椎管内不同麻醉方式对剖宫产产妇血流动力学的影响

Effects of Different Neuraxial Anesthesia on Hemodynamics in Pregnant Women Undergoing Cesarean Section

目的 比较蛛网膜下隙阻滞麻醉（SA）、硬脊膜外除阻滞（EA）与经蛛网膜下隙与硬脊膜外隙联合阻滞（CSEA）3 种麻醉方式在剖宫产手术中的麻醉效能及对产妇血流动力学的影响。方法 选择 2012 年 1 月－12 月拟行剖宫产的足月单胎初产妇 180 例，美国麻醉医师协会分级Ⅰ～Ⅱ级，采用随机数字表法将患者分为3 组，每组 60 例。产妇取左侧卧位，EA 组选腰 L1-2间隙穿刺，首次共用 1.73% 碳酸利多卡因 12 ～ 15 mL。SA 组与 CSEA 组穿刺点为腰 L1-2或 L3-4间隙，SA 组 0.75% 布比卡因 1.2 mL＋10% 葡萄糖注射液 1 mL，CSEA 组 0.5% 布比卡因 1.4 mL＋10% 葡萄糖注射液 0.8 mL。CA 组注药完毕退出蛛网膜下腔阻滞麻醉穿刺针，向头侧置入硬膜外导管 3 ～ 4 cm，并根据麻醉平面及麻醉平面消退情况行硬膜外补充用药。监测并记录基础血压和心率、围麻醉期最低血压和心率、脐静脉血血气分析以及麻醉起效时间、麻醉诱导时间及麻醉最高阻滞平面。结果 3 组产妇麻醉起效时间比较差异有统计学意义（F=24.642，P=0.000），其中 SA、CA 组麻醉起效时间显著低于 EA 组（t=8.076，7.996；P ＜ 0.05），SA 组麻醉诱导时间显著低于 EA、CSEA 组（t=8.191，5.805；P ＜ 0.05）；SA、CSEA 组最低血压及心率显著低于基础值（SBP：t=13.500，15.626，HR：t=11.151，12.942；P ＜ 0.05 或 P ＜ 0.01），SA 组最低血压及心率显著低于 EA 组（t=3.012，5.409；P ＜ 0.05），SA、CSEA 组低血压及心动过缓的发生率显著高于 EA 组（SBP：χ2=19.200，7.653；HR：14.400，5.072；P ＜ 0.05 或 P ＜ 0.01）。三组产妇的麻醉阻滞平面分别达到胸椎（8.12±1.22）（、8.36±1.88）、（8.52±1.92）水平，麻醉阻滞平面比较，差异无统计学意义（F=0.081，P=0.923）。结论 在剖宫产手术椎管内麻醉方式选择上，CSEA 和 EA 优于单纯 SA，而 1.73% 碳酸利多卡因用于 EA 剖宫产更能提高麻醉效能和维持血流动力学的相对稳定。

Objective To compare the anesthetic potency and influence on maternal hemodynamics among spinal anesthesia（SA）,epidural anesthesia（EA） and combined spinal epidural anesthesia（CSEA） for women undergoing cesarean sections.Methods A total of 180 singleton term nulliparous pregnancies of American Sociaty of Anethesiologists physical status I or II for cesarean sections in Guangyuan Central Hospital from January to December2012 were allocated into three groups using the method of random number table.Patients in group SA received SA（n=60）,group EA underwent EA（n=60） and patients in group CSEA accepted CSEA（n=60）.Patients were all placed in left lateral position.Group EA patients underwent punctures at the L_（1-2） interspace and the volume of carbonated lidocaine used initially was 12-15 mL.Group SA and CSEA accepted the anesthesia at either L_（2-3） or L_（3-4） interspace.The volume for group SA was 0.75%bupivacaine 1.2 mL with 10%glucose solution 1 mL,and for group CSEA was 0.5%bupivacaine1.4 mL with 10%glucose solution 0.8 mL.A catheter was inserted into the epidural space for 3-4 cm after spinal needle exit so as to add additional epidural medication according to the block level and the level of anesthesia subsidence.The values of the basis of blood pressure and heart rate,the lowest blood pressure and heart rate,umbilical venous blood gas,start effect and induction time of anesthesia and the highest block level of anesthesia were record.Results There were statistically significant differences in terms of start effect time of anesthesia among the three groups（F=24.642,P〈0.001）.The start effect time of anesthesia in group SA and CSEA was significantly shorter than that in group EA（t=8.076,7.996;P〈0.05）.The induction time of anesthesia in group SA was significantly shorter than those in group EA and CSEA（P〈0.05）.The lowest blood pressure and heart rate in group SA and CSEA were significantly lower than the values of basis（P〈0.05）.The lowest blood pressure and heart rate in group SA was significantly lower than that in group EA（P〈0.05）.The incidence of hypotension and bradycardia in group SA and CSEA was significantly higher than that in group EA（P〈0.05）.The block level of anesthesia in the three groups were at thoracic 8.12±1.22,8.36±1.88 and 8.52±1.92 respectively,and there was no significant difference among the three groups（F=0.081,P=0.923）.Conclusion EA and CSEA surpass SA in the choice of neuraxial anesthesia for cesarean sections,and 1.73%carbonated lidocaine for EA can improve anesthetic potency and better maintain relatively stable hemodynamic indexes.