殊群體?產(chǎn)婦麻醉后出現(xiàn)低血壓,且增大的子宮失去韌帶的支持后會(huì)壓迫下腔靜脈,導(dǎo)致回心血量減少,最終產(chǎn)生嚴(yán)重低血壓,從而使冠狀動(dòng)脈血供不足和子宮血流量降低而使胎兒發(fā)生缺氧?高碳酸血癥及酸中毒,嚴(yán)重時(shí)可導(dǎo)致心搏驟停?因此,在麻醉和手術(shù)過程中維持血流動(dòng)力學(xué)的平穩(wěn)和保障母嬰生命安全是麻醉醫(yī)師一直探討的課題?為觀察小劑量羅呱卡因復(fù)合舒芬太尼行蛛網(wǎng)膜下腔麻醉在剖宮產(chǎn)應(yīng)用中的效果及不良反應(yīng),本院從2010年2月至2011年10月對(duì)75例患者進(jìn)行對(duì)比研究,現(xiàn)報(bào)道如下?

1 資料與方法

1.1 一般資料 選擇行剖宮產(chǎn)的患者75例,年齡20～35歲,體質(zhì)量50～70kg,身高150～168cm,美國(guó)麻醉醫(yī)師協(xié)會(huì)(ASA)分級(jí)Ⅰ～Ⅱ級(jí),無椎管內(nèi)麻醉禁忌證?

1.2 實(shí)驗(yàn)設(shè)計(jì)方法 本研究采用隨機(jī)?對(duì)照?雙盲的分組方法?所有符合標(biāo)準(zhǔn)的患者分為A?B?C 3組?藥物由一名不知道具體分組的麻醉醫(yī)師配制,3組都用2mL空針盛裝,分別標(biāo)為A?B?C?麻醉由一名主治醫(yī)師實(shí)施,觀察和記錄者不知道具體分組?

1.3 麻醉方法 3組患者麻醉前均不用術(shù)前藥,入室常規(guī)監(jiān)測(cè)ECG?BP?SpO2?RR,并建立靜脈通路,均取左側(cè)臥位行L3～4腰硬聯(lián)合穿刺(如果L3～4間隙穿刺失敗則記錄為技術(shù)失敗,剔除出研究組),硬膜外穿刺成功后,再經(jīng)硬膜外穿刺針導(dǎo)入蛛網(wǎng)膜下腔麻醉針,見腦脊液后鞘內(nèi)注射麻醉藥?A組:0.75%羅呱卡因15mg(2mL);B組:0.75%羅呱卡因10mg(1.3mL);C組:0.75%羅呱卡因7.5mg+舒芬太尼5μg(0.75%羅呱卡因1.0mL+舒芬太尼0.1mL)?B?C組均加10%葡萄糖溶液至2mL,注藥時(shí)間約為20s,給藥后立即平臥,用針刺法判斷麻醉效果?

1.4 觀察評(píng)估指標(biāo) (1)血流動(dòng)力學(xué)的變化:入室后連接日本光電BSM-2301C多功能監(jiān)護(hù)儀,在行腰椎穿刺前分別連續(xù)測(cè)量3次平均動(dòng)脈壓(MAP)和心率,求其平均值為基礎(chǔ)值;蛛網(wǎng)膜下腔麻醉給藥后,每2min測(cè)一次 MAP和心率,記錄用藥20min內(nèi)患者M(jìn)AP和心率,求其平均值;發(fā)生低血壓者(收縮壓下降基礎(chǔ)值的25%或低于90mm Hg),靜注麻黃堿5～15 mg;心率低于55次/分,靜注阿托品0.25～0.5mg?(2)運(yùn)動(dòng)神經(jīng)阻滯評(píng)分:按Bromage評(píng)分法判定下肢運(yùn)動(dòng)神經(jīng)阻滯程度?(3)運(yùn)動(dòng)阻滯維持時(shí)間(min):從運(yùn)動(dòng)阻滯起效至雙下肢完全愎復(fù)運(yùn)動(dòng)的時(shí)間?(4)麻醉鎮(zhèn)痛維持時(shí)間(min):是從注射局麻藥完畢至患者感到手術(shù)部位出現(xiàn)疼痛或感覺恢復(fù)正常的時(shí)間?(5)感覺阻滯最高平面:用針刺法測(cè)定麻醉固定后的最高阻滯平面?(6)麻醉起效時(shí)間(min):從蛛網(wǎng)膜下腔麻醉給藥至患者出現(xiàn)下肢發(fā)熱?麻木感的時(shí)間?(7)新生兒Apgar評(píng)分?(8)術(shù)后尿潴留?惡心?嘔吐發(fā)生情況?

