腰麻下罗哌卡因复合硬膜外不同剂量舒芬太尼用于剖宫产麻醉的临床效果观察

发布时间：2018-01-14 20:40

  本文关键词：腰麻下罗哌卡因复合硬膜外不同剂量舒芬太尼用于剖宫产麻醉的临床效果观察　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

  更多相关文章： 剖宫产 罗哌卡因 腰麻联合硬膜外麻醉 舒芬太尼 合理剂量

【摘要】：目的:腰麻是当前临床剖宫产术式的主要麻醉方式。腰麻下的剖宫产手术因为也会与其他腰麻手术存在着类似相同的诸多不足之处,主要是其腰麻所用药物造成的各种不良反应以及血流动力学的紊乱;另外,腰麻下的剖宫产手术也会造成不同程度的运动恢复延迟,进而对产妇术后恢复也造成了一定的影响。因此,强化剖宫产麻醉不良反应的研究也成为了麻醉医师研究主要方向之一。目前经大量临床研究发现,硬膜外单次给予舒芬太尼最大剂量范围为10~20ug,但对舒芬太尼最佳镇痛量效关系仍未达成一致。本文则就腰硬联合麻醉下相同剂量罗哌卡因+不同剂量舒芬太尼对剖宫产患者麻醉结果及术后镇痛进行分析比较,以期为提高剖宫产临床麻醉合理剂量的应用提供更多的参考与借鉴。方法:选取2016年1月~2016年12月沧州市人民医院(颐和妇产分院)拟行择期剖宫产手术的90例健康、单胎足月待产妇,ASAⅠ~Ⅱ级。本研究经本院医学伦理委员会通过,且均获得患者知情同意。按照相同腰麻和不同硬膜外药物配比随机将研究资料分为三组:每组30例。A组:蛛网膜下腔0.75%罗哌卡因2ml+10%葡萄糖1ml(共2.5ml);硬膜外腔舒芬太尼20ug。B组:蛛网膜下腔0.75%罗哌卡因2ml+10%葡萄糖1ml(共2.5ml);硬膜外腔舒芬太尼15ug。C组:蛛网膜下腔0.75%罗哌卡因2ml+10%葡萄糖1ml(共2.5ml);硬膜外腔舒芬太尼10ug。三组于产妇入室后,立即开放静脉通路,选择L2~3间隙为穿刺点,确定进入硬膜外腔后用腰麻针行硬脊膜穿刺,待有突破感之后,拔出针芯;见清澈脑脊液回流以后注入0.75%罗哌卡因2ml+10%葡萄糖1ml共2.5ml;撤出腰麻针后,硬膜外腔注入不同剂量的舒芬太尼+0.9%生理盐水5ml,并置入硬膜外导管。完成后患者立即恢复平卧位,待患者痛觉消失后,开始手术。术毕连接硬膜外镇痛泵。观测指标:(1)感觉阻滞平面测定:每间隔5分钟用针刺测定疼痛感觉阻滞平面;给药后5分钟之内,则1分钟测定一次;以后每间隔5分钟测定一次;至手术开始切皮时。手术过程中每10分钟测定一次疼痛感觉消失平面。观测、记录对疼痛感觉阻滞起效时间(从首次注入至T6平面疼痛感觉消失时间)进行记录,并同时观测、记录疼痛感觉阻滞平面上界(以脊髓阶段表示)。(2)术后镇痛质量的评定:采用视觉模拟评分标准(VAS)对产妇离室、术后2小时、6小时、12小时的镇痛质量进行评分。0分:产妇无痛,10分为剧烈的疼痛。1~10分疼痛程度逐渐加重。记录术前、术后24h静脉血生化指标。(3)观测并记录三组产妇的血流动力学改变状况,记录各组实施麻醉前(T0),实施麻醉后1分钟(T1),3分钟(T2),切皮(T3),胎儿娩出时(T4),胎儿娩出后5分钟(T5),离室(T6),离室2小时(T7),离室6小时(T8)的ECG(心电图)、BP(无创血压)、HR(心率)、RR(呼吸频率)、SPO2(脉搏血氧饱和度)。(4)观察新生儿娩出后1分钟和5分钟Apgar评分;观察恶心、呕吐、瘙痒、尿潴留、寒战及低血压等并发症的发生率。结果:1三组研究资料的麻醉效果比较存在着一定的差异;其中A组和B组其麻醉质量效果明显优于C组(P0.05)。2对三组研究资料的疼痛VAS评分分析发现,A、B两组的疼痛VAS评分无明显统计学差异(P0.05);但A、B两组VAS评分结果明显优于C组而且具明显统计学差异(P0.05)。3术前三组观测研究对象的无创血压、心率、氧饱和度均无统计学差别(P0.05);术后,三组研究对象的脉搏血氧饱和度也无统计学差别(P0.05);但三组研究对象于术后各时间点的血压与心率存在较大差别。A、B两组与C组对比SBP在T2、T3、T7均下降(P0.05);A组DBP在T2、T3、T4、T8下降(P0.05);而B组DBP在T3、T4、T8下降(P0.05);A、B两组的HR在T2、T3、T7上升而在T8下降(P0.05)。与T0比较SBP,A组在T2、T3、T4、T7降低(P0.05),B组SBP在T2、T3、T4、T8下降(P0.05),C组SBP在T2下降(P0.05);与T0比较DBP,A组在T2、T3、T4、T5、T6、T7、T8降低,B组在T2、T3、T4、T6、T7、T8降低,C组在T2、T3、T4下降(P0.05)。与T0对比HR,A、B、C组均在T2、T3、T4上升而A、B组在T7、T8下降(P0.05)。4各组研究对象运动恢复时间、胎儿Apgar评分、最大运动阻滞程度的统计学比较无差异(P0.05)。5三组研究对象,均未出现新生儿窒息、低氧血症、心动过缓等严重不良反应;但各组均出现轻度恶心、呕吐、寒战、瘙痒、尿潴留,B组、C组与A组比较有明显统计学差异(P0.05)。结论:蛛网膜下腔0.75%罗哌卡因2ml+10%葡萄糖1ml(共2.5ml);硬膜外腔注入舒芬太尼15ug+%0.9生理盐水稀释至5ml,能够在剖宫产手术中得到最满意的麻醉效果与术后镇痛效果;且能在麻醉效果与不良反应间达到更理想的平衡。因此,该麻醉方案为更加适用于临床剖宫产麻醉及术后镇痛的合理剂量。
