硬膜外舒芬太尼复合罗哌卡因应用于分娩镇痛对新生儿的影响

Effects of epidural sufentanil and ropivacaine analgesia during labor on neonates

目的比较产妇分娩时舒芬太尼或芬太尼混合罗哌卡因患者自控硬膜外镇痛(PCEA)对新生儿的影响。方法无产科及硬膜外阻滞禁忌证的阴道分娩单胎初产妇180例,随机均分为3组:舒芬太尼混合罗哌卡因PCEA组(S组),芬太尼混合罗哌卡因PCEA组(F组),未行任何镇痛处理的60例为对照组(D组)。当产妇宫口开至3cm时,在L2～L3间隙行硬膜外穿刺置管,S组在硬膜外注射0.1%罗哌卡因和0.5mg/L舒芬太尼混合液试验剂量5mL,随后追加上述混合液10mL,30min后以0.1%罗哌卡因和0.5mg/L舒芬太尼混合液行PCEA。F组混合液中以2mg/L芬太尼替代0.5mg/L舒芬太尼,其他用药情况与S组相同。两组患者自控镇痛(PCA)剂量为5mL,背景剂量为5mL/h,锁定时间为15min。3组胎儿娩出后立即抽取新生儿脐动脉血进行血气分析,采用疼痛视觉模拟评分法(VAS评分)评估硬膜外给药后10、30、60、120和180min时的疼痛情况。记录新生儿1、5min Apgar评分及出生后1～5d的新生儿神经行为评分(NBNA)。结果3组间血气分析的各项指标的差异均无统计学意义(P值均>0.05)。给予PCEA后,S、F组的VAS评分逐渐降低(P<0.01),在宫口开全时S组显著低于F组(P<0.01),S、F组间其余各时间点的差异均无统计学意义(P值均>0.05)。S、F组镇痛后各时间点的VAS评分均显著低于D组(P值均<0.01)。S组与F组间PCA用量、按压次数、总按压次数/有效按压次数的差异均无统计学意义(P值均>0.05)。S、F组产妇使用催产素的构成比显著高于D组(P值均<0.01)。3组间器械助产、剖宫产率和新生儿1、5min Apgar评分的差异无统计学意义(P值均>0.05)。3组新生儿的NBNA总分均>35分。结论产妇分娩时予PCEA对新生儿安全且无明显不良影响。

Objective To compare the influences of sufentanil and fentany combined with ropivacaine in patient-controlled epidural analgesia （PCEA） during labor on the neonates. Methods One-hundred and eighty nulliparous parturients in active labor （cervical dilatation = 3 cm） were evenly randomized into 3 groups： receiving 5 mL of 0.15% ropivacaine with 0.5 mg/L sufentanil （group S）, receiving 5 mL of 0.15% ropivacaine and 2,0 mg/L fentanyl （group F）, and receiving no analgesia （group D） according to their personal preference. When correct placement of epidural catheter was confirmed another 10 mL was given. PCEA was commenced with 0.1% ropivacaine ＋ 0.5 mg/L sufentanil/2.0 mg/L fentanyl. The PCEA pump was set up with a bolus of 5 mL and the lockout interval was 15 min with a background 5 mL infusion. Then we studied the umbilical arterial samples of the infants right after birth for the pH, PO2, PCO2, SO2 and HCO3-. Pain was assessed using visual analog scale （VAS, 0= no pain, 100= worst pain）; Apgar score of neonates in 1, 5 min were recorded. Neonatal behavioral neurological assessments （NBNA） 1 -5 days after birth were also recorded. Results There was no significant difference in the blood gas parameters among the 3 groups （all P〉0.05）. The VAS score gradually decreased in group S and F after administration of PCEA （P〈0.01）; at the time of full cervical dilatation the score in S group was significantly lower than that of group F （ P〈0.01 ）, and there was no significant difference between group S and F at all other times （all P〈0.05）. The VAS scores at all time points after analgesia were significantly lower in group S and F compared with those in group D （all P〈0.01）. There were no significant differences in PCA amount, times of pressing, total pressing time/effective pressing time between group S and F （all P〈0.05）. The proportions of patients using oxytocin in group S, F were significantly higher than that in group D （P〈0.01）. There was no significant difference in the percentages of cesarean section, instrumental delivery or Apgar score （ 1, 5 min） among the 3 groups （all P〉0.05）. The NBNA scores of the infants in the 3 group were higher than 35. Conclusion It is suggested that patient-controlled epidural analgesia in nulliparas is safe to the neonates and has no severe adverse effect.