程控硬膜外脉冲式输注不同剂量罗哌卡因复合舒芬太尼行阶梯式分娩镇痛对母婴的影响

Effect of programmed intermittent epidural bolus with stepwise doses of ropivacaine mixed with sufentanil for labor analgesia on the parturients and the infants

目的探讨程控硬膜外脉冲式输注不同剂量罗哌卡因复合舒芬太尼行阶梯式分娩镇痛对母婴的影响。方法选取拟经阴道分娩足月妊娠初产妇141例,年龄22~35岁,BMI 18.5~30.0 kg/m 2,ASAⅠ或Ⅱ级,采用随机数字表法分为三组:对照组(C组)、阶梯式1组(S1组)和阶梯式2组(S2组),每组30例。三组均于L 3-4椎间隙穿刺行硬膜外分娩镇痛,镇痛泵配方为0.08%罗哌卡因+0.5μg/ml舒芬太尼。C组在分娩全程脉冲剂量为6 ml/h;S1组在宫口<3 cm时,脉冲剂量为6 ml/h,宫口≥3 cm时,脉冲剂量为8 ml/h;S2组在宫口<3 cm时,脉冲剂量为6 ml/h,宫口≥3 cm时,脉冲剂量为10 ml/h。记录宫口开3 cm、宫口开6 cm、宫口开全、分娩即刻产妇VAS疼痛评分。记录产程时间、镇痛泵按压次数、镇痛药使用总量、缩宫素使用情况、分娩方式、下肢运动功能(Bromage评分)及不良反应。胎儿脕出后,自全呼吸前,采集新生儿脐动脉血行血气分析,记录新生儿出生后1 min和5 min时Apgar评分。结果宫口开6 cm及宫口开全时S1组、S2组VAS疼痛评分明显低于C组,镇痛泵按压次数明显少于C组(P<0.05),且S2组VAS疼痛评分明显低于S1组,镇痛泵按压次数明显少于S1组(P<0.05);S1组、S2组第一产程和总产程时间均明显短于C组(P<0.05);S2组镇痛药使用总量明显少于C组,新生儿脐动脉Lac浓度明显低于C组(P<0.05)。三组缩宫素使用率、分娩方式、Bromage评分、不良反应及新生儿Apgar评分差异无统计学意义。结论采用程控硬膜外脉冲式输注罗哌卡因复合舒芬太尼行阶梯式分娩镇痛安全有效,且宫口≥3 cm时脉冲剂量10 ml/h镇痛效果更好,麻醉用药总量少,对母婴影响小。

Objective To explore the effect of programmed intermittent epidural bolus with stepwise doses of ropivacaine mixed with sufentanil for labor analgesia on the parturients and the infants.Methods A total of 141 parturients with full-term(gestational age≥37 weeks),primiparas,aged 22-35 years,with a BMI 18.5-30.0 kg/m 2,falling into ASA physical statusⅠorⅡ,were included the present study and randomized to one of the three groups(group C,S1,or S2),30 cases in each group.All the three groups were given epidural labor analgesia through L 3-4 intervertebral space.The analgesia solution was 0.08%ropivacaine+0.5μg/ml sufentanil.When the cervical dilatation was<3 cm,the hourly pulsed bolus dose in groups C,S1 and S2 were 6 ml.When the cervical dilatation was≥3 cm,the hourly pulsed bolus dose was 6 ml in group C,8 ml in group S1 and 10 ml in group S2.For all the groups,the loading dose was 10 ml,the patient-requested dose was 6 ml with a 30 min lockout time and the infusion rate of loading dose and bolus were 2 ml/min.The VAS scores at the time when cervical dilatation was 3,6,10 cm,and at the time of baby delivery were recorded.The total dose of local anesthetics and analgesic administered,duration of labor stages,proportion of patient-controlled epidural analgesia(PCEA)request,dose of oxytocin administered,type of delivery and Bromage score and the incidence of maternal adverse reactions were also recorded.Neonatal umbilical artery blood gas was analyzed and the 1-minute and 5-minute Apgar score were collected.Results The VAS scores at the time of the cervical dilatation of 6 cm and the 10 cm in group S1 and group S2 were lower than those in group C,and the lowest was in group S2(P<0.05).The total numbers of PCEA in groups S1 and S2 were fewer than those in group C,and the fewest was in group S2(P<0.05).The first stage of labor and total duration of labor were shorter in groups S1 and S2 than in group C(P<0.05).The total dose of analgesic used in group S2 was significantly less than that in group C(P<0.05),and the umbilical artery Lac level in group S2 was significantly lower than that in group C(P<0.05).No differences in the oxytocin consumption,type of delivery,Bromage score and neonatal Apgar score were found among the groups.Conclusion Programmed intermittent epidural bolus with stepwise doses of ropivacaine mixed with sufentanil for labor analgesia can provide effective and safe analgesia,and our study suggests that the hourly pulsed bolus dose of 10 ml after cervical dilation of 3 cm has better analgesic effects and less influence on parturients and infants with less dosage of drug.