1.5 統(tǒng)計(jì)學(xué)處理 計(jì)量數(shù)據(jù)數(shù)據(jù)以±s表示,組間兩兩比較用SNK-q檢驗(yàn),計(jì)數(shù)數(shù)據(jù)采用χ2檢驗(yàn),以P0.05為差異有統(tǒng)計(jì)學(xué)意義?

2 結(jié) 果

2.1 各組患者一般數(shù)據(jù)比較 3組患者年齡?體質(zhì)量?身高?手術(shù)時(shí)間比較差異均無統(tǒng)計(jì)學(xué)意義(P0.05),見表1?

表1 各組患者一般數(shù)據(jù)比較(±s)

表1 各組患者一般數(shù)據(jù)比較(±s)

組別 年齡(歲) 體質(zhì)量(kg) 身高(cm) 手術(shù)時(shí)間(min)A組26.2±5.8 60.2±8.3 161.1±3.2 68.5±8.2 B組 27.3±6.0 62.1±7.2 159.2±3.9 75.2±9.1 C組28.3±4.2 59.2±8.1 158.1±5.5 72.5±7.9

2.2 各組患者麻醉前后MAP?HR的變化 各組患者麻醉前后MAP?HR的變化,見表2?

2.3 各組患者麻醉效果比較 各組患者感覺阻滯起效時(shí)間?感覺阻滯持續(xù)時(shí)間?感覺阻滯最高平面?運(yùn)動(dòng)神經(jīng)阻滯持續(xù)時(shí)間及Bromage評(píng)分結(jié)果見表3?

2.4 各組患者中惡心?嘔吐?尿潴留的發(fā)生率及麻黃堿用量及新生兒Apgar評(píng)分比較 各組患者中惡心?嘔吐?尿潴留的發(fā)生率,麻黃堿用量比較見表4?3組孕婦所產(chǎn)新生兒Apgar評(píng)分比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)?

表2 各組患者麻醉前后MAP?HR的變化(±s,n=25)

表2 各組患者麻醉前后MAP?HR的變化(±s,n=25)

▲:P0.05,與同組麻醉前比較;◆:P0.05,與麻醉后 A?B組間比較;★:P0.05,與麻醉后A組比較?

組別麻醉前MAP(mm Hg) HR(次/分)麻醉后MAP(mm Hg) HR(次/分)A組 93.85±6.03 85.68±8.15 77.86±6.17▲ 76.69±7.15▲B組 92.18±6.05 85.86±9.19 84.15±6.98▲★ 78.81±8.13▲C組 94.03±6.18 86.98±7.97 91.16±6.55◆ 84.86±8.37◆

表3 各組患者麻醉效果比較(±s,n=25)

表3 各組患者麻醉效果比較(±s,n=25)

▲:P0.05,與A?C組比較;★:P0.05,與A 組比較;◆:P0.05,與A?B組比較?

組別 感覺阻滯起效時(shí)間(min) 感覺阻滯持續(xù)時(shí)間(min) 感覺阻滯最高平面(T) 運(yùn)動(dòng)神經(jīng)阻滯持續(xù)時(shí)間(min)Bromage評(píng)分(級(jí))A 組 3.7±1.4 307.6±18.0 4.8±0.4 241.2±21.0 2.4±0.4 B組 4.9±2.1 220.5±17.1▲ 8.2±0.3▲ 173.4±18.2★ 1.6±0.6★C組 1.9±0.5◆ 303.4±19.2 5.2±0.3 118.2±19.4◆ 1.0±0.2◆

表4 各組患者中惡心?嘔吐?尿潴留的發(fā)生情況及麻黃堿劑量比較(n=25)

3 討 論

剖宮產(chǎn)多數(shù)是急診手術(shù),麻醉要求具有誘導(dǎo)期短?麻醉效果確切?肌松良好?無術(shù)后麻醉殘留作用等特點(diǎn)?蛛網(wǎng)膜下腔麻醉能滿足這一要求,血壓下降是蛛網(wǎng)膜下腔麻醉常見的并發(fā)癥之一,嚴(yán)重低血壓可使孕婦冠狀動(dòng)脈血供不足導(dǎo)致心搏驟停,防止低血壓是剖宮產(chǎn)手術(shù)的關(guān)鍵,而且方法很多,包括快速擴(kuò)容?應(yīng)用縮血管收縮藥及體位的調(diào)節(jié)等,但這些方法對(duì)防治蛛網(wǎng)膜下腔麻醉后低血壓是有限的?為保證母嬰安全,國(guó)內(nèi)外許多學(xué)者對(duì)蛛網(wǎng)膜下腔麻醉在剖宮產(chǎn)中的應(yīng)用做了大量的研究,隨著國(guó)內(nèi)外學(xué)者對(duì)局麻藥復(fù)合阿片類藥物應(yīng)用于蛛網(wǎng)膜下腔麻醉的研究不斷深入,發(fā)現(xiàn)丁哌卡因復(fù)合芬太尼行蛛網(wǎng)膜下腔麻醉在剖宮產(chǎn)中的應(yīng)用可降低麻醉后低血壓發(fā)生率,但芬太尼對(duì)呼吸的抑制和心率減慢作用不可忽視,同時(shí)丁哌卡因?qū)χ袠猩窠?jīng)系統(tǒng)和心臟毒性大,在剖宮產(chǎn)的應(yīng)用仍存在一定爭(zhēng)議?因此,剖宮產(chǎn)麻醉方法和藥物的選擇對(duì)剖宮產(chǎn)患者圍術(shù)期的安全尤為重要?

