右美托咪定复合左布比卡因用于剖宫产术后硬膜外镇痛的临床研究

CHnical study of administration of dexmedetomidine combined levobupivacaine for peridural analgesia in post-cesareansection

目的探索右美托咪定（dexmedetomidine，Dex）联合低浓度左布比卡因在剖宫产术后硬膜外自控镇痛治疗中的应用可行性及对舒芬太尼消耗量的影响。方法90例足月孕单胎择期行剖宫产术的孕妇，ASA分级I、Ⅱ级，按随机数字表法分为3组（每组30例）：对照组（c组），舒芬太尼1．5wg／kg＋0．1％左布比卡因；Dex1组（D。组），舒芬太尼1．5wg／kg＋0．1％左布比卡因＋Dex0．02μg·kg^-1·h^-1；Dex2组（D2组），舒芬太尼1．5μg／kg＋0．1％左布比卡因＋Dex0．05μg·kg^-1·h^-1，各组药物均用生理盐水稀释至150ml。孕妇均采用L3-L4硬膜外腔联合蛛网膜下腔阻滞麻醉，术毕均快速泵注镇痛液2ml，背景输注速度为2ml／h，患者自控镇痛（patient controlled analgesia，PCA）锁定时间15min，每次2ml。记录术前产妇的一般资料，手术与麻醉时间，副作用（皮肤瘙痒、恶心、呕吐）的发生率，舒适度（Bruggrmann comfortscale，BCS）评分以及术后4、8、12、24、48h的VAS评分和Ramsay评分，统计PCA键有效按压次数和48h舒芬太尼用量。结果术后4、8、12、24、48h，C组Ramsay评分[（2．0±0．5）、（L7±0．5）、（1．6±0．6）、（1．6±0,5）、（1．8-．0．4）分]明显低于D，组[（2．3±0．5）、（2．3＋0．6）、（2．1±0．5）、（2．3±0．5）、（2．2±0．5）分]和D2组[（2．3±0．5）、（2．4＋0．5）、（2．3±0．5）、（2．4±0．5）、（2．3±0．5）分]（P〈O．05或P〈0．01）；DI组[（0．5±0．6）、（0．8±0．9）、（0．9＋0．9）、（1．0±0．9）、（1．1±0．8）分]和D2组[（0．4±0．6）、（0．5±0．7）、（0．7±0．7）、（0．8±0．8）、（0．9±0．7）分]VAS评分明显低于C组[（1．3±1．0）、（1．5±1．1）、（1．8±1．0）、（1．9±O．7）、（1．9±0．7）分]（P〈0．05或P〈0．01）。D2组皮肤瘙痒发生率（3．33％）明显低于C组（26．67％）（P〈0．05）。D2组BCS评分[（3．1±O．7）分]显著高于C组[（3．1±0．7）分]与D，组[（1．9＋0．7）分]（P〈O．05或P〈0．01）。C组48h舒芬太尼消耗量[（1．041±0．025）μg/kg]明显大于Dl组[（1．020±0．021）μg／kg]±D2组[（1．003±0．019）μg／kg]（P〈0．01），且Dl组比D2组消耗量大（P〈0．05）。结论小剂量Dex能明显提高左布比卡因和舒芬太尼剖宫产术后的镇痛效果和安全性，具有良好的应用前景。

Objective To explore the feasibility of application of dexmedetomidine（Dex） combination with low concentration of levobupivacaine and sufentanil performed by patient controlled epidural analgesia in cesarean section. Methods Totally 90 full- term pregnancy parturients of single birth with ASA I or If, in accordance with the random number table, were randomized into three groups（n=30）： control group （group C） sufentanil 1.5 μg/kg＋0.1% levobupivacaine, Dex group 1 （group D1） snfentanil 1.5 p.g/kg＋0.1% levobupivacaine＋Dex 0.02 μg·kg^-1·h^-1, and Dex group 2 （group D2） sufentanil 1.5 μg/kg＋0.1% levobupivacaine＋Dex 0.05 μg/kg^-1·h^-1, drugs in ＇all groups were dissolved in sterile saline solution with total volume 150 ml. All puerperas＂ anesthesia was performed by combining epidural and spinal block in L3-L4. At the end of operation, the patient controlled analgesia （PCA） program of all postoperative analgesia pumps were quickly delivered 2 ml, and set with background infusion of 2 ml/h, a lockout of 15 rain and a delivery of a bolus dose of 2 mL The normal information of puerperas, the time of operation and anesthesia, the incidence of adverse reactions （pruritus, nausea and emesis）, and the bruggrmann comfort scale （BCS） scores were recorded. In addition to, VAS scores and Ramsay scores were also recorded at 4, 8, 12, 24, 48 h time points after operation. And the number of valid PCA was recorded and the consumptions of sufentanil for 48 h analgesia were assessed. Results At the 4, 8, 12, 24, 48 h after operation, the Ramsay score of group C（2.0±0.5, 1.7±0.5, 1.6±0.6, 1.6±0.5, 1.8±0.4） was lower compared with group D±[（2.3±0.5）, （2.3＋0.6）, （2.1±0.5）, （2.3±0.5）, （2.2±0.5）land group D2 [（2.3±0.5）, （2.4±0.5）, （2.3±0.5）, （2.4±0.5）, （2.3±0.5）], respectively（P〈0.05 or P〈0.01）, and the VAS score of group D1[（0.5±0.6）, （0.8±0.9）, （0.9±0.9）, （1.0±0.9）, （1.1±0.8）] and group D2[（0.4±0.6）, （0.5±0.7）, （0.7±0.7）, （0.8±0.8）, （0.9±0.7）] were lower compared with group C[（1.3±1.0）, （1.5±1.1）, （1.8±1.0）, （1.9±0.7）, （1.9±0.7）], respectively（P〈0.05 or P〈0.01）. Compared the incidence of pruritus, group D2（3.33%） is lower than group C（26.67%）. In assessment of BCS score, group D2（3.1±0.7） was significantly higher than group C（3.1±0.7） and group D1（1.9±0.7）, respectively（P〈0.05 or P〈0.01）. In Assessment Of consumption of sufentanil for 48 h analgesia, group C[（1.041±0.025）μg,/kg] was apparently bigger compared with group D±[（1.020±0.021） μg/kg] and group D2 [（1.003±0.019） μg/kg], respectively （P〈0.01）, and group Dt was also bigger compared with group D2 （P〈0.05）. Conclusions The low Dex obviously enhances the security and analgesic effect of levobupivaeaine and sufentanil performed by patient controlled epidural analgesia for postoperative analgesia in post-cesarean section with better prospect of clinical application.