硬脊膜穿破硬膜外阻滞技术在剖宫产手术中的麻醉效果及安全性

Analgesic efficacy and safety of dural puncture epidural block in cesarean section

目的 探讨硬脊膜穿破硬膜外阻滞(DPE)技术用于剖宫产手术中的麻醉效果及安全性。方法 选取2021年6月至2022年9月在温州医科大学附属第二医院择期行剖宫产手术的产妇135例。采用随机数表法分为硬膜外阻滞(EP)组、DPE组和蛛网膜下腔-硬膜外联合阻滞(CSE)组,每组各45例。硬膜外穿刺成功后,EP组作硬膜外置管,DPE组用25G腰麻针刺破硬脊膜到达蛛网膜下腔(见脑脊液流出),拔掉腰麻针,作硬膜外置管,两组均硬膜外给予2%利多卡因5 mL,观察5 min无全脊麻后根据情况向硬膜外追加全量局麻药物(0.75%罗哌卡因8~12 mL);CSE组蛛网膜下腔给予0.5%罗哌卡因12.5~15.0 mg,并作硬膜外置管。比较3组产妇术中缩宫素用量、输液量、出血量以及新生儿1、5 min Apgar评分;3组产妇麻醉效果(包括感觉阻滞平面、牵拉反应程度与松弛程度评分);3组产妇在入手术室、消毒铺巾、切皮、胎儿娩出、清理腹腔、手术结束时的收缩压(SBP)、心率(HR)的变化;3组产妇不良反应、去甲肾上腺素总用量、丙泊酚使用情况。结果 3组产妇术中缩宫素用量、输液量、出血量以及新生儿1、5 min Apgar评分比较差异均无统计学意义(均P>0.05);感觉神经阻滞平面到达T6的时间与给药至切皮时间,EP组>DPE组>CSE组(P<0.01),CSE组和DPE组感觉神经最高阻滞平面高于EP组(P<0.01),且CSE组和DPE组术中牵拉反应Ⅰ级者明显多于EP组(P<0.01),Ⅲ级者明显少于EP组(P<0.01);CSE组和DPE组术中松弛程度评分明显高于EP组(P<0.01);CSE组在消毒铺巾时SBP低于EP组与DPE组(P<0.01),HR高于EP组与DPE组(P<0.01);CSE组总不良反应发生率明显高于EP组与DPE组(P<0.01),EP组和DPE组去甲肾上腺素总用量低于CSE组(P<0.01),且EP组丙泊酚使用率明显高于CSE组与DPE组(P<0.05)。结论 DPE组较EP组起效更快,镇痛效果确切,较CSE组术中血流动力学指标更稳定,不良反应更少,值得临床推广。

Objective To investigate the analgesic efficacy and safety of dural puncture epidural(DPE)block in cesarean section.Methods A total of 135 parturients undergoing elective cesarean section at the Second Affiliated Hospital of Wenzhou Medical University from June 2021 to September 2022 were randomly divided into three groups with 45 cases in each group,and epidural block(EP group),dural puncture epidural block(DPE group)and combined sponal-epidural block(CSE group)were used for anesthesia,respectively.The intraoperative oxytocin dosage,fluid infusion volume,blood loss,and 1 min and 5 min Apgar scores of newborns were compared among three groups.The anesthesia effects,including sensory blockade level,degree of traction response,and relaxation score were observed.The changes of systolic blood pressure(SBP)and heart rate(HR)were monitored at entering operation room,disinfecting and draping,skin incision,fetal delivery,abdominal cavity cleaning and the end of surgery.The adverse reactions,total dosage of norepinephrine,and administration of propofol were recorded in three groups.Results There were no significant differences in the general conditions,intraoperative oxytocin dosage,infusion volume,blood loss,and 1 min and 5 min Apgar scores of newborns among the three groups of parturients(all P>0.05).The time from administration to reaching the T6 plane and from administration to skin incision in the EP group was longer than that in the DPE group and CSE group(P<0.01).The highest level of sensory nerve block in the CSE group and DPE group was higher than that in the EP group(P<0.01).The number of grade I traction reactions during surgery in the CSE group and DPE group was significantly higher than that in the EP group(P<0.01),while the number of grade III reactions was significantly lower than that in the EP group(P<0.01).The relaxation scores during surgery in the CSE and DPE groups were significantly higher than those in the EP group(P<0.01).The average SBP of the CSE group was lower than that of the EP group and DPE group(P<0.01),while the average HR was higher than that of the EP group and DPE group(P<0.01)during disinfecting and draping.The overall incidence of adverse reactions in the CSE group was significantly higher than that in the EP and DPE groups(P<0.01).The dosage of norepinephrine used in the EP and DPE groups was lower than that in the CSE group(P<0.01),and the use of propofol in the EP group was significantly higher than that in the CSE and DPE groups(P<0.05).Conclusion Compared with CSE block,DPE block takes shorter time to achieve adequate analgesia effect in cesarean section,and it is also associated with less adverse reactions and better hemodynamic stability,indicating that DPE blosk is worthy of clinical promotion.