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        術(shù)前體位改變對剖宮產(chǎn)腰麻后引起低血壓的預(yù)測分析

        2017-11-15 18:15:29陳燁鄒聰華陳彥青
        中國醫(yī)學(xué)創(chuàng)新 2017年30期
        關(guān)鍵詞:心率變異性低血壓剖宮產(chǎn)

        陳燁 鄒聰華 陳彥青

        【摘要】 目的:探索術(shù)前體位改變引起的心率變異性能否預(yù)測剖宮產(chǎn)腰麻后的低血壓。方法:隨機(jī)選擇50例產(chǎn)婦在腰麻下進(jìn)行擇期剖宮產(chǎn)術(shù),在剖宮產(chǎn)前1 d進(jìn)行了體位變化檢查。按仰臥位、左側(cè)臥位和仰臥位的順序記錄無創(chuàng)血壓(NIBP)、心率(HR)、心電圖(ECG)和LF/HF比。采用5 min記錄1次參數(shù),在每個位置記錄BP 3次,持續(xù)監(jiān)測心電圖。為了分析心率變異性,從監(jiān)護(hù)儀獲得ECG信號,并將其輸入到計(jì)算機(jī)中以分析RR間期。使用MemCalc軟件進(jìn)行心率變異性(HRV)分析,每5秒計(jì)算1次LF、HF和LF/HF(低高頻率比),在第1次仰臥位記錄的LF/HF值作為對照值(基線LF/HF)。從左側(cè)臥位到仰臥位時,LF/HF比增長2倍以上的產(chǎn)婦分到陽性組,2倍以下分到陰性組。手術(shù)當(dāng)天的產(chǎn)婦均進(jìn)行ECG、HR、NIBP和氧飽和度的監(jiān)測,并在仰臥位靜脈滴注晶體液[4~6 mL/(kg·h)]。產(chǎn)婦仰臥時測的HR和BP為基線值。取左側(cè)臥位,L3~4間隙進(jìn)行腰麻,藥物為0.75%羅哌卡因2 mL,注射后產(chǎn)婦轉(zhuǎn)為平臥位。每分鐘測量無創(chuàng)血壓,直到血壓平穩(wěn)。結(jié)果:根據(jù)體位改變檢測結(jié)果,將產(chǎn)婦分為陽性組(23例)和陰性組(26例),71.4%(35/49)產(chǎn)婦發(fā)生低血壓,陽性組占60.0%(21/35),陰性組占40.0%(14/35)。PCT陽性組低血壓發(fā)生率為91.3%(21/23),高于陰性組的53.8%(14/26),差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。在腰麻(SA)剖宮產(chǎn)期間,PCT預(yù)測產(chǎn)婦低血壓的敏感性和特異性分別為60.0%[95%CI(52.4,62.3)]和87.5%[95%CI(63.5,98.2)]。PCT的陽性預(yù)測值(PPV)和陰性預(yù)測值(NPV)分別為91.3%[95%CI(52.4,62.3)]和53.8%[95%CI(37.6,55.7)]。PCT作為產(chǎn)婦低血壓的預(yù)測因子為0.76[95%CI(0.60,0.92)]。結(jié)論:術(shù)前體位改變引起的心率變化可預(yù)測剖宮產(chǎn)腰麻后低血壓。

        【關(guān)鍵詞】 低血壓; 心率變異性; 體位改變試驗(yàn); 剖宮產(chǎn)

        Prediction of Hypotension during Spinal Anesthesia for Elective Cesarean Section by Altered Heart Rate Variability Induced by Postural Change/CHEN Ye,ZOU Cong-hua,CHEN Yan-qing.//Medical Innovation of China,2017,14(30):019-022

