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近年来随着分娩镇痛技术在国内大力发展,麻醉医生们也越来越关注研究起效快效果确切并且相关并发症更少的镇痛方法。目前国内外越来越多的临床研究表明程控硬膜外间歇脉冲注入(programmed intermittent epidural bolus, PIEB)的方式,与传统的持续背景输注比较,PIEB具有追加率更低、用药量更少、视觉模拟评分法(visual analogue scale, VAS)评分更低、不良反应无明显增加及产妇的满意度更高等优点[1-5]。硬膜外穿透后硬膜外麻醉(dural puncture epidural, DPE)是一种区别于硬膜外和腰硬联合的技术,它是应用腰麻针戳破硬膜外,但不直接向蛛网膜下腔注药,而仍在硬膜外置管用药,而部分药物可能通过硬膜上的穿透孔加速药物完成了鞘内注射[6]。CAPPIELLO等[7]也报道,DPE技术在分娩镇痛中应用可获得良好的效果。本研究采用DPE联合PIEB的方式用于分娩镇痛,与目前常用的单纯持续硬膜外镇痛(continuous epidural analgesia, CEA)联合PIEB进行对比,观察DPE联合PIEB在分娩镇痛中的安全性、有效性及相关的并发症情况。现作报道。
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2组产妇的年龄、身高、体质量和是否经产妇差异无统计学意义(P>0.05)。所有产妇均成功实施了分娩镇痛,产程中2组产妇生命体征(BP、HR、SpO2、RR)和胎心率平稳,差异无统计学意义(P>0.05)(见表 1、2)。
分组 n 年龄/岁 身高/cm 体质量/kg 是否经产妇 经产妇 初产妇 A组 30 28.6±3.9 161.2±5.7 72.3±3.2 18 12 B组 30 30.2±2.6 160.8±4.3 74.2±4.7 19 11 t — 1.87 0.31 1.83 0.07* P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组一般情况比较(x±s)
分组 n T0 T1 T2 T3 T4 T5 T6 T7 F P MS组内 收缩压/mmHg A组 30 126.3±12.2 122.1±12.9 124.4±13.5 124.6±13.2 126.2±12.7 126.3±13.5 126.5±12.7 124.9±12.8 0.48 >0.05 169.213 B组 30 123.5±12.6 122.9±13.1 123.4±13.4 125.1±12.8 127.1±13.4 125.7±12.8 125.7±12.6 125.6±12.5 0.47 >0.05 169.528 t — 0.87 0.24 0.29 0.15 0.27 0.18 0.25 0.21 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 舒张压/mmHg A组 30 80.6±6.5 78.9±6.7 78.4±6.7 79.5±7.6 79.8±8.1 80.7±8.5 80.7±6.8 80.4±7.2 0.46 >0.05 54.608 B组 30 81.6±6.9 78.5±6.8 78.6±7.2 79.3±7.3 80.3±7.6 80.5±7.5 80.5±6.7 80.9±7.6 0.85 >0.05 52.165 t — 0.58 0.23 0.11 0.10 0.25 0.10 0.11 0.26 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — HR/(次/分) A组 30 98.3±9.5 98.5±9.7 98.3±9.5 98.6±9.4 98.6±9.5 98.5±9.7 98.4±9.6 98.3±9.7 0.01 >0.05 91.215 B组 30 98.6±9.6 98.7±9.8 98.5±9.3 98.7±9.6 98.3±9.8 98.7±9.5 98.2±9.3 98.2±9.2 0.01 >0.05 92.190 t — 0.12 0.08 0.08 0.04 0.12 0.08 0.08 0.04 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — SpO2/% A组 30 98.6±2.4 98.7±2.3 98.5±2.6 98.5±2.3 98.6±2.8 98.7±2.9 98.6±2.6 98.6±2.5 0.04 >0.05 6.558 B组 30 98.5±2.6 98.6±2.9 98.6±2.3 98.7±2.5 98.5±2.7 98.3±2.1 98.7±2.3 98.5±2.6 0.09 >0.05 6.402 t — 0.15 0.15 0.16 0.32 0.14 0.61 0.16 0.15 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — RR/(次/分) A组 30 13.5±4.6 14.6±5.2 15.4±5.1 13.5±5.3 13.4±4.3 13.5±3.8 13.6±4.2 14.3±4.9 0.91 >0.05 22.538 B组 30 13.9±4.9 14.8±4.6 15.6±5.1 13.9±4.2 13.8±4.9 13.9±3.7 14.2±4.3 13.9±3.8 0.76 >0.05 21.087 t — 0.33 0.16 0.15 0.32 0.34 0.41 0.55 0.35 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 胎心率/(次/分) A组 30 138.5±8.2 137.6±7.8 136.5±6.9 139.5±8.4 139.2±6.7 137.5±8.3 135.9±6.9 136.9±7.3 0.64 >0.05 60.458 B组 30 136.9±8.3 139.1±7.9 136.4±8.2 138.6±6.9 137.6±8.2 136.9±8.5 136.8±6.8 138.2±7.5 0.56 >0.05 60.548 t — 0.75 0.74 0.05 0.45 0.83 0.28 0.51 0.68 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 表 2 产程中2组产妇生命体征和胎心率比较(x±s)
