硬脊膜穿破硬膜外阻滞在产妇分娩镇痛中的应用

Application of dural puncture epidural technique for labor analgesia

目的探讨硬脊膜穿破硬膜外阻滞技术在分娩镇痛时对母婴的影响。方法本研究为前瞻性研究,选取2019年1至6月在温州医科大学附属第二医院拟行分娩镇痛的健康初产妇100例,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,美国纽约心脏病学会(NYHA)心功能分级Ⅰ或Ⅱ级。身高150~175 cm,体重50~90 kg,孕周37~45周。采用随机数字表法分为硬膜外镇痛组(P组,n=50)和硬脊膜穿破硬膜外镇痛组(D组,n=50)。硬膜外腔穿刺成功后P组作硬膜外置管;D组用27号腰麻穿刺针刺破硬脊膜到达蛛网膜下腔(确定标准:有脑脊髓液流出),再拔掉穿刺针,作硬膜外置管;两组均予0.1%罗哌卡因+0.25μg/ml舒芬太尼方案的硬膜外分娩镇痛。评定注药前、注药后30 min内每次宫缩时,以及注药后30、60、90 min及停止用药时的疼痛视觉模拟评分(VAS)。记录各产程情况、分娩方式、缩宫素使用增加病例数、两组产妇自控镇痛泵(PCA)有效按压次数、舒芬太尼及罗哌卡因用量和镇痛并发症发生情况及新生儿情况等。结果两组产妇产程、分娩方式及镇痛并发症(恶心呕吐、瘙痒、分娩后头痛、运动阻滞Bromage评分)等差异均无统计学意义(均P>0.05);两组胎儿胎心减速发生率及新生儿Aprar评分差异均无统计学意义(均P>0.05)。P组PCA有效按压次数、舒芬太尼用量、罗哌卡因用量及缩宫素使用增加率分别为(8.6±2.5)次、(29±4)μg、(105±15)mg、28%,D组分别为(4.6±2.1)次、(23±4)μg、(88±12)mg、10%,差异均有统计学意义(t=8.663、7.024、6.509,χ^2=4.159,均P<0.05)。P组在镇痛后前4次宫缩VAS评分分别为(7.9±1.1)、(6.8±0.9)、(5.6±0.8)、(4.5±0.8)分,均显著高于D组的(6.8±0.7)、(4.7±0.8)、(3.5±0.8)、(2.9±0.7)分,差异均有统计学意义(t=5.966、12.332、13.125、10.643,均P<0.05)。P组镇痛90 min、停药时的VAS评分分别为(2.7±0.6)、(2.9±0.7)分,明显高于D组的(2.4±0.6)、(2.5±0.6)分,差异均有统计学意义(t=2.500、3.068,均P<0.05)。结论采用硬脊膜穿破硬膜外阻滞技术行分娩镇痛较传统硬膜外技术能提供快速、有效的镇痛效果,镇痛药物用量少,且对母婴无不良影响。

Objective To investigate the effects of dural puncture epidural technique for labor analgesia on mothers and neonates.Methods From January to June 2019,one hundred healthy and nulliparous women,scheduled for elective labor analgesia in the Second Affiliated Hospital of Wenzhou Medical University,met inclusion criteriaand were recruitedin this prospective study.The inclusion criteria are as follows:American Society of Anesthesiologists physical statusⅠorⅡ,New York Heart Association gradeⅠorⅡ,150-175 cm in height,50-90 kg in weight and 37-45 weeks of gestation.They were randomly divided into epidural analgesia group(group P,n=50)and dural puncture epidural group(group D,n=50)by using random number table.Parturients in group D received epidural catheterization immediate after successful epidural puncture,while parturients in group P received a single dural puncture into subarachnoid space with a 27 gauge needle(successful puncture:outflow of cerebrospinal fluid)before epidural catheterization.Epidural labor analgesia was performed with epidural infusion of 0.1%ropivacaine plus 0.25μg/ml sufentanil in both groups.The VAS scores were evaluated at the following time points:before epidural infusion,each uterine contraction within 30 min after infusion,30 min,60 min and 90 min after infusion and withdrawal of infusion.Labor process,mode of delivery,cases of increased oxytocin using,effective PCA pressings,sufentanil and ropivacaine dosages,complications of analgesia,neonatal status were recorded,as well.Results There were no significant differences in labor duration,mode of delivery,analgesia complications(nausea and vomiting,itching,headache after delivery and Bromage score for motor block),deceleration of fetal heart rate and neonatal Apgar score between the two groups(P>0.05).The number of effective PCA pressings,sufentanil dosage,ropivacaine dosage and cases of increased using of oxytocin were significantly more in group P(t=8.663,7.024,6.509,χ^2=4.159,all P<0.05),with(8.6±2.5)times,(29±4)μg,(105±15)mg,28%in group P,compared with(4.6±2.1)times,(23±4)μg,(88±12)mg,10%in group D,respectively.The first four VAS scores of uterine contraction after analgesia in group P(VAS=7.9±1.1,6.8±0.9,5.6±0.8,4.5±0.8)were significantly higher than those in group D(VAS=6.8±0.7,4.7±0.8,3.5±0.8,2.9±0.7,t=5.966,12.332,13.125,10.643,all P<0.05).The VAS scores at 90 min after analgesia and withdrawal of analgesia(VAS=2.7±0.6,2.9±0.7)in group P were significantly higher than those in group D(VAS=2.4±0.6,2.5±0.6,t=2.500,3.068,all P<0.05).Conclusion Compared with traditional epidural technique,dural puncture epidural technique can provide a rapid and effective analgesia with less analgesics,but without increasing adverse effects on mother and infant.