barbotage注射法和单次注射法应用于剖宫产蛛网膜下腔-硬膜外联合麻醉的比较

Comparison of barbotage and single injection applied to combined spinal and epidural anesthesia in cesarean section

目的比较barbotage（Bbt）注射法和单次注射法应用于剖宫产蛛网膜下腔硬膜外联合麻醉（combined spinal and epidural anesthesia,CSEA）时产生的感觉及运动阻滞效果、产妇血流动力学的变化、新生儿Apgar评分等。方法100例足月产妇，20-40岁，ASA分级Ⅱ级，于L2-L3在CSEA下行剖宫产术，采用随机数字表法分为2组（每组50例）：Bbt注射法组（B组）和单次注射法组（S组），两组CSEA剂量均为0．5％罗哌卡因2．2ml（11mg）。B组采用Bbt注射法，即向产妇蛛网膜下腔注入半量局部麻醉药1．1ml后，回抽脑脊液至2．1ml，再次推注1．1ml混合液；第二次回抽脑脊液至1．6ml后再推注1．1ml混合液；第三次回抽至1．1ml后，将液体全部推注完毕。该法共推注4次，每次均为1．1ml，总注药时长为44s，平均注药速度为0．1ml／s。S组采用单次注射法，2．2ml药液一次推入蛛网膜下腔，注药总时长22s，平均注药速度同B组。注药后，若产妇出现BP降低，使用多巴胺或去氧肾上腺素维持循环稳定。分别记录产妇入室平静状态（t0）及注药后4min（t1）、6min（t2）、8min（t3）、10min（t4）时的BP、HR、相对感觉阻滞平面、改良Bromage评分、使用血管活性药物及硬膜外追加用药情况，观察并记录围手术期不良事件的发生情况及新生儿情况。结果B组各时间点感觉阻滞平面上升速度快于S组；t4时B组最大感觉阻滞平面高于S组（P〈0．05）；S组去氧肾上腺素使用率高于B组（P〉0．05）；两组硬膜外追加局部麻醉药用量、新生儿Apgar评分、各时间点改良Bromage评分差异均无统计学意义（P〉0．05）。结论在剖宫产CSEA中，Bbt注射法起效较快、药物扩散广、阻滞平面较单次注射法高，同时循环相对稳定。

Objective Comparing the outcome of barbotage （Bbt） and single injection applied to combined spinal and epidural anesthesia （CSEA） in cesarean section, including sensation block effect, motor block effect, changes of maternal hemodynamics, neonatal Apgar scores. Methods One hundred ASA Ⅱ parturients of 20-40 years with full-term pregnancy were scheduled for cesarean delivery under L2-L3 CSEA were included. They were randomly divided into 2 groups with 50 cases each group. 0.5% ropivacaine 2.2 ml（11 mg） were used in all patients. A Bbt technique was carried out in group B： 1st step, inject 1.1 ml of 2.2 ml total solution and withdrawing back to 2.1 ml, 2nd step, inject 1.1 ml of 2.1 ml solution and withdrawing back to 1.6 ml, 3rd step, inject 1.1 ml of 1.6 ml solution and withdrawing back to 1.1 ml, 4th step, inject the rest solution into subarachnoid space. The total injection time of group B is 44 s with an average speed of 0.1 ml/s. Single injection is carried out in group S within 22 s and sam e average speed. Dopamine and phenylephrine were used to stabilize maternal circlatory system. Record maternal blood pressure, heart rate, level of sensory block, Bromage score, usage of vasoactive drugs and local anesthetics at time of resting（t0） and 4 min （t1）, 6 min （t2）, 8 rain （t3）, 10 min （t4） min after injection. Record perioperative adverse reaction and condition of newborns.Results The speeds of block sensory level rising： group B〉group S（P〈0.05）. At t4, the highest sensory block level： group B〉group S （P〈0.05）, the usage rates of phenylephrine： group B〉group S （P〈0.05）. No significant difference is found in the usage of lidocaine, Apgar score, Bromage score during h-t4 between two groups（P〉0.05）. Conclusions In the spinal anesthesia of cesarean section, Bbt provides wider distribution of local anesthetics in subarachnoid space, which leads to faster nerve block and higher block level with more stable blood pressure and HR.