        【Abstract】 Objective:To investigate the effect of the postural change test with heart rate variability to predict the risk of hypotension during spinal anesthesia for cesarean section.Method:A total of 50 women scheduled to undergo cesarean section under spinal anesthesia were enrolled,a postural change test was performed the day before cesarean section.Non-invasive BP (NIBP) on the left arm,HR,electrocardiogram (ECG) and LF/HF ratio were recorded in the order of supine position,left lateral position and supine position.Each position was adopted for 5 min to record each parameter,blood pressure was recorded three times in each position,the ECG and HR were continuously monitored.In order to analyze heart rate variability,the ECG signal was obtained from the monitor and input into the computer to analyze the RR interval.Heart rate variability (HRV) analysis was performed using MemCalc software,the first time LF,HF and LF/HF (low to high frequency ratio) were calculated every 5 seconds,and the LF/HF value recorded in the first supine position was used as the control value (baseline LF/HF).From left recumbent position to supine position,LF/HF was more than 2 times allocated to the positive group,less than 2 times allocated to the negative group.On the operating day,all patients were monitored via ECG,HR,NIBP,oxygen saturation,and received intravenous crystalloid [4-6 mL/(kg·h)] in the supine position.We regarded HR and BP measured in the operating room just after lying supine on the operating room bed as baseline values.In all cases,SA was performed at the L3-4 interspace with the patient in the left lateral position.Hyperbaric 0.75% Ropivacaine 2 mL was administered through a spinal needle.Following injection,patients were immediately turned supine from the left lateral position,non-invasive BP was measured every minute until BP stabilized.Result:According to the result of body position change test,the pregnant women were divided into positive group (23 cases) and negative group (26 cases),71.4%(35/49) of maternal hypotension occurred,the positive group accounted for 60.0%(21/35),the negative group accounted for 40.0%(14/35).The incidence of hypotension in PCT positive group was 91.3%(21/23),which was higher than 53.8%(14/26) in negative group,the difference was statistically significant(P<0.01).Sensitivity and specificity of the PCT to predict maternal hypotension during cesarean section under SA were 60.0%[95%CI(52.4,62.3)] and 87.5%[95%CI(63.5,98.2)] respectively.Positive predictive value (PPV) and negative predictive value (NPV) of the PCT was 91.3%[95%CI(52.4,62.3)] and 53.8%[95%CI(37.6,55.7)],respectively.PCT as a predictor of maternal hypotension was 0.76[95%CI (0.60,0.92)].Conclusion:The change of heart rate caused by the change of body position before operation can predict hypotension after cesarean section.endprint

        【Key words】 Hypotension; Heart rate variability; Postural change test; Cesarean section

        First-authors address:The Fujian Provincial Jinshan Hospital,F(xiàn)uzhou 350000,China

        doi:10.3969/j.issn.1674-4985.2017.30.006

        腰麻是剖宮產(chǎn)手術(shù)常見的麻醉方法[1],但腰麻后妊娠子宮壓迫腹部大血管可引起產(chǎn)婦低血壓,導(dǎo)致產(chǎn)婦和胎兒出現(xiàn)一系列問題,如惡心、嘔吐、胎兒窘迫等[2-4]。因此預(yù)防產(chǎn)婦出現(xiàn)低血壓是非常必要的。之前已有多種方法來預(yù)測剖宮產(chǎn)腰麻后產(chǎn)婦低血壓,包括脈搏變異指數(shù)、腦氧飽和度(SCO2)和術(shù)前體位改變引起的心率變化[5-10],但預(yù)防效果均較差。而本次研究是利用心率變異性(heart rate variability,HRV)來預(yù)測剖宮產(chǎn)腰麻后低血壓的發(fā)生。HRV反映了自主神經(jīng)功能變化,由低頻(LF)(0.04~0.15 Hz)和高頻(HF)(0.2~0.4 Hz)組成。LF代表交感神經(jīng)和副交感神經(jīng)系統(tǒng),而HF代表副交感神經(jīng)系統(tǒng),因此LF/HF比的大小可代表交感神經(jīng)系統(tǒng)的功能性[11-15]。本研究旨在探討體位改變引起的LF/HF變化能否預(yù)測剖宮產(chǎn)腰麻術(shù)后低血壓的發(fā)生,現(xiàn)報道如下。

        1 資料與方法

        1.1 一般資料 隨機(jī)選擇2016年10月-2017年2月接受擇期剖宮產(chǎn)的產(chǎn)婦50例,ASA Ⅰ級,身高160~165 cm,年齡24~30歲。排除標(biāo)準(zhǔn):排除妊娠期高血壓病、糖尿病、胎盤前置及心血管疾病。