決定蛛網(wǎng)膜下腔麻醉阻滯平面高低因素很多,主要取決于局麻藥劑量,當(dāng)較大劑量的局麻藥用于蛛網(wǎng)膜下腔麻醉時(shí),感覺和運(yùn)動(dòng)神經(jīng)阻滯均完全[1],而且平面較高,很容易產(chǎn)生嚴(yán)重低血壓?另外,有研究表明,局麻藥混合一定劑量舒芬太尼不僅可以減少其用量,而且血流動(dòng)力學(xué)更加穩(wěn)定[2]?聯(lián)合應(yīng)用能協(xié)同增強(qiáng)感覺神經(jīng)的阻滯作用而不增加交感神經(jīng)的阻滯,有助于減少局麻藥用量,同時(shí)減少血管活性藥物的應(yīng)用[3]?本研究發(fā)現(xiàn)隨著羅呱卡因用量的減少,患者出現(xiàn)血流動(dòng)力學(xué)穩(wěn)定,運(yùn)動(dòng)神經(jīng)阻滯減輕,阻滯平面下移等特點(diǎn)?且舒芬太尼并不能強(qiáng)化羅呱卡因的運(yùn)動(dòng)阻滯效應(yīng)?這些作用可能與局麻藥用量大時(shí)容量血管擴(kuò)張,運(yùn)動(dòng)阻滯完善,致肌肉血泵作用減弱,交感神經(jīng)的抑制作用較強(qiáng),副交感神經(jīng)則相對(duì)興奮,從而使心率減慢,心輸出量隨之減少和回心血量降低導(dǎo)致血壓嚴(yán)重下降有關(guān)?

羅呱卡因是一種左旋體長(zhǎng)效酰胺類局麻藥,與丁哌卡因相比其特點(diǎn)是中樞神經(jīng)毒性及心臟毒性小[4]?舒芬太尼為μ阿片受體高選擇性激動(dòng)劑,其高脂溶性對(duì)脊髓等神經(jīng)組織親和力高,蛛網(wǎng)膜下腔注射后可經(jīng)脊髓后角直接作用于阿片受體,又因其易向頭端擴(kuò)散[5],產(chǎn)生鎮(zhèn)靜作用[6],與局麻藥混合使用后,可產(chǎn)生協(xié)同阻滯效用,增強(qiáng)鎮(zhèn)痛作用[7],使產(chǎn)婦牽拉不適反應(yīng)減少,緩解緊張,提高麻醉質(zhì)量?本研究結(jié)果表明羅呱卡因用量的增加可以提升運(yùn)動(dòng)阻滯的程度和時(shí)間,通過加入舒芬太尼可減少羅呱卡因用量,小劑量羅哌卡因復(fù)合舒芬太尼可提供較長(zhǎng)的術(shù)后鎮(zhèn)痛時(shí)間,從而延長(zhǎng)術(shù)后開始應(yīng)用鎮(zhèn)痛藥的時(shí)間?同時(shí)小劑量羅呱卡因復(fù)合舒芬太尼行蛛網(wǎng)膜下腔麻醉感覺阻滯起效時(shí)間快,不良反應(yīng)少,其原理可能與舒芬太尼在蛛網(wǎng)膜下腔易于向頭部擴(kuò)散,并能直接作用于脊髓背角的阿片受體有關(guān)?

舒芬太尼在無痛分娩的大量應(yīng)用已經(jīng)證明其鞘內(nèi)給藥的有效性和安全性[8]?舒芬太尼的半數(shù)致死劑量(ED50)為2.6μg,95%致死劑量(ED95)為8.9μg,故本研究將舒芬太尼用量取其中間值5μg,術(shù)中無一例出現(xiàn)呼吸抑制,可能是舒芬太尼的用量不大,在進(jìn)入蛛網(wǎng)膜下腔后由于其高脂溶性而被脊髓及硬膜外脂肪吸收,所以腦脊液中殘留的少量舒芬太尼不至于對(duì)延髓產(chǎn)生影響[9-12]?

