新斯的明降低分娩期患者A控硬膜外镇痛（PCEA）的布比卡因用量：一项随机对照研究

背景鞘内注射新斯的明产生镇痛作用的同时可能导致重度恶心。相反，硬膜外注射新斯的明可以增强阿片类药物和局部麻醉药的镇痛作用而不产生恶心呕吐。以往的研究只针对单次硬膜外注射新斯的明，而对连续硬膜外注射新斯的明和母婴安全性未进行评估。因此，本研究拟验证在分娩期患者中新斯的明复合布比卡因硬膜外注射是否减少布比卡因用量。方法12例择期剖宫产的健康产妇随机分组，分别接受40μg（n=6）和80μg（n=6）新斯的明单次注射，监测20分钟胎心率（fetalheartrate，FHR）和宫缩。然后，另外40例健康的分娩期产妇随机分组，分别接受布比卡因1．25mg／ml或联合新斯的明4μg／ml产妇自控硬膜外镇痛（patient—controlledepiduralanalgesia，PCEA）。主要观察指标为每小时布比卡因用量。结果硬膜外新斯的明单次注射未导致FHR基础值改变，未诱导宫缩或产生恶心。硬膜外新斯的明的使用可使全部产妇的布比卡因用量减少19％，P〈0．05（使用4小时以上产妇用量减少达25％，P〈0．05），但可能导致轻度镇静。两组产妇的分娩方式、恶心发生率和FHR异常情况均相似。结论以上数据显示硬膜外使用新斯的明可降低PCEA中布比卡因每小时需要量的19％-25％。单次给药和连续注射新斯的明均不会诱发恶心、诱导宫缩或FHR异常，但可能导致轻度镇静。

BACKGROUND： Intrathecal neostigmine not only produces analgesia but also severe nausea. In contrast, epidural neostigmine enhances opioid and local anesthetic analgesia without causing nausea. Previous studies examined only single epidural neostigmine bolus administration and did not assess the efficacy of continuous epidural infusion or several as- pects of maternal and fetal safety. We therefore tested the hypothesis that epidural neostigmine in combination with bupivacaine by continuous infusion during labor would reduce the amount of bupivacaine required. METHODS： Twelve healthy women scheduled for elective cesarean delivery were assigned to receive epidural neostigmine, 40 μg （first six subjects） or 80 μg （second six subjects） as a single bolus, with fetal heart rate （FHR） and uterine contractions monitored for 20 min. In a subsequent experiment, 40 healthy laboring women were randomized to receive bupivacaine 1.25 mg/ml alone or with neostigmine 4 μg/ml by patient-controlled epidural analgesia. The primary outcome measure was hourly bupivacaine use. RESULTS： Epidural neostigmine bolus did not alter baseline FHR, induce contractions, or produce nausea. Epidural neostigmine infusion reduced bupivacaine requirement by 19% in all patients and 25% in those with 4 h of treatment （P 〈 0.05 for both） but might have contributed to the incidence of mild sedation. Mode of delivery, incidence of maternal nausea, and FHR abnormality were similar between groups. CONCLUSIONS： These data show that adding epidural neostig- mine 4μg/ml reduces the hourly bupivacaine requirement by 19% - 25% with patient-controlled epidural analgesia during labor. Administered as a bolus and by continuous infusion at the studied doses, epidural neostigmine does not cause nausea and does not induce uterine contractions or FHR abnormalities, but mild sedation can occur.