去甲肾上腺素预防腰硬联合麻醉下剖宫产低血压对母婴的影响
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摘要
目的研究去甲肾上腺素预防腰硬联合麻醉下剖宫产低血压对母婴的影响。方法采用前瞻性研究方法,选择腰硬联合麻醉下择期行剖宫产的患者60例,按区组分A、B、C三组,每组20例。在麻醉开始前20 min分别按照以下速度恒速泵入药品,A组去甲肾上腺素0.05μg/kg·min,B组去甲肾上腺素0.1μg/kg·min,C组生理盐水0.1μg/kg·min,均持续20分钟停止。三组患者均在L_(3-4)间隙注入0.5%罗哌卡因3 mL行腰麻。观察记录三组患者以下时间点的平均动脉压(MAP)及心率(HR)变化,麻醉前(T_1)、腰麻给药(T_2)、给药后5 min(T_3)、给药后10 min(T_4)、给药后20 min(T_5)和术毕(T_6)术后8 h(T_7)和术后24 h(T_8),观察三组新生儿Apgar评分、血气分析、产妇不良反应发生情况。结果三组患者T_1时MAP及HR差异无统计学意义,A、B两组患者在各时间点MAP及HR差异无统计学意义(P>0.05)。与T_1时比较,C组患者T_3、T_4、T_5时MAP明显降低,T_4时HR明显降低,差异有统计学意义(P<0.05)。T_3、T_4、T_5时C组患者MAP明显低于A组和B组,差异有统计学意义(P<0.05)。三组胎儿脐血PaO_2、PaCO_2、PH水平对比均不明显,差异均无统计学意义(P>0.05)。A、B组患者恶心、呕吐、头痛发生率均显著低于C组,差异均有统计学意义(P<0.05)。三组新生儿1 min、5 min的Apgar评分比较不明显,差异均无统计学意义(P>0.05)。结论麻醉前去甲肾上腺素0.05μg/kg·min可有效预防腰硬联合麻醉下剖宫产低血压,且对母婴的影响较小,安全性较佳。
Objective To observe the effects of norepinephrine on preventing hypotension during cesarean section under combined spinal-epidural anesthesia(CSEA)for mothers and infants.Methods This was a prospective study.Sixty patients undergoing cesarean section under CSEA were block divided into three groups,Group A,Group B and Group C,20 cases in each group.Twenty minutes before initiation of combined spinal and epidural anaesthesia,patients were randomized to receive norepinephrine0.05μg·kg~(-1)·min~(-1)in group A,norepinephrine 0.1μg·kg~(-1)·min~(-1)in group B,and saline 0.1μg·kg~(-1)·min~(-1)in group C,respectively.All the groups of patients were injected with 0.5%ropivacaine 3 mL at the L_(3-4)space for spinal anesthesia.Mean arterial pressure(MAP)and heart rate(HR)in the three groups of patients were observed and recorded at the following eight time points:before anesthesia(T_1),spinal injection of the anesthetic(T_2),5 min after spinal anesthesia(T_3),10 min after spinal anesthesia(T_4),20 min after spinal anesthesia(T_5),postoperation(T_6),postoperative 8 h(T_7)and postoperative24 h(T_8).The neonatal Apgar score,blood gas analysis,maternal adverse reactions in the three groups were observed.Results There was no statistical difference in MAP and HR among the three groups at T_1,and no statistical difference in MAP and HR between group A and group B at each time point(P>0.05).Compared with T_1,MAP in group C at T_3,T_4and T_5decreased significantly,HR in group C at T4 decreased significantly(P<0.05).At T_3,T_4and T_5,MAP in group C was significantly decreased than that in group A and group B(P<0.05).The levels of PaO_2,PaCO_2 and PH in umbilical cord blood of the three groups were not statistically different(P>0.05).The incidences of nausea,vomiting and headache in group A and group B were significantly lower than those in group C(P<0.05).The Apgar scores at 1 min and 5 min after born in the three groups were not significantly different(P>0.05).Conclusion The outcomes showed preanesthesia 0.05 μg/kg·min norepinephrine was effective in preventing hypotension in cesarean section under combined spinal epidural anesthesia,and has little impact on mothers and infants,thus was safe.
