不同剂量布比卡因腰硬联合麻醉对剖宫产患者循环的影响

Dose-dependent effects of bupivacaine on maternal hemodynamics in combined with spinal-epidural anesthesia for cesarean delivery

目的探讨不同剂量的布比卡因腰硬联合麻醉对剖宫产孕妇循环的影响。方法90例择期行剖宫产术的孕产妇,按数字表法随机分为3组,行腰麻-硬膜外联合麻醉(CSEA),分别在蛛网膜下腔注入0.5%布比卡因(0.75%布比卡因2 mL+0.9%生理盐水1 mL)1.3 mL(A组)、<160 cm为1.2 mL,160～165 cm为1.3 mL,165～170 cm为1.4 mL,>170为1.5 mL(B组)和1.0 mL+硬膜外2%利多卡因3 mL(C组)。记录各组麻醉至手术开始的时间和手术时间;观察各组麻醉阻滞效果、麻黄碱用量;记录各组产妇在麻醉前、麻醉后仰卧、麻醉后5 min、麻醉后10 min、娩婴、各时间点心率、血压的变化情况;记录产妇恶心、呕吐、低血压等情况。结果三组间的手术时间及麻醉至手术开始的时间差异无统计学意义(P>0.05);麻醉后5 min收缩压C组(112.9±1.8)mmHg,高于A组(101.9±2.4)mmHg,P<0.05;麻醉后10 min收缩压C组(111.6±2.2)mmHg,低于A组(102.3±2.7)mmHg,P<0.05;娩婴时收缩压C组(121.4±2.5)mmHg与A组(109.8±2.3)mmHg、B组(113.8±2.0)mmHg比较,差异有统计学意义(P<0.05);麻醉后10 min舒张压C组(68.7±1.5)mmHg与A组(59.5±2.0)mmHg比较,差异有统计学意义(P<0.05);其他各时间点三组收缩压与舒张压间差异无统计学意义(P>0.05)。三组间各时间点心率变化无统计学意义。A、B、C三组的阻滞效果分别为(1.00±0.00)、(1.00±0.00)和(1.20±0.07)分,A、B组阻滞完善度优于C组(P<0.05);麻黄碱用量C组(0.0±0.0)低于A组(5.3±1.2)和B组(6.0±1.6),P<0.05;低血压发生率A组43.3%,B组40%,高于C组3.3%,P<0.05;三组间的恶心、呕吐及胸闷发生率差异没有统计学意义(P>0.05)。结论小剂量腰麻(1.0 mL)复合硬膜外追加利多卡因3 mL对剖宫产患者循环影响最小,恶心、呕吐及低血压发生率低,麻黄素用量少,麻醉效果相对差;固定剂量组1.3 mL与根据身高调整腰麻用量组相比,差异均无统计学意义。

Objective To study dose-dependent effects on maternal hemodynarnics of bupivacaine in combined-spinal epidural anesthesia for cesarean section. Methods Ninety patients ready for caesarean section were recruited and randomly divided into three groups （group A, group B and group C with 30 cases for each group）and received combined with spinal-epidural anesthesia（CSEA）. Patients were injected intrathecally with 0. 5% bupivacaine（0. 75% bupivaeaine 2 mL＋NS 1 mL）1.3 mL（group A）, 〈160 cm..1.2 mL,160 - 165 cm：1.3 mL,165-170 cm：1.4 mL, 〉 170 cm ： 1.5 mL（ group B） and 1.0 mL ＋ 2% epidural lidocaine 3 mL（ group C）. Additional 2% lidocaine were added if necessary. If the systolic pressure Was less than 90 mmHg or the diastolic pressure was 20% less than standard values, 10 mg ephedrine would be used to correct it. Then all medical indexes were observed as follows：time from anesthesia to skin incision and operation time were recorded;meanwhile the blockade effectiveness, and the dosage of ephedrine requirements as well as patients heart rate, blood pressure, and blood oxygen saturation at each post-anesthetic time interval were recorded. Side effects such as nausea, vomiting, hypotension and chest distress were also observed. Results There was no significant difference in the time from anesthesia to skin incision and operation time among three groups. Blockage effect of group A （ 1. 0 ±0.0） and group B （ 1.0 ±0. 0 ） were superior to group C （ 1.2 ±0. 07 ） （ P 〈 0. 05 ） ; Dosage of ephedrine in group A （ 5.3 ±1.2） mg and group B （ 6. 0 ±1.6 ） mg were more than group C （ 0. 0 ± 0. 0）mg. Systolic pressures at post-anesthetic 5 minute,10 minute in group A[ （ 101.9 ±2.4 ）mmHg, （ 102. 3 ±2. 7 ） mmHg] correspondingly were lower than group C [ （ 112. 9 ±1.8 ） mmHg, （ 111.6 ±2. 2 ） mmHg 3 respectively （ P 〈 0.05 ） , and at delivery group A （ 109. 8 ±2. 3 ） mmHg and group B （ 113.8 ±2. 0 ） mmHg were lower than group C （ 121.4 ±2. 5） mmHg（P 〈0. 05）. Diastolic pressure at post-anesthetic 10 minutes of group A（59. 5 ±2. 0） mmHg was lower than that of group C （68.7 ±1.5 ） mmHg （ P 〈 0. 05 ）. But there was no difference at other time among three groups （ P 〉 0. 05 ）. Also there was no difference in terms of heart rate, SpO2 , Apgar scores of the neonate, nausea, vomit and chest distress among three groups（P 〉0. 05）. Hypotension in group A（43.3% ） and group B（40% ） were more often than group C（ P 〈 0.05 ）. Conclusion 0. 5 % bupivacaine 5 mg spinal anesthesia combined with epidural 2% lidocaine 3 mL can provide reliable anesthesia and has the minimal effect on maternal hemodynamies. There was no significant difference between fxed dose group 1.3 mL and height adjusted dose group.