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2组产妇T1~T7时间点的VAS评分均较T0降低(P < 0.05),B组T1~T4的VAS评分均低于A组,差异有统计学意义(P < 0.05), 2组产妇所有时间点的改良Bromage评分均为0分(见表 3)。
分组 n T0 T1 T2 T3 T4 T5 T6 T7 F MS组内 P A组 30 9.9±0.5 7.6±2.0* 5.8±1.9* 4.6±2.1* 3.6±1.8* 3.3±1.3* 3.0±1.9 2.9±1.7 68.19 2.867 < 0.05 B组 30 9.6±0.7 2.7±2.6* 2.4±2.3* 2.3±2.1* 2.6±1.9* 3.3±2.0* 2.8±2.0 2.8±1.9 59.73 4.093 <0.05 t — 1.91 8.18 6.24 4.24 2.09 0.00 0.40 0.21 — — — P — >0.05 < 0.01 < 0.01 < 0.01 < 0.05 >0.05 >0.05 >0.05 — — — 与T0比较*P < 0.05 表 3 2组病人不同时间的镇痛效果比较(x±s; 分)
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2组新生儿Apgar评分、产程、分娩方式差异无统计学意义(P>0.05)。B组产妇按压镇痛泵的次数、镇痛药物用量少于A组(P < 0.01和P < 0.05)。B组产妇满意度高于A组(P < 0.05) (见表 4)。
分组 n 新生儿Apgar评分/分 产程/min 分娩方式[n; 百分率(%)] 镇痛泵按压次数/次 舒芬太尼用量/mg 产妇满意度/分 1 min 5 min 第一产程 第二产程 第三产程 剖宫产 自然分娩 A组 30 9.2±1.3 10.0±0.0 389.2±126.3 47.3±10.8 8.8±1.8 2(6.7) 28(93.3) 4.8±1.2 58.7±25.7 8.3±1.5 B组 30 9.3±1.5 10.0±0.0 396.6±140.9 45.2±13.6 9.0±1.6 0(0.0) 30(100.0) 2.0±0.9 43.5±25.2 9.4±1.1 t — 0.28 0.00 0.21 0.66 0.45 0.52* 10.15 2.31 3.24 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.05 < 0.05 *示χ2值 表 4 2组产妇分娩过程及结局比较(x±s)
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2组产妇术后均发生不同程度的恶心、瘙痒及头痛,2组并发症发生差异无统计学意义(P>0.05)(见表 5)。
分组 n 恶心 瘙痒 头痛 总不良反应 χ2 P A组 30 1(3.3) 0(0.0) 0(0.0) 1(3.3) B组 30 1(3.3) 1(3.3) 0(0.0) 2(6.7) 3.45 >0.05 合计 60 2(3.3) 1(3.3) 0(0.0) 3(5.0) 表 5 分娩不良反应比较[n; 百分率(%)]
硬膜穿孔后硬膜外联合程控硬膜外间歇脉冲注入在分娩镇痛中的应用
The application value of DPE combined with PIEB in labor analgesia after epidural perforation
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摘要:
目的探讨硬膜穿孔后硬膜外(dural puncture epidural,DPE)镇痛联合程控硬膜外间歇脉冲注入(programmed intermittent epidural bolus,PIEB)在分娩镇痛中的安全性和有效性。 方法选择自愿接受分娩镇痛的单胎足月初产妇60名,随机分为单纯硬膜外(continuous epidural analgesia,CEA)联合PIEB分娩镇痛组(A组)和DPE联合PIEB分娩镇痛组(B组)。A组产妇实施硬膜外穿刺置管。B组在硬膜外穿刺成功后放入25G腰麻穿刺针,以发现脑脊液回流为准,不注药,行硬膜外置管,药物配方及PIEB设置2组相同。记录镇痛前(T0)、镇痛后5 min(T1)、镇痛后10 min(T2)、镇痛后15 min(T3)、镇痛后20 min(T4)、镇痛后1 h(T5)、宫口开全(T6)和胎儿娩出(T7)时的视觉模拟评分法(visual analogue scale,VAS)评分和运动阻滞情况;记录各组自控镇痛(patient controlled epidur alanalgesia,PCEA)次数、舒芬太尼的用量、镇痛不良反应、产程及分娩方式结果、产妇满意度。 结果所有产妇均成功实施了分娩镇痛,产程中2组产妇的生命体征(血压、心率、血氧饱和度、呼吸频率)和胎心率平稳,无明显变化(P>0.05)。2组产妇T1~T7时间点的VAS评分较T0降低(P < 0.05),B组T1~T4的VAS评分低于A组(P < 0.05)。2组新生儿Apgar评分、产程、分娩方式差异无统计学意义(P>0.05)。B组产妇按压镇痛泵的次数、镇痛药物用量少于A组(P < 0.05)。B组产妇满意度高于A组(P < 0.05)。2组产妇术后改良Bromage差异无统计学意义(P>0.05),术后2组并发症发生差异无统计学意义(P>0.05)。 结论DPE联合PIEB是安全、有效的镇痛方法,可用于分娩镇痛。 -
关键词:
- 硬膜穿孔后硬膜外 /
- 程控硬膜外间歇脉冲注入 /
- 分娩镇痛
