硬脊膜穿破硬膜外阻滞在分娩镇痛中的应用

Application of dural puncture epidural technique for labor analgesia

目的探讨硬脊膜穿破硬膜外(dural puncture epidural,DPE)阻滞分娩镇痛在起效速度、阻滞效果和副作用等方面的价值。方法选取要求行分娩镇痛、单胎、头位、足月的初产妇662例,ASA分级Ⅰ、Ⅱ级,采用在线随机数生成器将产妇分为蛛网膜下腔-硬膜外联合(combined spinal epidural,CSE)组(231例)、硬脊膜穿破硬膜外(dural puncture epidural,DPE)组(225例)和硬膜外(epidural,EP)组(206例)。于给药后前20 min每隔2 min评估并记录1次产妇的疼痛数字评分(Numeric Rating Scale,NRS),以3组产妇达到NRS评分≤1分的时间为主要结果。次要结果包括双侧感觉阻滞平面至T10及S2、不对称阻滞、麻醉医师干预、更换导管、剖宫产、器械助产、Bromage评分≥1分、胎儿心动过缓、子宫收缩过频、低血压、恶心、瘙痒、头痛、神经损伤、新生儿1 min及5 min Apgar评分≤7分的发生率,宫口开全时疼痛评分(NRS2),第一产程及第二产程时长。结果与CSE组比较:DPE组达到NRS≤1分的时间延长(P<0.05),麻醉医师干预发生率降低(P<0.05);EP组达到NRS≤1分的时间延长(P<0.05),双侧感觉阻滞平面至S2、不对称阻滞发生率及NRS2评分升高(P<0.05)。与EP组比较:DPE组达到NRS≤1分的时间缩短(P<0.05),双侧感觉阻滞平面至S2、不对称阻滞、麻醉医师干预的发生率及NRS2评分降低(P<0.05)。与CSE组比较:DPE组和EP组Bromage评分≥1分、胎儿心动过缓、子宫收缩过频、低血压、瘙痒的发生率降低(P<0.05)。其余指标差异无统计学意义(P>0.05)。结论DPE阻滞镇痛起效快、镇痛效果好、不良反应发生率低。

Objective This study aims to evaluate the analgesia onset,block quality and side effects of dural puncture epidural technique for labor analgesia.Methods Six hundreds and sixty two American Society of Anesthesiologists(ASA)ⅠorⅡprimiparas with singleton,vertex presentation fetuses at 38 to 42 weeks'gestation with spontaneous parturiton were selected.All patients were randomly divided into 3 groups:combined spinal epidural group(group CSE),dural puncture epidural(group DPE)and epidural group(group EP).In the first 20 min,Numeric Rating Scale(NRS)score was recorded every 2 min to determine the time to reach NRS≤1,and this was the main outcome.Secondary outcomes included the occurrence of bilateral sensory block plane to the tenth thoracical(T10)or the second sacral(S2),incidence of asymmetric block,anesthesiologist supplementary intervention,catheter replacement,cesarean section or instrumental delivery,the incidence of Bromage score≥1,fetal bradycardia,excessive uterine contractions,maternal hypotension,nausea,itching,headache,nerve injury,the incidence of Apgar score less than 7 at 1 min and 5 min,the Numerical Rating Scale(NRS2)when the uterine neck whole opened,time of the first and second stage of labor.Results Compared with group CSE,the time reached NRS≤1 was longer(P<0.05)and the incidence of anesthesiologist intervention was reduced in group DPE(P<0.05);the time reached NRS≤1 was longer(P<0.05),bilateral sensory block to S2,asymmetric block and NRS2 score increased in group EP(P<0.05).Compared with group EP,the time reached NRS≤1 was shorter(P<0.05),and the incidence of bilateral sensory block to S2,asymmetric block,anesthesiologist intervention,and NRS2 score decreased in group DPE(P<0.05).Compared with group CSE,Bromage score≥1,fetal bradycardia,excessive uterine contraction,hypotension,and itching in group DPE and EP was reduced(P<0.05).Additionally,there was no significant difference in other indexes(P>0.05).Conclusions Dural puncture epidural technique has rapid analgesia,excellent analgesic effect and low incidence of side effects.