[1]贺端端 张华① 张江超 史成梅 李民 郭向阳**.不同麻醉方案椎管内麻醉用于剖宫产手术的比较研究[J].中国微创外科杂志,2020,01(1):4-9.
　He Duanduan*,Zhang Hua,*Zhang Jiangchao,et al.A Comparative Study on Intrathecal Anesthesia With Different Anesthesia Schemes for Cesarean Section[J].Chinese Journal of Minimally Invasive Surgery,2020,01(1):4-9.
点击复制

不同麻醉方案椎管内麻醉用于剖宫产手术的比较研究()
分享到：

《中国微创外科杂志》[ISSN:1009-6604/CN:11-4526/R]

卷:
01
期数:
2020年1期
页码:
4-9
栏目:
临床研究
出版日期:
2020-03-25

文章信息/Info

Title:
A Comparative Study on Intrathecal Anesthesia With Different Anesthesia Schemes for Cesarean Section
作者:
贺端端 张华① 张江超 史成梅 李民 郭向阳**
（北京大学第三医院麻醉科，北京100191）
Author(s):
He Duanduan*;  Zhang Hua;  *Zhang Jiangchao;  et al.
*Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
关键词:
剖宫产手术; 椎管内麻醉; 目标导向平面控制; 低血压
Keywords:
Cesarean section; Intrathecal anesthesia; Targetoriented control of level; Hypotension
文献标志码:
A
摘要:
目的探讨适合目标导向式控制腰麻平面用于剖宫产手术的方法及局麻药选择。方法回顾分析我院2016年10月～2018年10月148例腰麻-硬膜外联合阻滞剖宫产，比较不同麻醉方案腰麻后的麻醉效果及低血压的发生情况。34例采用0.5%罗哌卡因（0.5% R组）L2～3穿刺间隙；38例采用0.5%布比卡因（0.5% B组）L2～3穿刺间隙；38例采用0.4%布比卡因（0.4% B组）L2～3穿刺间隙； 38例采用0.67%罗哌卡因（0.67% R组）L3～4穿刺间隙。腰麻剂量按身高给药，160～170 cm患者上述4组给药剂量分别为12、10、10、16 mg，低于160 cm或高于170 cm患者在此基础上分别减少2 mg或增加2 mg对应局麻药。通过2种体位调节控制阻滞平面至目标，减少低血压风险及持续时间。观察切皮时刻及胎儿娩出时刻阻滞平面，术中牵拉反应情况，腰麻操作完毕至左倾位和左倾位改为平卧位2个时点低血压的发生情况。结果切皮时刻腰麻平面中位数05% B组和0.4% B组为T7，0.5% R组和0.67% R组为T8。胎儿娩出时刻，0.5% R组达到目标平面T6比例最低为353%，目标平面超过T6比例0.5% B组31.6%最高，其次是0.4% B组（23.7%），0.67% R组（21.1%），0.5% R组最低（2.9%）；0.5% R组所达平面中位数为T7，其余3组中位数为T6。0.5% R组和0.4% B组与0.67% R组和0.5% B组相比，有更高比例患者需要硬膜外补充给药达到要求平面（分别为61.8%、23.7%、10.5%、10.5%）（χ2=32.424，P=0000），以及静脉辅助用药减轻牵拉反应（分别为44.1%、28.9%、13.2%、15.8%， χ2=11.505，P=0.009）。各组患者平卧位后低血压发生率明显高于左倾位期间：0.5% R组（32.4% vs. 0.0%，Z=-3.002，P=0.003），0.5% B组（57.9% vs. 316%，Z=-2.466，P=0.014）, 0.4% B组（55.3% vs. 31.6%，Z=-2.601，P=0.009），0.67% R组（42.1% vs. 10.5%，Z=-2.526，P=0.012）。0.5% B组和0.4% B组中重度低血压发生率在左倾位和平卧位时均明显高于0.67% R组和05% R组（左倾位时中重度低血压发生率分别为18.4%、7.9%、5.3%、0.0%， χ2=17.216，P=0.001；平卧位时中重度低血压发生率依次为44.7%、34.2%、21.1%、14.7%， χ2=8.459，P=0.037）。结论剖宫产手术选择L3～4穿刺间隙，0.67%罗哌卡因腰麻，按身高给药，适合目标导向性控制阻滞平面，不易出现高平面阻滞，且硬膜外追加少，牵拉反应少，低血压发生率低，是可供选择的腰麻给药方式。
Abstract:
ObjectiveTo explore a more suitable method for targetoriented control of spinal anesthesia level for cesarean section and the selection of local anesthetics.MethodsA retrospective analysis was made on 148 cases of caesarean section under combined spinalepidural anesthesia in our hospital from October 2016 to October 2018. The anesthesia effect and incidence of hypotension after spinal anesthesia with different intrathecal anesthesia schemes were compared. For scheme 1, 34 cases were treated with 0.5% ropivacaine (0.5% R group) at L2-3 puncture interval; for scheme 2, 38 cases with 0.5% bupivacaine (0.5% B group) at L2-3 puncture interval; for scheme 3, 38 cases with 0.4% bupivacaine (0.4% B group) at L2-3 puncture interval; for scheme 4, 38 cases with 0.67% ropivacaine (0.67% R group) at L3-4 puncture interval. Spinal anesthesia dosage was given by height, and the 4 groups were treated with 12 mg, 10 mg, 10 mg, and 16 mg, respectively for body height in 160-170 cm. On this basis, the local anesthetics were reduced or increased by 2 mg for less than 160 cm or greater than 170 cm respectively. Two postural adjustments were designed to control the level of anesthesia to the target and reduce the risk and duration of hypotension. The anesthesia level at the time of skin incision and fetal delivered and the intraoperative traction reaction were examined. The occurrence of hypotension was observed at the time of spinal anesthesia operation to leftleaning position and leftleaning position to supine position.ResultsAt the time of skin incision, the median blockade plane was T7 in the B groups and T8 in the R groups. At the time of fetus delivered, the lowest proportion of reaching the target plane T6 was in the 0.5% R group (35.3%), and the plane in B groups was easily above T6 (31.6% in the 0.5% B group), followed by 0.4% B group (23.7%), 0.67% R group (21.1%), and 0.5% R group (2.9%). The median plane in the 0.5% R group was T7 and in the other three groups was T6. The 0.5% R group and 0.4% B group had a higher proportion of patients who needed epidural supplementation as compared with the 0.67% R group and 0.5% B group (61.8%, 237%, 10.5% and 10.5%, respectively, χ2=32.424,P=0.000), which were similar to the intravenous supplementation for reducing traction reaction (44.1%, 28.9%, 13.2%, 15.8%, respectively, χ2=11.505,P=0.009). The incidences of hypotension in supine position were significantly higher than those in leftleaning position in each group (0.5% R group: 32.4% vs. 0.0%, Z=-3.002,P=0.003; 0.5% B group: 57.9% vs. 31.6%, Z=-2.466,P=0.014; 0.4% B group: 55.3% vs. 31.6%, Z=-2.601,P=0.009; 0.67% R group: 42.1% vs. 10.5%, Z=-2.526,P=0.012, respectively). The incidences of moderate and severe hypotension in the 0.5% B group and 0.4% B group were higher than those in the 0.67% R group and 0.5%R group in all the leftleaning and supine position. In the leftleaning position, the incidence was 18.4% in the 0.5% B group, 7.9% in the 0.4% B group, 5.3% in the 0.67% R group, and 0.0% in the 0.5% R group, respectively (χ2=17.216,P=0.001), while in the supine position, the incidence was 44.7%, 34.2%, 21.1% and 14.7% respectively (χ2=8.459,P=0.037).ConclusionsIntrathecal injection 0.67% ropivacaine by height at L3-4 puncture space, which is administered according to height, is suitable for targetoriented control of anesthesia level for caesarean section. It is not easy to appear high plane block, and there is less epidural addition, less traction reaction, and low incidence of hypotension. It is an alternative way of lumbar anesthesia administration.