Abstract:ObjectiveTo investigate the safety and effectiveness of dural puncture epidural(DPE) analgesia combined with programmed epidural intermittent pulse injection(PIEB) in labor analgesia after epidural perforation. MethodsSixty parturient women were randomly divided into group A[treatment with continuous epidural analgesia(CEA) combined with PIEB] and group B(treatment with DPE combined with PIEB).The group A were treated with epidural puncture and catheterization.After successful epidural puncture, the 25G lumbar anesthetic needle was placed in group B, and the epidural tube was placed without injection after cerebrospinal fluid reflux was found.The drug formulation and PIEB settings in group B were the same as the group A.The visual analogue scale(VAS) scores and motor block in two groups before analgesia(T0), after 5 minutes, 10 minutes, 15 minutes, 20 minutes and 1 hour of analgesia(T1, T2, T3, T4 and T5, respectively), full cervical dilation(T6) and during delivery of fetus(T7) were recorded.The controlled epidur alanalgesia(PCEA) frequency, dosage of analgesic drug, analgesic adverse reactions, labor process, delivery results and maternal satisfaction were recorded in two groups. ResultsThe labor analgesian in all parturient women were successfully performed, and the vital signs(including blood pressure, heart rate, pulse oxygen saturation and respiratory rate) and fetal heart rate in two groups were stable during the labor process(P>0.05).The VAS scores in two groups at T1 to T7 time points were significantly lower than at T0(P < 0.05), and the VAS scores in group B at T1 to T4 were significantly lower than those in group A(P < 0.05).There was no statistical significance in Apgar score, labor process and delivery method between two groups(P>0.05).The number of times of pressing analgesic pump and dosage of analgesics in group B were significantly less than those in group A(P < 0.05).The maternal satisfaction in group A was significantly higher than that in group B(P < 0.05).There was no statistical significance in postoperative modified Bromage between two groups(P>0.05), and there was no statistical significance in postoperative complications between two groups(P>0.05). ConclusionsDPE combined with PIEB is a safe and effective method of analgesia, and which can be used for labor analgesia. -
表 1 2组一般情况比较(x±s)
分组 n 年龄/岁 身高/cm 体质量/kg 是否经产妇 经产妇 初产妇 A组 30 28.6±3.9 161.2±5.7 72.3±3.2 18 12 B组 30 30.2±2.6 160.8±4.3 74.2±4.7 19 11 t — 1.87 0.31 1.83 0.07* P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 产程中2组产妇生命体征和胎心率比较(x±s)
