硬膜外注射小剂量艾司氯胺酮对剖宫产椎管内麻醉后寒战及术后恢复质量的影响

Effect of epidural injection of low-dose esketamine on shivering after intrathecal anesthesia for cesarean sections and postoperative recovery quality

目的评估硬膜外注射小剂量艾司氯胺酮对剖宫产椎管内麻醉后寒战发生率和产妇术后恢复质量的影响。方法选择行择期椎管内麻醉下剖宫产手术的单胎妊娠产妇158例, 采用随机数字表法分为两组(每组79例):艾司氯胺酮组(E组)和对照组(C组)。腰硬联合麻醉(combined spinal and epidural anesthesia, CSEA)后, E组以0.2 ml/s的速度经硬膜外导管向硬膜外腔推注0.25 mg/kg的艾司氯胺酮5 ml, C组推注等体积生理盐水。比较两组产妇术前状态-特质焦虑量表(State-Trait Anxiety Inventory, S-TAI)评分[包括状态焦虑量表(State Anxiety Inventory, S-AI)评分和特质焦虑量表(Trait Anxiety Inventory, T-AI)评分]、术前40项恢复质量量表(40-item Quality of Recovery Score, QoR-40)评分(包括情绪、身体舒适度、心理支持、行为独立和疼痛5个维度评分及总分)、胸神经感觉阻滞平面、术中失血量和手术时间等一般情况, 椎管内麻醉后中重度寒战的总发生率, 90 min内的警觉/镇静评估(Observer''s Assessment of Alertness/Sedation, OAA/S)评分;新生儿出生后1 min Apgar评分和5 min Apgar评分, 新生儿脐动脉血pH值、PaO_(2)、PaCO_(2)、血氧饱和度(oxyhemoglobin saturation, SaO_(2))、乳酸水平;记录两组产妇术中不良反应(包括低血压、呼吸困难、心动过缓、恶心、呕吐、头晕)的发生情况, 术后24、48 h QoR-40评分情况。结果 E组椎管内麻醉后90 min内中重度寒战的总发生率、椎管内麻醉后30 min OAA/S评分低于C组(P<0.05)。E组术后24 h QoR-40评分在情绪、身体舒适度、心理支持3个维度及总分, 术后48 h QoR-40评分在情绪、心理支持两个维度及总分, 高于C组(P<0.05)。其余指标差异均无统计学意义(P>0.05)。结论硬膜外注射小剂量艾司氯胺酮能够降低剖宫产手术椎管内麻醉后中重度寒战的发生率, 具有轻度的术中镇静作用并且能够改善产妇的术后恢复质量。

Objective To evaluate the effect of epidural injection of low-dose esketamine on the incidence of shivering after intrathecal anesthesia for cesarean sections and the quality of postoperative recovery in parturients.Methods A total of 158 singleton pregnant women undergoing elective cesarean sections under intrathecal anesthesia were selected.According to the random number table method,they were divided into two groups(n=79):an esketamin group(group E)and a control group(group C).After combined spinal and epidural anesthesia(CSEA),group E was administered with 5 ml of 0.25 mg/kg esketamine through epidural infusion via epidural catheter,whereas group C was given the same volume of normal saline.Both groups were compared for the preoperative State-Trait Anxiety Inventory(S-TAI)score[including the State Anxiety Inventory(S-AI)scores and Trait Anxiety Inventory(T-AI)scores],40-item Quality of Recovery Score(QoR-40),thoracic nerve sensory block plane,intraoperative blood loss and duration of operation.Furthermore,the total incidence of moderate and severe shivering after spinal anesthesia and the Observer's Assessment of Alertness/Sedation(OAA/S)score within 90 min were compared.The following parameters in newborns were recorded:the Apgar score at 1 min and 5 min after birth,as well as pH value,arterial partial pressure of oxygen(PaO_(2)),arterial partial pressure of carbon dioxide(PaCO_(2)),oxyhemoglobin saturation(SaO_(2))and lactic acid level in the umbilical artery blood.The incidences of adverse reactions(including hypotension,dyspnea,bradycardia,nausea,vomiting and dizziness)in the two groups were compared.Meanwhile,the scores of QoR-40(including five dimensions of emotional,physical comfort,psychological support,behavioral independence,and pain scores and total scores)were recorded at postoperative 24 h and 48 h the two groups.Results Group E showed remarkable decreases in the total incidence of moderate and severe shivering within 90 min after spinal anesthesia,and the OAA/S score at 30 min after spinal anesthesia,compared with group C(P<0.05).Furthermore,compared with group C,group E presented increases in the QoR-40 scores at postoperative 24 h in the dimensions of emotion,physical comfort,and psychological support,and the total score,as well as the QoR-40 scores at postoperative 48 h in the dimensions of emotion and psychological support,and the total score(P<0.05).There was no statistical difference in other indicators(P>0.05).Conclusions Epidural injection of low-dose esketamine can reduce the incidence of moderate and severe shivering after CSEA for cesarean sections.It also has slight sedative effect during operation and can improve the postoperative recovery of parturients.