参考文献/References:

[1]Lee JE, George RB, Habib AS. Spinalinduced hypotension: Incidence, mechanisms, prophylaxis, and management: Summarizing 20 years of research. Best Pract Res Clin Anaesthesiol,2017,31(1):57-68.
[2]Habib AS. A review of the impact of phenylephrine administration on maternal hemodynamics and maternal and neonatal outcomes in women undergoing cesarean delivery under spinalanesthesia. Anesth Analg,2012,114(2):377-390.
[3]Lee MH, Kim EM, Bae JH, et al. Head elevation in spinalepidural anesthesia provides improved hemodynamics and appropriate sensory block height at caesarean section. Yonsei Med J,2015,56(4):1122-1127.
[4]Hasanin A, Soryal R, Kaddah T, et al. Hemodynamic effects of lateral tilt before and after spinal anesthesia during cesarean delivery: an observational study. BMC Anesthesiol,2018,18(1):8.
[5]Xu F, Liu Y, Wei Y, et al. Differences in lumbar dural sac dimension in supine and lateral positions in late pregnancy: a magnetic resonance imaging study. Int J Obstet Anesth,2016,26:19-23.
[6]Danelli G, Zangrillo A, Nucera D, et.al. The minimum effective dose of 0.5% hyperbaric spinal bupivacaine for cesarean section. Minerva Anestesiol,2001,67(7-8):573-577.
[7]Geng ZY, Wang DX, Wu XM. Minimum effective local anesthetic dose of intrathecal hyperbaric ropivacaine and bupivacaine for cesarean section. Chin Med J (Engl),2011,124(4):509-513.
[8]Chen XZ, Chen H, Lou AF, et al. Doseresponse study of spinal hyperbaric ropivacaine for cesarean section. J Zhejiang Univ Sci B,2006,7(12):992-997.
[9]Kumar SS, Talwar V, Gupta P, et al. Comparison of the efficacy of intrathecal isobaric ropivacaine and bupivacaine in day care knee arthroscopy: a randomized controlled trial. Anesth Essays Res,2018,12(4):859-864.
[10]Solakovic N. Comparison of hemodynamic effects of hyperbaric and isobaric bupivacaine in spinal anesthesia. Med Arh,2010,64(1):11-14.
[11]D’Ambrosio A, Spadaro S, Mirabella L, et al. The anaesthetic and recovery profile of two concentrations (0.25% and 0.50%) of intrathecal isobaric levobupivacaine for combined spinalepidural (CSE) anaesthesia in patients undergoing modified Stark method caesarean delivery: a double blinded randomized trial. Eur Rev Med Pharmacol Sci,2013,17(23):3229-3236.
[12]Van de Velde M. Lowdose spinal anesthesia for cesarean section to prevent spinalinduced hypotension. Curr Opin Anaesthesiol,2019,32(3):268-270.

备注/Memo

备注/Memo:
基金项目：国家自然科学基金面上项目（81873726）**Email：puthmzk@hsc.pku.edu.cn ①临床流行病学研究中心
更新日期/Last Update: 2020-04-16