不同剂量纳布啡复合舒芬太尼在硬膜外分娩镇痛中的应用效果及对母婴的影响

Application effect of different doses of nalbuphine combined with sufentanil in epidural labor analgesia and its influence on parturients and infants

目的探讨不同剂量纳布啡复合舒芬太尼在硬膜外分娩镇痛中的应用效果及对母婴的影响。方法采用前瞻性方法,选择2022年1月至2024年1月于唐山市妇幼保健院行阴道分娩并自愿接受分娩镇痛的单胎初产妇160例,年龄23~35岁,身体质量指数(body mass index,BMI)25~35 kg/m^(2),美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级Ⅰ或Ⅱ级。采用随机数字表法将其分为4组:C组(舒芬太尼0.4μg/L+0.1%盐酸罗哌卡因)、N1组(纳布啡0.05 g/L+舒芬太尼0.4μg/L+0.1%盐酸罗哌卡因)、N2组(纳布啡0.1 g/L+舒芬太尼0.4μg/L+0.1%盐酸罗哌卡因)和N3组(纳布啡0.15 g/L+舒芬太尼0.4μg/L+0.1%盐酸罗哌卡因),每组各40例。4组产妇均进行自控硬膜外镇痛(patient-controlled epidural analgesia,PCEA)。观察4组产妇分娩镇痛前(T_(0))、分娩镇痛开始后30 min(T_(1))、分娩镇痛开始后60 min(T_(2))、宫口开全时(T_(3))、开始分娩时(T_(4))以及产后2 h(T_(5))的一般生命体征、疼痛视觉模拟评分(visual analogue scale,VAS)、Ramsay镇静评分。记录镇痛起效时间、镇痛持续时间、自控镇痛泵按压次数,以及产妇和新生儿不良反应的发生率,并记录新生儿Apgar评分及新生儿行为神经测定(neonatal behavioral neurological assessment,NBNA)评分以及产妇蒙特利尔认知评估量表(Montreal cognitive assessment,MoCA)评分、符号数字转换测验90(symbol digit modalities test 90,SDMT 90)评分。统计学方法采用t检验、重复测量方差分析、χ^(2)检验。结果与T_(0)时比较,4组产妇镇痛开始后各时间点疼痛VAS评分均降低,Ramsay镇静评分均升高,差异均有统计学意义(P<0.05)。与C组比较,其余3组产妇镇痛开始后疼痛VAS评分、镇痛起效时间、自控镇痛泵按压次数均降低,Ramsay镇静评分及镇痛持续时间均升高,N2组与N3组产妇恶心呕吐及皮肤瘙痒发生率均降低,差异均有统计学意义(P<0.05)。与N1组比较,N2组及N3组产妇镇痛开始后疼痛VAS评分、镇痛起效时间、自控镇痛泵按压次数、并发症发生率均降低,镇痛持续时间升高,N3组产妇Ramsay镇静评分及嗜睡发生率均升高,差异均有统计学意义(P<0.05)。与N2组比较,N3组产妇镇痛开始后Ramsay镇静评分及嗜睡发生率均升高,差异均有统计学意义(P<0.05)。4组新生儿出生后1 min和5 min Apgar评分、胎儿窘迫发生率、湿肺发生率比较,差异均无统计学意义(P>0.05)。随访发现,4组新生儿的NBNA评分及产妇的MoCA评分、SDMT90评分差异均无统计学意义(P>0.05)。结论0.1 g/L纳布啡联合0.4μg/L舒芬太尼和0.1%盐酸罗哌卡因硬膜外分娩镇痛效果满意,不良反应发生率低,且对新生儿及产妇的神经功能无影响,可安全、有效地应用于产妇的分娩镇痛。

Objective To investigate the effect of different doses of nalbuphine combined with sufentanil in epidural labor analgesia and its effect on parturients and infants.Method Prospective selection of 160 single primiparou women who chosed vaginal delivery and voluntarily accepted epidural analgesia in Tangshan Maternal and Child Health Hospital from January 2022 to January 2024 were conducted,aged 23-35 years,with a body mass index(BMI)of 25-35 kg/m^(2),and American Society of Anesthesiologists(ASA)gradeⅠorⅡ.They were divided into 4 groups by random number table method,including group C(sufentanil 0.4μg/L+0.1%ropivacaine),group N1(nalbuphine 0.05 g/L+sufentanil 0.4μg/L+0.1%ropivacaine),group N2(nalbuphine 0.1g/L+sufentanil 0.4μg/L+0.1%ropivacaine),and group N3(nalbuphine 0.15 g/L+sufentanil 0.4μg/L+0.1%ropivacaine),with 40 cases in each group.All patients in four groups were given patient-controlled epidural analgesia(PCEA).The general vital signs,visual analogue scale(VAS)of pain,Ramsay sedation score of the patients were observed before labor analgesia(T_(0)),30 min after labor analgesia started(T_(1)),60 min after labor analgesia started(T_(2)),at the time of cervix opening(T_(3)),at the time of delivery start(T_(4)),and 2 h after delivery(T_(5)).The onset time of analgesia,duration of analgesia,number of PCEA button presses,incidence of adverse reactions in the parturients and the infants,and the Apgar score and neonatal behavioral neurological assessment(NBNA)score of the infants and maternal Montreal cognitive assessment(MoCA)score and symbol digit modalities test 90(SDMT 90)score were recorded.Statistical methods performed by t-test,repeated measures ANOVA,andχ^(2)test.Result Compared with T_(0),VAS score of pain was significantly decreased and Ramsay sedation score was increased at each time after analgesia in four groups,the differences were statistically significant(P<0.05).Compared with group C,VAS score of pain,onset time of analgesia,the number of patient-controlled analgesic pump compressions were decreased,Ramsay sedation score and duration of analgesia were increased in three groups.The incidence of nausea,vomiting and pruritus in group N2 and group N3 were significantly decreased,the differences were statistically significant(P<0.05).Compared with group N1,VAS score of pain,onset time of analgesia,the number of patient-controlled analgesic pump compressions,the incidence of complications were decreased,duration of analgesia in group N2 and group N3 were increased,Ramsay sedation score and incidence of drowsiness in group N3 were increased,the differences were statistically significant(P<0.05).Compared with group N2,Ramsay sedation score and incidence of drowsiness in group N3 were increased after the onset of analgesia,the differences were statistically significant(P<0.05).There were no significant differences in 1 min and 5 min Apgar score after birth,the incidence of fetal distress and wet lung among the four groups(P>0.05).There were no significant differences in NBNA score of infants,MoCA scale score and SDMT90 score of parturients among the four groups(P>0.05).Conclusion The analgesic effect of 0.1 g/L nalbuphine combined with 0.4μg/L sufentanil and 0.1%ropivacaine for epidural labor analgesia is satisfactory,the incidence of adverse reactions is low,and has no effect on the neurological function of infants and parturients.It can be safely and effectively applied to labor analgesia in parturients.