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腰麻联合硬膜外麻醉因起效快,麻醉效果确切,可获得满意的肌松,现已广泛应用于剖宫产手术,但这种麻醉方式最大的隐患是麻醉后可能出现产妇低血压,从而导致胎盘血流减少,影响胎儿安全。为了减轻对母婴的影响,临床现多采取液体扩容、调整体位、使用血管活性药物以及几者相结合的方式预防麻醉后低血压。临床工作证实,预防性使用缩血管药物,如麻黄碱、甲氧明、去氧肾上腺素、去甲肾上腺素等,可以减少腰麻联合硬膜外麻醉后剖宫产低血压的发生[1-2]。
去甲肾上腺素为较强的α受体激动剂,对β1受体作用较弱,对β2受体几乎无作用,近年来开始使用于产科麻醉中。临床使用去甲肾上腺素,多以治疗为主,预防性治疗不多。本研究探讨去甲肾上腺素麻醉前预泵注对剖宫产病人麻醉后血流动力学的影响。现作报道。
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2组病人手术时间、麻醉操作时间及出血量差异均无统计学意义(P>0.05)(见表 1)。
分组 n 出血量/mL 手术时间/min 麻醉操作时间/min 对照组 30 260.0±56.32 41.3±8.79 4.6±1.08 观察组 30 246.6±62.88 38.8±6.46 4.5±1.19 t — 0.87 1.26 0.34 P — >0.05 >0.05 >0.05 表 1 2组病人手术指标比较(x±s)
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2组病人T0时MAP、HR差异均无统计学意义(P>0.05);观察组T2时MAP高于对照组(P < 0.05),T2、T3时HR低于对照组(P < 0.01和P < 0.05);与T0时比较,对照组病人MAP在麻醉后有所降低,但差异无统计学意义(P>0.05),T2、T3时HR增快明显(P < 0.05);观察组病人各时点MAP和HR与T0时差异均无统计学意义(P>0.05)(见表 2)。
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 MAP/mmHg 对照组 30 89.00±9.42 87.16±9.43 85.13±8.05 85.50±6.33 86.76±5.94 85.70±6.38 1.03 >0.05 59.821 观察组 30 87.86±8.58 86.33±5.65 88.9±5.31 85.76±5.51 85.63±4.96 86.16±4.94 1.45 >0.05 35.582 t — 0.52 0.45 2.16 0.13 0.78 0.27 — — — P — >0.05 >0.05 < 0.05 >0.05 >0.05 >0.05 — — — HR/(次/分) 对照组 30 89.46±9.61▲■ 91.33±7.06▲ 95.40±6.39#*△ 94.70±5.55#△ 90.26±7.82▲■ 89.16±8.20▲■ 3.81 < 0.01 57.113 观察组 30 89.26±8.30 90.06±8.30 89.13±9.42 89.90±10.66 86.80±9.00 86.80±8.98 0.73 >0.05 83.440 t — 0.09 0.35 3.03 2.19 1.59 1.07 — — — P — >0.05 >0.05 < 0.01 < 0.05 >0.05 >0.05 — — — q检验:与T0比较#P < 0.05;与T1比较*P < 0.05;与T2比较▲P < 0.05;与T3比较■P < 0.05;与T4比较△P < 0.05 表 2 2组病人MAP、HR比较(x±s)
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2组病人低血压、高血压、恶心呕吐和心动过缓发生率差异均无统计学意义(P>0.05)(见表 3)。
分组 n 低血压 高血压 恶心呕吐 心动过缓 对照组 30 4(13.33) 0(0.00) 3(10.00) 0(0.00) 观察组 30 1(3.33) 1(3.33) 0(0.00) 1(3.33) χ2 — 0.87 — 1.40 — P — >0.05 >0.05 >0.05 >0.05 表 3 2组病人不良反应发生率比较[n;百分率(%)]
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2组新生儿1 min、5 min Apgar评分差异均无统计学意义(P>0.05)(见表 4)。
分组 n 1 min Apgar评分 5 min Apgar评分 对照组 30 9.7±0.4 9.8±0.4 观察组 30 9.7±0.4 9.8±0.4 t — 0.00 0.00 P — >0.05 >0.05 表 4 2组新生儿Apgar评分比较(x±s;分)
去甲肾上腺素预泵注对腰硬联合麻醉下剖宫产产妇血流动力学影响的临床观察
Clinical observation of the effect of pre-pumping norepinephrine on hemodynamics of cesarean section parturients under combined spinal-epidural anesthesia
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摘要:
目的观察预泵注去甲肾上腺素对腰硬联合麻醉后剖宫产病人血流动力学的影响。 方法选择60例ASA Ⅰ~Ⅱ级、择期行腰硬联合麻醉后剖宫产病人,随机分为观察组和对照组,各30例。所有病人麻醉前30 min输注羟乙基淀粉10 mL/kg,腰硬联合麻醉穿刺开始时对照组病人持续泵注0.9%氯化钠溶液0.75 mL·kg-1·h-1,观察组持续泵注去甲肾上腺素0.75 mL·kg-1·h-1(0.05 μg·kg-1·min-1),直至胎儿娩出。比较2组入室时(T0)、扩容后(T1)、麻醉后1 min(T2)、麻醉后3 min(T3)、胎儿娩出时(T4)、术毕(T5)时的平均动脉压(MAP)、心率(HR),新生儿1 min、5 min Apgar评分及不良反应发生情况。 结果2组病人手术时间、麻醉操作时间及出血量差异均无统计学意义(P>0.05)。2组病人T0时MAP、HR差异均无统计学意义(P>0.05);观察组T2时MAP高于对照组(P < 0.05),T2、T3时HR低于对照组(P < 0.01和P < 0.05);与T0时比较,对照组病人MAP在麻醉后有所降低,但差异无统计学意义(P>0.05),T2、T3时HR增快(P < 0.05);观察组病人各时点MAP和HR与T0时差异均无统计学意义(P>0.05)。2组病人低血压、高血压、恶心呕吐和心动过缓发生率差异均无统计学意义(P>0.05)。2组新生儿1 min、5 min Apgar评分差异均无统计学意义(P>0.05)。 结论麻醉前预泵注去甲肾上腺素0.05 μg·kg-1·min-1,产妇血流动力学平稳,对新生儿无影响,能够提高剖宫产母婴安全。 