蛛网膜下腔阻滞联合硬脊膜外腔阻滞麻醉应用于先天性心脏病合并轻中度肺动脉高压产妇剖宫产术

Combined spinal-epidural anesthesia in caesarean section patients with congenital heart disease and mild to moderate pulmonary hypertension

目的探讨低剂量蛛网膜下腔阻滞联合硬脊膜外腔阻滞麻醉在先天性心脏病(CHD)合并轻中度肺动脉高压产妇剖宫产术中的可行性。方法 36例CHD合并轻中度肺动脉高压择期行剖宫产术的产妇,随机分入硬膜外组、腰硬联合5组和腰硬联合7.5组,每组12例。产妇均以L2与L3间隙为穿刺点行椎管内阻滞。硬膜外组产妇实施连续硬脊膜外腔阻滞,予2%利多卡因试验剂量后,追加注射0.75%罗哌卡因控制麻醉平面在T6至T8平面。腰硬联合5组和腰硬联合7.5组产妇实行蛛网膜下腔阻滞联合硬脊膜外腔阻滞,分别给予蛛网膜下腔注射罗哌卡因5和7.5mg后,留置硬脊膜外腔导管,根据麻醉平面追加注射0.75%罗哌卡因控制麻醉平面在T6至T8平面。在产妇入手术室(T0),手术切皮前椎管内末次给药后5min(T1)、7.5min(T2)、10min(T3)、15min(T4),手术开始(T5),胎儿娩出即刻(T6),胎儿娩出后5min(T7)、30min(T8),以及手术结束(T9)各时间点,记录产妇的心率(HR)和桡动脉平均动脉压(MAP)。记录术中牵拉痛、恶心呕吐、术后尿潴留和头痛等不良事件的发生情况。检测胎儿娩出时产妇动脉血和胎儿脐动、静脉血的pH值和乳酸值。记录手术开始至胎儿娩出时间和手术时间。结果 3组间手术开始至胎儿娩出时间和手术时间的差异均无统计学意义(P值均>0.05)。硬膜外组产妇的术中自觉牵拉痛发生率显著高于另两组(P值均<0.05),3组间其他不良反应发生率的差异均无统计学意义(P值均>0.05)。3组产妇在T0时间点的HR和MAP的差异均无统计学意义(P值均>0.05)。3组内各时间点和3组间同时间点HR的差异均无统计学意义(P值均>0.05)。硬膜外组产妇在T2至T5和T7、T8时间点,腰硬联合5组产妇在T2、T4、T5和T7、T8时间点,腰硬联合7.5组产妇在T2至T9时间点的MAP均较同组T0时间点显著下降(P值均<0.05)。腰硬联合7.5组产妇在T3和T5时间点的MAP显著低于硬膜外组和腰硬联合5组同时间点(P值均<0.05)。腰硬联合7.5组使用去氧肾上腺素产妇的构成比显著高于其余两组(P值均<0.01)。3组新生儿1和5min Apgar评分均为10分。腰硬联合7.5组胎儿脐静脉乳酸值显著高于硬膜外组和腰硬联合5组(P值均<0.05)。结论低剂量蛛网膜下腔阻滞(0.5%等比重罗哌卡因5mg)联合硬脊膜外腔阻滞可安全、有效地应用于CHD伴轻中度肺动脉高压产妇剖宫产术。

Objective To evaluate the efficacy of low-dose combined spinal-epidural anesthesia （CSEA） in caesarean section parturients with congenital heart disease （CHD） and mild to moderate pulmonary hypertension （PH）. Methods Thirty-six patients presenting for elective caesarean section with CHD and mild to moderate PH were randomly allocated to 3 groups （n = 12） ： group E （patients received continuous epidural anesthesia）, group 5 （patients received intrathecal 5 mg ropivacaine with CSEA） and group S7.5 （patients received intrathecal 7.5 mg ropivacaine with CSEA）. Intraspinal anesthesia was conducted at L2 - L3 interspace. Patients in group E received 0.75% ropivacaine after first dose of 2% lidocaine under epidural anesthesia to control the sensory blocking to T6 - T8 plane. Patients in group S5 and S7.5 received intrathecal 5 mg and 7.5 mg ropivacaine, respectively; after an epidural catheter was inserted into epidural space, the patients received 0.75 % ropivacaine to control the sensory blocking to T6 -T8 plane. Heart rate （HR） and mean radial artery pressure （MAP） were measured before anesthesia （To）, 5 min （T1）, 7.5 min （T2）, 10 min （T3） and 15 min （T4） after induction of anesthesia, at the beginning of operation （T5）, immediately after delivery （T6）, 5 min （T7） and 30 min （T8） after delivery, and at the end of operation （T9）. Adverse events, such as referred pain, nausea and vomiting, urine retention and headache were recorded. Hydrogen ion exponent and lactic acid concentration of maternal arterial blood, fetal umbilical venous and arterial blood were tested after delivery. The duration of fetal disengagement and surgical operation were also recorded. Results There were no significant differences in the duration of fetal disengagement or surgical operation between groups （all P〉0.05）. The incidence of referred pain in group E was significantly higher than that in group S5 and S7.5 （both P〈0.05）, but there was no significant difference in the other adverse events between groups （all P〉0.05）. There were no significant differences in the HR or MAP at To between groups （all P〉0.05）. There were no significant differences in intra-group or inter-group HR （all P〉 0.05）. Compared with the MAP at To, MAP from T2 to T5, and at T7 ,T8 in group E, at T2, T4, T5, T7 and T8 in group S5, from T2 to T9 in group S7.5 were significantly decreased （all P〈0.05）. MAP at T3 and Ts in group S7.5 were significantly lower than those in group $5 （all P〈0.05）. The percentage of phenylephrine used in parturients in group S7.5 was significantly higher than other two groups （both P〈0.01）. The Apgar score at 1 min and 5 min after delivery were all 10. The concentration of lactic acid in fetal umbilical venous blood was significantly higher than other two groups （both P〈0.05）. Conclusion Low-dose CSEA （0.5% ropivacaine 5 mg） can be safely used in caesarean section for the patients with CHD and mild to moderate PH. （Shanghai Med J, 2014, 37= 652-656）