剖宫产术后产妇镇痛不全的危险因素分析

Risk factors of inadequate pain control after cesarean delivery under neuraxial anesthesia

目的 分析接受椎管内麻醉并于剖宫产术后行静脉自控镇痛(PCIA)产妇镇痛不全的危险因素。方法 筛选2017年7月至2020年7月于空军军医大学西京医院行剖宫产手术的产妇,根据术后24 h活动痛评分[采用数字等级评分(NRS)],分为轻度及以下疼痛(NRS 0~3分)组和中重度疼痛(NRS 4~10分)组,收集两组产妇的人口学、合并症、产科以及围术期资料,通过单因素和多因素logistic回归分析,甄选出可能与剖宫产术后中重度疼痛相关的危险因素。结果 最终纳入2 254例进行分析,中重度疼痛1 992例,发生率达88.4%。单因素logistic回归分析提示术后PCIA配方、术前合并妊娠期糖尿病、术中合并其他手术、术中给予硬膜外吗啡、术中静脉注射非甾体抗炎药(NSAIDs)与剖宫产术后中重度疼痛关系有统计学意义(P<0.01,P<0.05)。多因素logistic回归分析提示下列因素与剖宫产术后中重度疼痛相关:PCIA配方(舒芬太尼+纳布啡,P<0.001,OR=0.588,95%CI:0.439~0.788;芬太尼,P=0.013,OR=1.828,95%CI:1.136~2.941),妊娠合并糖尿病(P=0.013,OR=2.262,95%CI:1.184~4.320)、术中硬膜外注射吗啡(P=0.023,OR=0.428,95%CI:0.206~0.889)及术中静脉注射NSAIDs(P<0.001,OR=0.508,95%CI:0.388~0.665)。结论 妊娠合并糖尿病为剖宫产术后镇痛不全的危险因素,术中硬膜外给予吗啡、静脉注射NSAIDs可减少中度以上疼痛发生,PCIA配方选择纳布啡混合舒芬太尼相比于舒芬太尼或芬太尼亦可减少镇痛不全的发生。

Objective To analyze the risk factors of inadequate pain control in parturients who received neuraxial anesthesia and underwent patient-controlled intravenous analgesia(PCIA)after cesarean delivery(CD).Methods The parturients who underwent CD in Xijing Hospital,Air Force Medical University from July 2017 to July 2020 were screened,and according to the 24 h postoperative activity pain score[using Numerical Rating Scale(NRS)],they were divided into no to mild pain(NRS 0-3 points)group and moderate to severe pain(NRS 4-10 points)group.Demographic,co-morbidity,obstetric and perioperative data of parturients in the two groups were collected.Univariate and multivariate logistic regression analysis was used to identify the risk factors that might be related to moderate to severe pain after CD.Results Finally,2254 cases were included for analysis,and 1992 cases experienced moderate to severe pain,with an incidence of 88.4%.Univariate logistic regression analysis showed that postoperative PCIA formula,preoperative combination of gestational diabetes mellitus(GDM),intraoperative combination of other operations,intraoperative epidural morphine,and intraoperative intravenous injection of non-steroid anti-inflammatory drugs(NSAIDs)were statistically associated with moderate to severe pain after CD(P<0.01,P<0.05).Multivariate logistic regression analysis showed that the following factors were associated with moderate to severe pain after CD:PCIA formula(P<0.001,OR=0.588,95%CI:0.4390.788 in sufentanil+nalbuphine group;P=0.013,OR=1.828,95%CI:1.1362.941 in fentanyl group),GDM(P=0.013,OR=2.262,95%CI:1.1844.320),intraoperative epidural morphine(P=0.023,OR=0.428,95%CI:0.2060.889)and intraoperative intravenous injection of NSAIDs(P<0.001,OR=0.508,95%CI:0.3880.665).Conclusion GDM is a risk factor of inadequate pain control after CD under neuraxial anesthesia.Intraoperative epidural morphine and intravenous injection of NSAIDs can reduce the occurrence of moderate to severe pain after CD.Compared with sufentanil or fentanyl,the combination of nalbuphine and sufentanil in PCIA formula can also reduce the occurrence of inadequate pain control.