Objective To observe the effects of norepinephrine on preventing hypotension during cesarean section under combined spinal-epidural anesthesia(CSEA)for mothers and infants.Methods This was a prospective study.Sixty patients undergoing cesarean section under CSEA were block divided into three groups,Group A,Group B and Group C,20 cases in each group.Twenty minutes before initiation of combined spinal and epidural anaesthesia,patients were randomized to receive norepinephrine0.05μg·kg~(-1)·min~(-1)in group A,norepinephrine 0.1μg·kg~(-1)·min~(-1)in group B,and saline 0.1μg·kg~(-1)·min~(-1)in group C,respectively.All the groups of patients were injected with 0.5%ropivacaine 3 mL at the L_(3-4)space for spinal anesthesia.Mean arterial pressure(MAP)and heart rate(HR)in the three groups of patients were observed and recorded at the following eight time points:before anesthesia(T_1),spinal injection of the anesthetic(T_2),5 min after spinal anesthesia(T_3),10 min after spinal anesthesia(T_4),20 min after spinal anesthesia(T_5),postoperation(T_6),postoperative 8 h(T_7)and postoperative24 h(T_8).The neonatal Apgar score,blood gas analysis,maternal adverse reactions in the three groups were observed.Results There was no statistical difference in MAP and HR among the three groups at T_1,and no statistical difference in MAP and HR between group A and group B at each time point(P>0.05).Compared with T_1,MAP in group C at T_3,T_4and T_5decreased significantly,HR in group C at T4 decreased significantly(P<0.05).At T_3,T_4and T_5,MAP in group C was significantly decreased than that in group A and group B(P<0.05).The levels of PaO_2,PaCO_2 and PH in umbilical cord blood of the three groups were not statistically different(P>0.05).The incidences of nausea,vomiting and headache in group A and group B were significantly lower than those in group C(P<0.05).The Apgar scores at 1 min and 5 min after born in the three groups were not significantly different(P>0.05).Conclusion The outcomes showed preanesthesia 0.05 μg/kg·min norepinephrine was effective in preventing hypotension in cesarean section under combined spinal epidural anesthesia,and has little impact on mothers and infants,thus was safe.
引文
[1]de Souza VP,do Amaral JL,Tardelli MA,et al.Effects of prophylactic continuous infusion of phenylephrine on reducing the mass of local anesthetic in patients undergoing spinal anesthesia for cesarean section[J].Rev Bras Anestesiol,2011,61(4):409-424.
[2]Loubert C.Fluid and vasopressor management for cesarean delivery under spinal anesthesia:continuing professional development[J].Can J Anaesth,2012,59(6):604-619.
[3]蒋润年,詹如富,蔡三英,等.FloTrac/VigileoTM监测剖宫产预注血管活性药对产妇腰硬联合给药后血流动力学及新生儿的影响[J].临床医学工程,2016,23(9):1181-1183.
[4]谢自明,马帆.去氧肾上腺素和麻黄碱预防择期剖宫产产妇术中低血压和对胎儿代谢的影响[J].宁夏医学杂志,2016,38(1):67-69.
[5]Lirk P,HallerI,Wong CA,et al.Management of spinal anaesthesia induced hypotension for caesarean delivery:a European survery[J].Eur J Anaesthesiol,2012,29(9):452-453.
[6]Vallejo MC,Attaallah AF,Elzamzamy OM,et al.An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine?infusion in prevention of spinal hypotension during cesarean delivery[J].Int JObstet Anesth,2017,29:18-25.
[7]Ayorinde BT,Buczkowski P,Brown J,et al.Evaluation of preemptive intramuscular phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension during Caesarean section[J].Br J Anaesth,2001,86(3):372-376.
[8]王建波,张庆,郑红,等.麻黄碱和去氧肾上腺素用于防治脊椎-硬膜外联合麻醉下剖宫产术患者低血压时对脐动脉血流和胎儿的影响[J].中华麻醉学杂志,2012,32(3):377-378.
[9]Gunusen I,Karaman S,Ertugrul V,et al.Effects of fluid preload(crystalloid or colloid)compared with crystalloid co-load plus ephedrine infusion on hypotension and neonatal outcome during spinal anaesthesia for caesarean delivery[J].Anaesth Intensive Care,2010,38(4):647-653.
[10]Ansari T,Hashem MM,Hassan AA,et al.Comparison between two phenylephrine infusion rates with moderate co-loading for the prevention of spinal anaeshtesia-induced hypotension during elective caesarean section[J].Middle East J Anaesthesiol,2011,21(3):361-366.
[11]Loke GP,Chan EH,Sia AT.The effect of 10 degrees head-up tilt in the right lateral position on the systemic blood pressure after subarachnoid block for caesarean section[J].Anaesthesia,2002,57(2):169-172.
[12]中华医学会麻醉学分会.中国麻醉学指南与专家共识[M].2017版.北京:人民卫生出版社,2017:241-250.
[13]Ngan Kee WD.Prevention of maternal hypotension after regional anaesthesia for caesarean section[J].Curr Opin Anaesthesiol,2010,23(3):304-309.
[14]Onwochei DN,Ngan Kee WD,Fung L,et al.Norepinephrine intermittent intravenous boluses to prevent hypotension during spinal anesthesia for cesarean delivery:A sequential allocation dose-finding study[J].Anesth Analg,2017,125(1):212-218.
[15]Ngan Kee WD,Lee SW,Ng FF,et al.Randomized Doubleblinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery[J].Anesthesiology,2015,122:736-745.
[16]Ngan Kee WD.A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery[J].Anesthesiology,2017,127(6):934-941.