        1.2 方法 在剖宮產(chǎn)前1 d下午進(jìn)行體位變化試驗(yàn)(postural change test,PCT)。以仰臥位、左側(cè)臥位及仰臥位順序進(jìn)行持續(xù)無創(chuàng)血壓(NIBP)、心率(HR)、心電圖(ECG)和LF/HF比的記錄[7]。每個體位維持5 min,并記錄各個參數(shù),每個體位血壓記錄3次。為了分析HRV,從心電監(jiān)測儀上拷貝ECG信號,并輸入電腦使用MemCalc軟件進(jìn)行RR間期和HRV線性分析[16]。MemCalc軟件可從RR間期每隔5 s計(jì)算出LF、HF和LF/HF。在第一次仰臥位記錄的LF/HF值視為對照值(基線LF/HF),從左側(cè)臥位變?yōu)檠雠P位時,LF/HF顯示出2倍以上增加的產(chǎn)婦視為陽性組。為了確保產(chǎn)婦和胎兒的安全,當(dāng)產(chǎn)婦因低血壓引起惡心,眩暈或其他癥狀難以仰臥時,試驗(yàn)終止。

        手術(shù)的產(chǎn)婦均進(jìn)行ECG、HR、NIBP和氧飽和度的監(jiān)測,并在仰臥位靜脈滴注晶體液

        [4~6 mL/(kg·h)]。產(chǎn)婦仰臥時測的HR和BP為基線值。取左側(cè)臥位,L3~4間隙進(jìn)行腰麻,藥物為0.75%羅哌卡因2 mL。注射后產(chǎn)婦由仰臥位轉(zhuǎn)為平臥位。每分鐘測量無創(chuàng)血壓,直到血壓平穩(wěn)。為預(yù)防產(chǎn)婦低血壓,晶體加快輸注[16~20 mL(kg·h),子宮向左推移]。低血壓定義為收縮壓低于基線值得20%。必要時予靜脈注射麻黃堿維持血壓穩(wěn)定。

        1.3 統(tǒng)計(jì)學(xué)處理 統(tǒng)計(jì)軟件采用SPSS 22.0進(jìn)行分析。所有參數(shù)數(shù)據(jù)表示為平均值±標(biāo)準(zhǔn)偏差(x±s)。使用Mann-Whitney U檢驗(yàn)分析產(chǎn)婦年齡、胎齡、基線LF/HF、布比卡因劑量、感覺阻滯水平、麻黃堿給藥頻率和Apgar評分。使用Fisher精確檢驗(yàn)來比較PCT陽性和PCT陰性組之間的低血壓和麻黃堿的使用頻率。另外,使用SPSS 22.0軟件測量受試者工作特征曲線(ROC)下的面積來評估研究前確定的截止點(diǎn)的準(zhǔn)確性,曲線下面在0.5~0.7時診斷準(zhǔn)確性較低,在0.7~0.9時有中度準(zhǔn)確性,在0.9以上有高準(zhǔn)確性。

        2 結(jié)果

        50例產(chǎn)婦均能完成PCT,其中1例腰麻失敗改為全身麻醉。23例產(chǎn)婦被分配到PCT陽性組,另外26例產(chǎn)婦轉(zhuǎn)入PCT陰性組。兩組身高、體重、胎齡、基線LF/HF,基線BP和HR、羅哌卡因劑量、感覺阻滯平面、手術(shù)和麻醉時間、晶體液量、失血量及尿量比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),見表1。71.4%(35/49)產(chǎn)婦發(fā)生低血壓,陽性組占60.0%(21/35),陰性組占40.0%(14/35)。PCT陽性組低血壓發(fā)生率為91.3%(21/23),高于陰性組的53.8%(14/26),差異有統(tǒng)計(jì)學(xué)意義(P<0.01);PCT陽性組麻黃堿給藥總劑量大于PCT陰性組,差異有統(tǒng)計(jì)學(xué)意義(P<0.01),見表2。PCT陽性組中最低的SBP為(81±15)mm Hg,與PCT陰性組的(90±13)mm Hg相比,差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。在腰麻(SA)剖宮產(chǎn)期間,PCT預(yù)測產(chǎn)婦低血壓的敏感性和特異性分別為60.0%[95%CI(52.4,62.3)]和87.5%[95%CI(63.5,98.2)]。PCT的陽性預(yù)測值(PPV)和陰性預(yù)測值(NPV)分別為91.3%[95%CI(52.4,62.3)]和53.8%[95%CI(37.6,55.7)]。ROC曲線下面積值:0.760[95%CI(0.599,0.921)],最佳診斷點(diǎn)為204%,見圖1。

