全身麻醉剖宫产术不同麻醉诱导方法的对比研究

Comparative study of different anesthesia induction methods in general anesthesia cesarean section

目的比较不同麻醉方案对产妇血流动力学、新生儿Apgar评分的影响,为临床麻醉工作中全身麻醉剖宫产麻醉诱导方案的选择提供参考.方法选择30例ASAⅠ～Ⅱ级足月择期行剖宫产的产妇.随机分为3组：氯胺酮组（Ⅰ组）、瑞芬太尼组（Ⅱ组）、氯胺酮＋瑞芬太尼组（Ⅲ组）,每组各10例.Ⅰ组麻醉诱导依次静脉滴注异丙酚1mg/kg,氯胺酮1mg/kg,维库溴铵8mg;Ⅱ与Ⅲ组依次静脉滴注异丙酚1mg/kg,瑞芬太尼1μg/kg,维库溴铵8mg,瑞芬太尼推注时间＞60s.Ⅰ、Ⅱ组患者麻醉诱导过程中气管插管与手术切皮同时进行;Ⅲ组患者麻醉诱导只完成气管插管的工作,5min后静脉给予氯胺酮0.5mg/kg再开始手术操作.记录3组产妇全身麻醉诱导前（T1）、诱导后（T2）、气管插管成功后1min（T3）的血流动力学变化情况;麻醉诱导至胎儿取出断脐（I-D）时间;胎儿娩出后1、5minApgar评分.结果所有麻醉方案均能满足全身麻醉剖宫产术的手术要求.血流动力学：与T1比较,Ⅰ组产妇在T3的SBP、DBP明显升高,HR明显升快;Ⅱ、Ⅲ组产妇在T2的HR明显下降（P＜0.05）;与Ⅰ组比较,Ⅱ、Ⅲ组产妇在T2SBP、DBP下降,HR减慢（P＜0.05）;麻醉诱导至胎儿取出断脐（I-D）时间：Ⅲ组与Ⅰ、Ⅱ组比较,时间明显延长;新生儿Apgar评分：Ⅱ组新生儿1minApgar评分明显降低,与Ⅰ、Ⅲ组比较,差异有统计学意义（P＜0.05）.结论麻醉诱导依次给予异丙酚1mg/kg,瑞芬太尼1.0μg,/kg,维库溴铵8mg,麻醉诱导期间只完成气管插管的工作;5min后静脉给予氯胺酮0.5mg/kg再开始手术操作的方法可有效降低气管插管以及手术操作等刺激引发的不良应激反应,避免产妇血流动力学的剧烈波动,同时又不会影响新生儿的Apgar评分,可推荐作为择期全身麻醉剖宫产术的常用方法.

Objective To compare the influence of each anesthesia programme on the maternal hemodynamics and neonatal Apgar score and provide reference for the selection of anesthesia induction program in general anesthesia cesarean section. Methods 30 full term puerperae with ASA grade Ⅰ - Ⅱ who chosed cesarean section were selected and randomly divided into the three groups：the ketamine group （group Ⅰ ）, the remifentanil group （group Ⅱ） and the ketamine ＋ remifentanil group （group Ⅲ）, with 10 puerperae in each group.the group Ⅰ received intravenous injection of propofol 1 mg/kg,ketamine 1 mg/kg and vecuronium bromide 8 mg in sequence for the purpose of anesthesia induction;the group Ⅱ and group Ⅲ received intravenous injection of propofol 1 mg/kg,remifentanil 1 μg/kg and vecuronium bromide 8 mg in sequence and the injection time of remifentanil was longer than 60 seconds.In the group Ⅰ and group Ⅱ ,during the anesthesia induction process,tracheal intubation and surgical skin incision preceded at the same time;in the group m ,only tracheal intubation was completed during anesthesia induction and surgical operations did not begin until ketamiine 0.5 mg/kg was given intravenously 5 minutes later.The hemodynamic changes before general anesthesia in- duction （T 1）,after induction （T2）,1 minute after tracheal intubation success （T3）,the time from anesthesia induction to um- bilical cord break （I-D） and the neonatal Apgar scores 1 and 5 minutes after birth of the three groups were recorded. Results All anesthesia programmes could meet the surgical requirements of general anesthesia cesarean section.In terms of maternal hemodynamics,compared to T1,SBP and DBP elevated significahtly and HR increased significantly in the group Ⅰ at T3;HR of group Ⅱ and group IU at T2 decreased significantly （P〈0.05）;compared to the group Ⅰ ,SBP and DBP dropped and HR slowed in group Ⅱ and group Ⅲ at T2 （P〈0.05）.In terros of I-D time,the group Ⅲ prolonged significantly compared to group Ⅰ and group Ⅱ ;In terms of neonatal scores,1-minute neonatal Apgar score of group Ⅱ reduced significantly,with statistically significant difference to the group Ⅱ and group Ⅲ. Conclusion Administration of propofol 1 mg/kg, remifentanil 1.0 ug/kg and vecuronium bromide 8 mg in sequence,completion of only tracheal intu- bation during anesthesia induction process,and surgical operations after intravenous administration of ketamine 0.5 mg/ kg 5 minutes later can effectively reduce the adverse stress reactions induced by tracheal intubation and surgical oper- ations,and can avoid acute maternal hemodynamic severe fluctuation and does not influence the neonatal Apgar score, thus can serve as a common method for selective general anesthesia cesarean section.