分组 n T0 T1 T2 T3 T4 T5 T6 T7 F P MS组内 收缩压/mmHg A组 30 126.3±12.2 122.1±12.9 124.4±13.5 124.6±13.2 126.2±12.7 126.3±13.5 126.5±12.7 124.9±12.8 0.48 >0.05 169.213 B组 30 123.5±12.6 122.9±13.1 123.4±13.4 125.1±12.8 127.1±13.4 125.7±12.8 125.7±12.6 125.6±12.5 0.47 >0.05 169.528 t — 0.87 0.24 0.29 0.15 0.27 0.18 0.25 0.21 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 舒张压/mmHg A组 30 80.6±6.5 78.9±6.7 78.4±6.7 79.5±7.6 79.8±8.1 80.7±8.5 80.7±6.8 80.4±7.2 0.46 >0.05 54.608 B组 30 81.6±6.9 78.5±6.8 78.6±7.2 79.3±7.3 80.3±7.6 80.5±7.5 80.5±6.7 80.9±7.6 0.85 >0.05 52.165 t — 0.58 0.23 0.11 0.10 0.25 0.10 0.11 0.26 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — HR/(次/分) A组 30 98.3±9.5 98.5±9.7 98.3±9.5 98.6±9.4 98.6±9.5 98.5±9.7 98.4±9.6 98.3±9.7 0.01 >0.05 91.215 B组 30 98.6±9.6 98.7±9.8 98.5±9.3 98.7±9.6 98.3±9.8 98.7±9.5 98.2±9.3 98.2±9.2 0.01 >0.05 92.190 t — 0.12 0.08 0.08 0.04 0.12 0.08 0.08 0.04 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — SpO2/% A组 30 98.6±2.4 98.7±2.3 98.5±2.6 98.5±2.3 98.6±2.8 98.7±2.9 98.6±2.6 98.6±2.5 0.04 >0.05 6.558 B组 30 98.5±2.6 98.6±2.9 98.6±2.3 98.7±2.5 98.5±2.7 98.3±2.1 98.7±2.3 98.5±2.6 0.09 >0.05 6.402 t — 0.15 0.15 0.16 0.32 0.14 0.61 0.16 0.15 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — RR/(次/分) A组 30 13.5±4.6 14.6±5.2 15.4±5.1 13.5±5.3 13.4±4.3 13.5±3.8 13.6±4.2 14.3±4.9 0.91 >0.05 22.538 B组 30 13.9±4.9 14.8±4.6 15.6±5.1 13.9±4.2 13.8±4.9 13.9±3.7 14.2±4.3 13.9±3.8 0.76 >0.05 21.087 t — 0.33 0.16 0.15 0.32 0.34 0.41 0.55 0.35 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 胎心率/(次/分) A组 30 138.5±8.2 137.6±7.8 136.5±6.9 139.5±8.4 139.2±6.7 137.5±8.3 135.9±6.9 136.9±7.3 0.64 >0.05 60.458 B组 30 136.9±8.3 139.1±7.9 136.4±8.2 138.6±6.9 137.6±8.2 136.9±8.5 136.8±6.8 138.2±7.5 0.56 >0.05 60.548 t — 0.75 0.74 0.05 0.45 0.83 0.28 0.51 0.68 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — 表 3 2组病人不同时间的镇痛效果比较(x±s; 分)
分组 n T0 T1 T2 T3 T4 T5 T6 T7 F MS组内 P A组 30 9.9±0.5 7.6±2.0* 5.8±1.9* 4.6±2.1* 3.6±1.8* 3.3±1.3* 3.0±1.9 2.9±1.7 68.19 2.867 < 0.05 B组 30 9.6±0.7 2.7±2.6* 2.4±2.3* 2.3±2.1* 2.6±1.9* 3.3±2.0* 2.8±2.0 2.8±1.9 59.73 4.093 <0.05 t — 1.91 8.18 6.24 4.24 2.09 0.00 0.40 0.21 — — — P — >0.05 < 0.01 < 0.01 < 0.01 < 0.05 >0.05 >0.05 >0.05 — — — 与T0比较*P < 0.05 表 4 2组产妇分娩过程及结局比较(x±s)
分组 n 新生儿Apgar评分/分 产程/min 分娩方式[n; 百分率(%)] 镇痛泵按压次数/次 舒芬太尼用量/mg 产妇满意度/分 1 min 5 min 第一产程 第二产程 第三产程 剖宫产 自然分娩 A组 30 9.2±1.3 10.0±0.0 389.2±126.3 47.3±10.8 8.8±1.8 2(6.7) 28(93.3) 4.8±1.2 58.7±25.7 8.3±1.5 B组 30 9.3±1.5 10.0±0.0 396.6±140.9 45.2±13.6 9.0±1.6 0(0.0) 30(100.0) 2.0±0.9 43.5±25.2 9.4±1.1 t — 0.28 0.00 0.21 0.66 0.45 0.52* 10.15 2.31 3.24 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.05 < 0.05 *示χ2值 表 5 分娩不良反应比较[n; 百分率(%)]
分组 n 恶心 瘙痒 头痛 总不良反应 χ2 P A组 30 1(3.3) 0(0.0) 0(0.0) 1(3.3) B组 30 1(3.3) 1(3.3) 0(0.0) 2(6.7) 3.45 >0.05 合计 60 2(3.3) 1(3.3) 0(0.0) 3(5.0) -
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