蛛網(wǎng)膜下腔麻醉術(shù)中嚴(yán)重低血壓使心腦供血不足,再加上副交感神經(jīng)興奮性增加,使胃腸逆蠕動(dòng)增強(qiáng),則出現(xiàn)惡心?嘔吐不適癥狀[13-14]?術(shù)后尿潴留原因較多,主要是支配膀胱的副交感神經(jīng)纖維很細(xì),對(duì)局麻藥很敏感,阻滯后恢復(fù)較晚,以及患者不習(xí)慣床上排尿?手術(shù)創(chuàng)口疼痛等都能引起尿潴留?本研究結(jié)果顯示小劑量羅呱卡因復(fù)合舒芬太尼對(duì)血流動(dòng)力學(xué)的影響及運(yùn)動(dòng)神經(jīng)阻滯較輕,可能是惡心?嘔吐發(fā)生率較低的原因;同時(shí)對(duì)骶神經(jīng)阻滯作用相對(duì)較弱,患者膀胱功能也相應(yīng)恢復(fù)較早,可能是其術(shù)后尿潴留發(fā)生率低的重要原因?術(shù)后頭痛是蛛網(wǎng)膜下腔麻醉常見的并發(fā)癥,其主要原因是腦脊液外漏引起,本研究術(shù)后隨訪無一例患者發(fā)生頭痛,這與針套針方法的使用提高了蛛網(wǎng)膜下腔麻醉穿刺的成功率,避免了反復(fù)穿刺有關(guān)?

綜上所述,小劑量羅呱卡因復(fù)合舒芬太尼行蛛網(wǎng)膜下腔麻醉應(yīng)用于剖宮產(chǎn)患者,可以增強(qiáng)麻醉效果,且血流動(dòng)力學(xué)穩(wěn)定?不良反應(yīng)少?對(duì)新生兒無影響,因而是安全可行的,值得臨床推廣使用?

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Small doses of ropivacaine combined with sufentanil spinal anesthesia used for clinical observation of cesarean section*

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ObjectiveTo observe the effects of small doses of ropivacaine combined with sufentanil spinal anesthesia for cesarean section anesthesia.Methods75cases of ASAⅠ-Ⅱclass cesarean delivery were randomly divided into A,B,C,three groups,each group of 25cases.GroupA:0.75%ropivacaine 15mg(0.75%ropivacaine 2mL),group B:0.75%ropivacaine 10mg(0.75%ropivacaine 1.3mL),group C:0.75%ropivacaine 7.5mg+sufentanil 5μg(0.75%ropivacaine 1.0mL+sufentanil 0.1mL).Both B and C groups were added 10%glucose solution to 2mL.After anesthesia,the hemodynamic changes,the degree of motor block,motor block to maintain time,the highest plane of sensory block,analgesic duration,onset time,neonatal Apgar score,adverse reactions and dosage of ephedrine were observed.ResultsAfter anesthesia,the MAP and HR in group A and B were decreased,which were statistically significant compared with theResultsin group C(P0.05);and there was significant difference in MAP between group A and group B(P0.05).After anesthesia,the onset time of sensory block in group C was shorter than in group A and group B(P0.05);the duration of sensory block in group B was shorter than in group A and group C (P0.05),while there was no statistically significant difference between the group A and group C(P0.05);the highest sensory block plane in group B was lower than in group A and group C (P0.05),while there was no statistically significant difference between group A and group C(P0.05).The duration of sensory block of motor nerves in group C was shorter than in group A and group B (P0.05);the bromage score in group C was lower than in group A and group B(P0.05).The rates of postoperative urinary retention,nausea,vomiting and yellow alkali dosage in group C were significantly lower than group A and group B(P0.05),There was no significant difference in neonatal Apgar score between the groups(P0.05).ConclusionCombination of small dose of ropivacaine with sufentanil was an ideal anesthetic for cesarean section,for the exact effects of spinal anesthesia,hemodynamic stability,minimal impact on breathing,as well as fewer adverse reactions.

sufentanil;subarachnoid space;anesthesia;cesarean section;ropivacaine

10.3969/j.issn.1671-8348.2012.18.012

A

1671-8348(2012)18-1821-03

* 基金項(xiàng)目:廣西壯族自治區(qū)衛(wèi)生廳課題(Z 2010089)?△

,E-mail:chengronghua2012@126.com?

2012-02-09

2012-03-27)

?短篇及病例報(bào)道?