Abstract:ObjectiveTo observe the effect of pre-pumping norepinephrine on hemodynamics of cesarean section patients under combined spinal-epidural anesthesia. MethodsSixty ASA Ⅰ-Ⅱ patients with elective cesarean section after combined spinal-epidural anesthesia were randomly divided into the observation group and control group, with 30 cases in each group.All patients were infused with mL/kg hydroxyethyl starch 30 min before anesthesia.At the beginning of combined spinal-epidural anesthesia, the patients in the control group were continuously pumped with 0.75 mL·kg-1·h-1 of 0.9% sodium chloride solution, and the patients in the observation group were continuously pumped with 0.75 mL·kg-1·h-1 (0.05 μg·kg-1·min-1) of noradrenaline until delivery of the fetus.The mean arterial pressure (MAP), heart rate (HR), 1 min and 5 min Apgar score of neonate, and adverse reactions were compared between the two groups at the time of admission (T0), after volume expansion (T1), 1 min after anesthesia (T2), 3 min after anesthesia (T3), at the time of fetal delivery (T4), and at the end of operation (T5). ResultsThere was no significant difference in operation time, anesthesia time and bleeding volume between the two groups (P>0.05).There was no significant difference in MAP and HR between the two groups at T0 (P>0.05);the MAP in the observation group at T2 was higher than that in the control group (P < 0.05), and the HR at T2 and T3 was lower than that in the control group (P < 0.01 and P < 0.05);compared with T0, the MAP in the control group decreased after anesthesia, but the difference was not statistically significant (P>0.05), and the HR increased at T2 and T3 (P < 0.05);there was no significant difference in MAP and HR between each time point and T0 in the observation group (P>0.05).There was no significant difference in the incidence of hypotension, hypertension, nausea and vomiting, and bradycardia between the two groups (P>0.05).There was no significant difference in 1 min and 5 min Apgar score between the two groups (P>0.05). ConclusionsPre-pumping 0.05 μg·kg-1·min-1norepinephrine before anesthesia can stabilize the maternal hemodynamics, and has no effect on the neonate, which can improve the safety of the mother and baby in cesarean section. -
Key words:
- cesarean section /
- combined spinal-epidural anesthesia /
- noradrenaline /
- pre-pumping /
- hemodynamics
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表 1 2组病人手术指标比较(x±s)
分组 n 出血量/mL 手术时间/min 麻醉操作时间/min 对照组 30 260.0±56.32 41.3±8.79 4.6±1.08 观察组 30 246.6±62.88 38.8±6.46 4.5±1.19 t — 0.87 1.26 0.34 P — >0.05 >0.05 >0.05 表 2 2组病人MAP、HR比较(x±s)
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 MAP/mmHg 对照组 30 89.00±9.42 87.16±9.43 85.13±8.05 85.50±6.33 86.76±5.94 85.70±6.38 1.03 >0.05 59.821 观察组 30 87.86±8.58 86.33±5.65 88.9±5.31 85.76±5.51 85.63±4.96 86.16±4.94 1.45 >0.05 35.582 t — 0.52 0.45 2.16 0.13 0.78 0.27 — — — P — >0.05 >0.05 < 0.05 >0.05 >0.05 >0.05 — — — HR/(次/分) 对照组 30 89.46±9.61▲■ 91.33±7.06▲ 95.40±6.39#*△ 94.70±5.55#△ 90.26±7.82▲■ 89.16±8.20▲■ 3.81 < 0.01 57.113 观察组 30 89.26±8.30 90.06±8.30 89.13±9.42 89.90±10.66 86.80±9.00 86.80±8.98 0.73 >0.05 83.440 t — 0.09 0.35 3.03 2.19 1.59 1.07 — — — P — >0.05 >0.05 < 0.01 < 0.05 >0.05 >0.05 — — — q检验:与T0比较#P < 0.05;与T1比较*P < 0.05;与T2比较▲P < 0.05;与T3比较■P < 0.05;与T4比较△P < 0.05 表 3 2组病人不良反应发生率比较[n;百分率(%)]
分组 n 低血压 高血压 恶心呕吐 心动过缓 对照组 30 4(13.33) 0(0.00) 3(10.00) 0(0.00) 观察组 30 1(3.33) 1(3.33) 0(0.00) 1(3.33) χ2 — 0.87 — 1.40 — P — >0.05 >0.05 >0.05 >0.05 表 4 2组新生儿Apgar评分比较(x±s;分)
分组 n 1 min Apgar评分 5 min Apgar评分 对照组 30 9.7±0.4 9.8±0.4 观察组 30 9.7±0.4 9.8±0.4 t — 0.00 0.00 P — >0.05 >0.05 -
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