[17]曹云.剖宫产手术行腰硬联合麻醉对术中低血压的预防及处理[J].昆明医科大学学报,2016,37(3):85-87.
[18]唐培佳.去氧肾上腺素预防剖宫产脊麻后低血压的研究进展[J].微创医学,2013,8(2):198-200.
[19]Chen D,Qi X,Huang X,et al.Efficacy and safety of different norepinephrine regimens for prevention of spinal hypotension in cesarean section:a randomized trial[J].Biomed Res Int,2018,2018:2708175.
[20]Siddik-Sayyid SM,Taha SK,Kanazi GE,Aouad MT.A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery[J].AnesthAnalg,2014,118(3):611-618.
[21]Sharkey AM,Siddiqui N,Downey K,et al.Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries:randomized controlled trial[J].Anesth Analg.2018 Aug 14.doi:10.1213/ANE.0000000000003704.[Epub ahead of print]2018-08-29
[2]Loubert C.Fluid and vasopressor management for cesarean delivery under spinal anesthesia:continuing professional development[J].Can J Anaesth,2012,59(6):604-619.
[3]蒋润年,詹如富,蔡三英,等.FloTrac/VigileoTM监测剖宫产预注血管活性药对产妇腰硬联合给药后血流动力学及新生儿的影响[J].临床医学工程,2016,23(9):1181-1183.
[4]谢自明,马帆.去氧肾上腺素和麻黄碱预防择期剖宫产产妇术中低血压和对胎儿代谢的影响[J].宁夏医学杂志,2016,38(1):67-69.
[5]Lirk P,HallerI,Wong CA,et al.Management of spinal anaesthesia induced hypotension for caesarean delivery:a European survery[J].Eur J Anaesthesiol,2012,29(9):452-453.
[6]Vallejo MC,Attaallah AF,Elzamzamy OM,et al.An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine?infusion in prevention of spinal hypotension during cesarean delivery[J].Int JObstet Anesth,2017,29:18-25.
[7]Ayorinde BT,Buczkowski P,Brown J,et al.Evaluation of preemptive intramuscular phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension during Caesarean section[J].Br J Anaesth,2001,86(3):372-376.
[8]王建波,张庆,郑红,等.麻黄碱和去氧肾上腺素用于防治脊椎-硬膜外联合麻醉下剖宫产术患者低血压时对脐动脉血流和胎儿的影响[J].中华麻醉学杂志,2012,32(3):377-378.
[9]Gunusen I,Karaman S,Ertugrul V,et al.Effects of fluid preload(crystalloid or colloid)compared with crystalloid co-load plus ephedrine infusion on hypotension and neonatal outcome during spinal anaesthesia for caesarean delivery[J].Anaesth Intensive Care,2010,38(4):647-653.
[10]Ansari T,Hashem MM,Hassan AA,et al.Comparison between two phenylephrine infusion rates with moderate co-loading for the prevention of spinal anaeshtesia-induced hypotension during elective caesarean section[J].Middle East J Anaesthesiol,2011,21(3):361-366.
[11]Loke GP,Chan EH,Sia AT.The effect of 10 degrees head-up tilt in the right lateral position on the systemic blood pressure after subarachnoid block for caesarean section[J].Anaesthesia,2002,57(2):169-172.
[12]中华医学会麻醉学分会.中国麻醉学指南与专家共识[M].2017版.北京:人民卫生出版社,2017:241-250.
[13]Ngan Kee WD.Prevention of maternal hypotension after regional anaesthesia for caesarean section[J].Curr Opin Anaesthesiol,2010,23(3):304-309.
[14]Onwochei DN,Ngan Kee WD,Fung L,et al.Norepinephrine intermittent intravenous boluses to prevent hypotension during spinal anesthesia for cesarean delivery:A sequential allocation dose-finding study[J].Anesth Analg,2017,125(1):212-218.
[15]Ngan Kee WD,Lee SW,Ng FF,et al.Randomized Doubleblinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery[J].Anesthesiology,2015,122:736-745.
[16]Ngan Kee WD.A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery[J].Anesthesiology,2017,127(6):934-941.
[17]曹云.剖宫产手术行腰硬联合麻醉对术中低血压的预防及处理[J].昆明医科大学学报,2016,37(3):85-87.
[18]唐培佳.去氧肾上腺素预防剖宫产脊麻后低血压的研究进展[J].微创医学,2013,8(2):198-200.
[19]Chen D,Qi X,Huang X,et al.Efficacy and safety of different norepinephrine regimens for prevention of spinal hypotension in cesarean section:a randomized trial[J].Biomed Res Int,2018,2018:2708175.
[20]Siddik-Sayyid SM,Taha SK,Kanazi GE,Aouad MT.A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery[J].AnesthAnalg,2014,118(3):611-618.
[21]Sharkey AM,Siddiqui N,Downey K,et al.Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries:randomized controlled trial[J].Anesth Analg.2018 Aug 14.doi:10.1213/ANE.0000000000003704.[Epub ahead of print]2018-08-29