地佐辛辅助给药时机选择对剖宫产术患者镇静遗忘及血流动力学的影响

Influence of dezocine treatment on sedation, amnesia and hemodynamics in caesarean section

目的 探讨地佐辛在剖宫产硬膜外麻醉中辅助给药时机对剖宫产术患者镇静遗忘及血流动力学的影响.方法 选择2012年1-6月安徽医科大学附属合肥医院-合肥市第二人民医院在硬膜外麻醉下行下腹部剖宫产术患者60例,完全随机分为对照组（C组）、常规给药麻醉组（D1组）和超前给药麻醉组（D2组）,每组20例.C组硬膜外穿刺后首先给予0.9％氯化钠溶液5 ml缓慢静脉推注,胎儿取出后给予0.9％氯化钠溶液5 ml缓慢静脉推注;D1组硬膜外穿刺后首先给予0.9％氯化钠溶液5 ml缓慢静脉推注,胎儿取出后给予地佐辛0.2 mg/kg稀释到5 ml缓慢静脉推注;D2组硬膜外穿刺后给予地佐辛0.2 mg/kg稀释到5 ml缓慢静脉推注,胎儿取出后给予0.9％氯化钠溶液5 ml缓慢静脉推注.观察第1次静脉给药后10 min（S1）、第2次静脉给药后10 min（S2）和术后2 h（S3）3个时点患者的镇静（采用改良警觉和镇静评分,OAA/S）和遗忘情况（采用图形回放）;同时观察入室后（T0）、硬膜外起效后（T1）、第1次静脉给药3 min后（T2）、切皮（T3）、胎儿取出后（T4）、第2次静脉给药3 min后（T5）6个时点的平均动脉压（MAP）、心率、脉搏血氧饱和度（SpO2）的变化;观察手术过程中各类不良反应的发生情况.结果 在S1时点,D2组镇静程度OAA/S评分低分层例数明显高于C组和D1组[12例（60.0％）比5例（25.0％）、4例（20.0％）,P＜0.05];在S2、S3时点,D1、D2组OAA/S评分低分层例数明显高于C组[13例（65.0％）、14例（70.0％）比6例（30.0％）;14例（70.0％）、15例（75.0％）比8例（40.0％）],差异均有统计学意义（均P ＜0.05）.在S1、S2、S3时点,C、D1、D23组间遗忘情况比较差异无统计学意义（P＞0.05）.3组MAP在T0、T1、T2时点差异均无统计学意义（P＞0.05）,在T3、T4时点,C组、D1组MAP高于D2组,差异有统计学意义[（85.3±2.7）、（85.8 ±3.0）mmHg（1 mmHg =0.133 kPa）比（81.6±3.6）mmHg,（84.3±3.5）、（84.2±3.2） mmHg比（80.6±3.7） mmHg,P＜0.05];在T5时点,C组MAP高于D1、D2组[（84.4±2.8）mmHg比（80.0±3.2）、（80.5±3.5） mmHg],差异有统计学意义（P＜0.05）.在T0、T1、T2时点3组心率差异无统计学意义（P＞0.05）;在T3、T4时点,C组和D1组心率高于D2组[（77±4）、（77±5）次/min比（72±5）次/min,（76±5）、（76±5）次/min比（70±4）次/min],差异有统计学意义（P ＜0.05）];在T5时点,C组心率高于D1、D2组[（75±6）次/min比（70±5）、（70±4）次/min],差异有统计学意义（P＜0.05）.在6个时点3组间SpO2水平差异均无统计学意义（P＞0.05）.3组术中不良反应发生情况比较,差异无统计学意义（P＞0.05）.结论 地佐辛超前给药辅助剖宫产硬膜外麻醉可达到良好的镇静作用,并稳定血流动力学水平.

Objective To investigate the influence of dezocine pretreatment on sedation,amnesia and hemodynamics of epidural anesthesia in caesarean section.Methods Sixty patients undergoing selective lower abdominal cesarean section under epidural anesthesia from January to June in 2012 were randomized divided into control group （20 cases）,dezocine conventional treatment group and dezocine pretreatment group （20 cases）.In control group,0.9% sodium chloride solution （5 ml） was slowly injected after epidural puncture and after fetal birth;in dezocine conventional treatment group 0.9% sodium chloride solution （5 ml） was slowly injected after epidural puncture and dezocine （0.2 mg/kg,diluted into 5 ml 0.9% sodium chloride solution） was slowly injected after fetal birth;in dezocine pretreatment group,dezocine （0.2 mg/kg,diluted into 5 ml 0.9% sodium chloride solution） was slowly injected after epidural puncture and 5 ml 0.9% sodium chloride solution was slowly injected after fetal birth.The sedation was assessed by observer assessment of alertness/sedation （OAA/S score） and the amnestic effects were observed by graphic playback at 10 min after the first intravenous administration （S1）,10 min after the second intravenous administration （S2） and 2 h post operation （S3）.The hemodynamic index including mean arterial pressure （MAP）,heart rate （HR） and oxygen saturation （SpO2） were measured at followed time：admission （T0）,epidural response （T1）,3 min after the first intravenous injection （T2）,skin incision （T3）,immediately after fetal birth （T4）,3 min after the second intravenous injection （T5）.The intraoperative adverse reactions were also observed.Results At S1 time point,the proportion of low OAA/S score stratification in dezocine pretreatment group was significantly higher than that in control group and dezocine conventional treatment group [12 （60.0%） vs 5 （25.0%）,4 （20.0%）] （P 〈0.05）.At S2 and S3 time points,the proportion of low OAA/S score stratification in dezocine conventional treatment and dezocine pretreatment group was significantly higher than that in control group [13 （65.0%）,14 （70.0%） vs6 （30.0%）,14 （70.0%）,16 （75.0%） vs8 （40.0%）] （P〈0.05）.The number of patients experiencing amnesia at S1,S2,S3 time points had no significant difference among the three groups （P 〉 0.05）.There were no significant differences of MAP among the three groups at T0,T1 and T2 time points （P 〉 0.05）.At T3 and T4 time points,the MAP in control group and dezocine conventional treatment was significantly higher than that in dezocine pretreatment group [（85.3 ±2.7）,（85.8 ±3.0） mmHg vs （81.6 ±3.6） mmHg,（84.3 ±3.5）,（84.2 ±3.2） mmHg vs （80.6 ±3.7） mmHg] （P 〈0.05）.At T5 time point,MAP in control group was significantly higher than that in dezocine conventional treatment group and dezocine pretreatment group [（84.4 ± 2.8） vs （80.0 ± 3.2）,（80.5 ± 3.5） mmHg] （P 〈 0.05）.There were no significant differences of HR among the three groups at T0,T1 and T2 （P 〉 0.05）;at T3 and T4,HR in control group and dezocine conventional treatment group was significantly higher than that in dezocine pretreatment group [（77 ±4）,（77 ±5） times/min vs （72 ± 5） times/min,（76 ± 5）,（76 ± 5） times/min vs （70 ± 4） times/min] （P 〈 0.05）;at T5 time point,HR in control group was significantly higher than that in dezocine conventional treatment group and dezocine pretreatment group [（75 ±6） times/min vs （70 ±5）,（70 ±4） times/rmin,P 〈0.05].There were no significant differences of SpO2 among the three groups at all 6 time points （P 〉0.05）.The intraoperative adverse reactions were not significantly different among the three groups （P 〉 0.05）.Conclusion Pretreatment of dezocine during epidural anesthesia in the cesarean section may provide satisfactory sedation,amnesia and sustain steady hemodynamics.