不同麻醉方案椎管内麻醉用于剖宫产手术的比较研究

A Comparative Study on Intrathecal Anesthesia With Different Anesthesia Schemes for Cesarean Section

目的探讨适合目标导向式控制腰麻平面用于剖宫产手术的方法及局麻药选择。方法回顾分析我院2016年10月~2018年10月148例腰麻-硬膜外联合阻滞剖宫产,比较不同麻醉方案腰麻后的麻醉效果及低血压的发生情况。34例采用0.5%罗哌卡因(0.5%R组)L 2~3穿刺间隙;38例采用0.5%布比卡因(0.5%B组)L 2~3穿刺间隙;38例采用0.4%布比卡因(0.4%B组)L 2~3穿刺间隙;38例采用0.67%罗哌卡因(0.67%R组)L 3~4穿刺间隙。腰麻剂量按身高给药,160~170 cm患者上述4组给药剂量分别为12、10、10、16 mg,低于160 cm或高于170 cm患者在此基础上分别减少2 mg或增加2 mg对应局麻药。通过2种体位调节控制阻滞平面至目标,减少低血压风险及持续时间。观察切皮时刻及胎儿娩出时刻阻滞平面,术中牵拉反应情况,腰麻操作完毕至左倾位和左倾位改为平卧位2个时点低血压的发生情况。结果切皮时刻腰麻平面中位数0.5%B组和0.4%B组为T 7,0.5%R组和0.67%R组为T 8。胎儿娩出时刻,0.5%R组达到目标平面T 6比例最低为35.3%,目标平面超过T 6比例0.5%B组31.6%最高,其次是0.4%B组(23.7%),0.67%R组(21.1%),0.5%R组最低(2.9%);0.5%R组所达平面中位数为T 7,其余3组中位数为T 6。0.5%R组和0.4%B组与0.67%R组和0.5%B组相比,有更高比例患者需要硬膜外补充给药达到要求平面(分别为61.8%、23.7%、10.5%、10.5%)(χ2=32.424,P=0.000),以及静脉辅助用药减轻牵拉反应(分别为44.1%、28.9%、13.2%、15.8%,χ2=11.505,P=0.009)。各组患者平卧位后低血压发生率明显高于左倾位期间:0.5%R组(32.4%vs.0.0%,Z=-3.002,P=0.003),0.5%B组(57.9%vs.31.6%,Z=-2.466,P=0.014),0.4%B组(55.3%vs.31.6%,Z=-2.601,P=0.009),0.67%R组(42.1%vs.10.5%,Z=-2.526,P=0.012)。0.5%B组和0.4%B组中重度低血压发生率在左倾位和平卧位时均明显高于0.67%R组和0.5%R组(左倾位时中重度低血压发生率分别为18.4%、7.9%、5.3%、0.0%,χ2=17.216,P=0.001;平卧位时中重度低血压发生率依次为44.7%、34.2%、21.1%、14.7%,χ2=8.459,P=0.037)。结论剖宫产手术选择L 3~4穿刺间隙,0.67%罗哌卡因腰麻,按身高给药,适合目标导向性控制阻滞平面,不易出现高平面阻滞,且硬膜外追加少,牵拉反应少,低血压发生率低,是可供选择的腰麻给药方式。

Objective To explore a more suitable method for target-oriented control of spinal anesthesia level for cesarean section and the selection of local anesthetics.Methods A retrospective analysis was made on 148 cases of caesarean section under combined spinal-epidural anesthesia in our hospital from October 2016 to October 2018.The anesthesia effect and incidence of hypotension after spinal anesthesia with different intrathecal anesthesia schemes were compared.For scheme 1,34 cases were treated with 0.5%ropivacaine(0.5%R group)at L 2-3 puncture interval;for scheme 2,38 cases with 0.5%bupivacaine(0.5%B group)at L 2-3 puncture interval;for scheme 3,38 cases with 0.4%bupivacaine(0.4%B group)at L 2-3 puncture interval;for scheme 4,38 cases with 0.67%ropivacaine(0.67%R group)at L 3-4 puncture interval.Spinal anesthesia dosage was given by height,and the 4 groups were treated with 12 mg,10 mg,10 mg,and 16 mg,respectively for body height in 160-170 cm.On this basis,the local anesthetics were reduced or increased by 2 mg for less than 160 cm or greater than 170 cm respectively.Two postural adjustments were designed to control the level of anesthesia to the target and reduce the risk and duration of hypotension.The anesthesia level at the time of skin incision and fetal delivered and the intraoperative traction reaction were examined.The occurrence of hypotension was observed at the time of spinal anesthesia operation to left-leaning position and left-leaning position to supine position.Results At the time of skin incision,the median blockade plane was T 7 in the B groups and T 8 in the R groups.At the time of fetus delivered,the lowest proportion of reaching the target plane T 6 was in the 0.5%R group(35.3%),and the plane in B groups was easily above T 6(31.6%in the 0.5%B group),followed by 0.4%B group(23.7%),0.67%R group(21.1%),and 0.5%R group(2.9%).The median plane in the 0.5%R group was T 7 and in the other three groups was T 6.The 0.5%R group and 0.4%B group had a higher proportion of patients who needed epidural supplementation as compared with the 0.67%R group and 0.5%B group(61.8%,23.7%,10.5%and 10.5%,respectively,χ2=32.424,P=0.000),which were similar to the intravenous supplementation for reducing traction reaction(44.1%,28.9%,13.2%,15.8%,respectively,χ2=11.505,P=0.009).The incidences of hypotension in supine position were significantly higher than those in left-leaning position in each group(0.5%R group:32.4%vs.0.0%,Z=-3.002,P=0.003;0.5%B group:57.9%vs.31.6%,Z=-2.466,P=0.014;0.4%B group:55.3%vs.31.6%,Z=-2.601,P=0.009;0.67%R group:42.1%vs.10.5%,Z=-2.526,P=0.012,respectively).The incidences of moderate and severe hypotension in the 0.5%B group and 0.4%B group were higher than those in the 0.67%R group and 0.5%R group in all the left-leaning and supine position.In the left-leaning position,the incidence was 18.4%in the 0.5%B group,7.9%in the 0.4%B group,5.3%in the 0.67%R group,and 0.0%in the 0.5%R group,respectively(χ^2=17.216,P=0.001),while in the supine position,the incidence was 44.7%,34.2%,21.1%and 14.7%respectively(χ^2=8.459,P=0.037).Conclusions Intrathecal injection 0.67%ropivacaine by height at L 3-4 puncture space,which is administered according to height,is suitable for target-oriented control of anesthesia level for caesarean section.It is not easy to appear high plane block,and there is less epidural addition,less traction reaction,and low incidence of hypotension.It is an alternative way of lumbar anesthesia administration.