        3 討論

        腰麻因起效快,阻滯完善,肌松效果好,目前被廣泛應(yīng)用于剖宮產(chǎn)術(shù)。剖宮產(chǎn)腰麻后易出現(xiàn)低血壓,其主要原因是巨大的子宮壓迫腹部血管,而使下肢和腹部的回心血流受阻,從而產(chǎn)生產(chǎn)婦和胎兒一系列并發(fā)癥,嚴(yán)重可威脅生命。剖宮產(chǎn)腰麻后低血壓的預(yù)測方法有許多種:如當(dāng)產(chǎn)婦由左側(cè)臥位變?yōu)槠脚P位時心率增加10次,煩躁,麻醉前高脈搏變異指數(shù),腰麻后SCO2減少,麻醉前心率<71次/min或>89次/min[4-7,10]。但以上各種方案特異性差,而PCT的使用,使患者能更早應(yīng)用血管活性藥[17-19],從而保持循環(huán)穩(wěn)定。心理狀態(tài)也會影響心率變異性,例如焦慮會增加LF,減低HF[20]。雖然心率變異性的測量是非侵入性的,但也會受到患者心理狀況和環(huán)境的影響。產(chǎn)婦進(jìn)行測量時應(yīng)在心理平靜狀態(tài)下完成[15],因此為了創(chuàng)造良好環(huán)境和穩(wěn)定患者情緒,筆者在門診試驗(yàn)時播放古典音樂。endprint

        腰麻期間LF/HF的減低反映了交感神經(jīng)活動減少和副交感神經(jīng)活動相對增加[21-22]。本研究通過體位改變使LF/HF減少并出現(xiàn)低血壓,提示副交感神經(jīng)占優(yōu)勢可能是導(dǎo)致低血壓的重要因素。ROC曲線多用于臨床診斷試驗(yàn)的評估,其曲線下面積值越大,診斷價值越高。本研究得出的最佳診斷點(diǎn)204%與試驗(yàn)前預(yù)設(shè)的入選PCT的臨界值(2倍)非常接近,因此該值可作為預(yù)測產(chǎn)婦腰麻后低血壓的臨界值。PCT的特異性為87.5%,敏感性為60.0%,PCT的PPV和NPV分別為91.3%和53.8%。PCT的特異性和PPV高,但敏感性和NPV較低。

        本研究是PCT和HRV的第一次結(jié)合試驗(yàn),表明術(shù)前體位改變試驗(yàn)導(dǎo)致的LF/HF值增加≥2倍時,對產(chǎn)婦腰麻后低血壓的預(yù)測具有高特異性和低敏感性。因?yàn)樾g(shù)前體位改變和心率變異都是非侵入性操作,所以具有心率變異分析的體位改變試驗(yàn)更適用預(yù)測低血壓的發(fā)生。由于本研究樣本少,PCT的陰性預(yù)測值較低,這可能使PCT試驗(yàn)的準(zhǔn)確性有限。因此,如果要預(yù)測具有較高陰性預(yù)測值的產(chǎn)婦腰麻后低血壓,需要進(jìn)行其他研究。

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        [20]左昕,李敏,彭李,等.心理彈性訓(xùn)練對水面艦艇軍人正/負(fù)性情緒和心率變異性的影響[J].第三軍醫(yī)大學(xué)學(xué)報,2011,7(22):134-138.

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        (收稿日期:2017-06-07) (本文編輯:張爽)endprint

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