腰麻-硬膜外联合阻滞分娩镇痛中腰麻剂量的探讨

The Study of Effect and Doses of Anaesthelic via the Combined Spinal Epidural Analgesia during Labor

目的研究不同剂量的腰麻药在腰麻一硬膜外联合阻滞（Combined Spinal Epidural Analgesia，CSEA）分娩镇痛中对产妇的影响。方法60例初产妇按入院前后随机分成2组。L2-3 CSEA联合穿刺成功后，A组：蛛网膜下腔注入0．25％布比卡因1ml＋2．5μg芬太尼1ml共计2ml;B组：蛛网膜下腔注入0．17％布比卡因1ml＋2．5μg芬太尼1ml共计2ml，常规向头端置入硬膜外导管。疼痛程度采用视觉模拟疼痛评分（VAS），采用改良Bromage评分（MBS）评价产妇下肢运动神经阻滞情况。记录各组产妇的生命体征、胎心率（FHR）、产程时间、分娩方式、催产素使用情况度新生儿Apgar评分。结果1、A组和B组产妇镇痛效果满意，两组起效时间相同。同一时点镇痛效果相同。VAS评分无统计学差异（P〉0．05），B组腰麻镇痛时间146分钟与A组150分钟比较无统计学差异（P〉0．05）；2、产程：活跃期A组140分钟和B组142分钟相同，无统计学差异（P〉0．05）。第二产程A组65分钟和B组60分钟比较有延长的趋势，但无统计学差异（P〉0．05），器械助产率A组7（23．3％）与B组3（10％）比较有增多的趋势，但无统计学差异（P〉0．05），两组第三产程无差别（P〉0．05）；3、A组与B组采用改良Bromage评分评价下肢运动阻滞程度，A组MBS为3．9分与B组4．97分比较运动神经阻滞较重，有统计学差异（P〈0.05）；4、A组阻滞平面T2高于B组T10，有统计学差异（P〈0．05）。结论A组和B组起效迅速、镇痛完善，都是行之有效的分娩镇痛方法。但B组对产妇下肢运动神经阻滞轻微，麻醉平面易于调控，产妇血流动力学稳定，恶心、呕吐发生率低，更具有优越性。CSEA分娩镇痛中，腰麻药选用1．7mg布比卡因更合适。

Objective To investigate the effect and safety of combined spinal-epidural analgesia （CSEA） with different doses of anaesthetic during labor. Methods 60 ASA Ⅰ-Ⅱ full term primigravidae were randomly divided into two groups according the turn of inpatients. When the external cervical os was dilated to 2 - 3cm lumbar puncture was performed at L2-3 with a special CSE needle. A group ： 0. 25% bupivacaine 1ml and 2.5ug fentanyl lml,total 2ml injected into subarachnoid space. B group ：0. 17% bupivaeaine 1ml and fentanyl 1ml, total 2ml, injected into subarachnoid space. The ruble catheterized through epidural L2-3 toward head. The pain intensity were evaluated according to visual analog scale （VAS）. The adequency of motor function for ambulation was assessed by using Modified Bromage Score（MBS）. The vital signs, fetal heart rate（FHR）,birth process, delivery mode and the consumed volumes of oxytocin were recorded. The neonate was assessed using Apgar＇s score. Result 1. Both A and B group showed good effect on relief of labor pain and the same onset time. Analgesic effect was the same in the same time. There was no significant difference on VAS score （P〉0.05）. There was no significant difference on dulation time of spinal analgesia between 146 minute of group B with 150 minute of group A （P〉0.05）. 2. Labor stage ： active phase of A group 140 minute and 142 minute of B group was same, there was no significant difference （P〉0. 05）. Comparing second labor stage A group 65 minute with B group 60 minute, there was longed tendency, but there was no significant difference （P〉0.05）. Instrumental delivery rate,A group was more than B group, but there was no significant difference （P〉0.05）. There was no significant difference in the third stage of labor. 3. The adequeney of motor function for ambulation was assessed by using MBS. A group MBS 3.9 was lower than B group MBS 4.97,there was significant difference （P〈0. 05）. 4. The block level A group T7 was higher than B group T10, there was statistic difference（P〈0. 05）. Conclusion Both A group and B group were safe and effective for labor pain relief,but B group was safe and highly effective with less motor block, easily analgesic level control, stealy henodynamics of labor women and less incidence of nausea and vomitus. Subarachnoid bupivacaine 1.7 mg was suitable dose for labor pain relief with CSEA.