[Abstract]:Objective: spinal anesthesia is the main mode of current clinical cesarean section under spinal anesthesia. The cesarean section because there will be a lot of shortcomings similar with other spinal surgery, which is mainly caused by spinal anesthesia with drug adverse reactions and hemodynamic disorder; in addition, the waist anesthesia for cesarean section will cause delayed recovery of different degrees of movement, and also caused some impact on maternal postoperative recovery. Therefore, strengthening the research of cesarean section anesthesia adverse reactions has become one of the main directions of research at present. By a large number of anesthesiologists clinical study found that single epidural sufentanil maximum the dose range of 10~20ug, but the best analgesic sufentanil dose effect relationship has not yet agreed. This paper is under combined spinal epidural anesthesia with the same dose of ropivacaine combined with different doses of sufentanil on patients with cesarean section anesthesia The results of comparison and analysis of drunk analgesia after operation, in order to provide reference for the application of more reasonable and improve the cesarean section clinical anesthesia dose. Methods: from January 2016 December ~2016 Cangzhou People's Hospital (Yihe maternity branch) undergoing cesarean section in 90 cases of healthy, full-term singleton pregnant women, ASA I II. The study by the medical ethics committee of the hospital through, and obtain informed consent of patients. In the same spinal anesthesia and epidural drug ratio of different random research data will be divided into three groups:.A group, 30 cases in each group: subarachnoid 0.75% ropivacaine 2ml+10% glucose 1ml (CO 2.5ml); epidural cavity subarachnoid sufentanil 20ug.B group: 0.75% ropivacaine 2ml+10% glucose 1ml (2.5ml); group 15ug.C: epidural sufentanil subarachnoid 2ml+10% ropivacaine 0.75% 1ml glucose (2.5ml); epidural sufentanil three 10ug. In women after the burglary, immediately open venous access, select the L2~3 clearance for the puncture point, determined to enter the epidural cavity after spinal anesthesia needle for dural puncture, after a breakthrough, pull out the needle core; clear cerebrospinal fluid reflux after injection of 0.75% ropivacaine 2ml+10% glucose 1ml 2.5ml; spinal anesthesia after needle withdrawal, epidural injection of different doses of sufentanil +0.9% saline 5ml, and placed in the epidural catheter. Patients recovered immediately after the completion of the supine position after the patients pain disappeared after surgery. The surgery began to connect epidural analgesia pump. Observation index: (1) the level of sensory block was determined every 5 minutes to measure the pain with acupuncture the level of sensory block; after administration of 5 minutes, 1 minutes after the test once every 5 minutes; Determination of time; to surgical incision at the start. During the operation was measured every 10 min pain feeling disappeared. Plane observation, records of 鐤肩棝鎰熻�夐樆婊炶捣鏁堟椂闂�(浠庨�栨�℃敞鍏ヨ嚦T6骞抽潰鐤肩棝鎰熻�夋秷澶辨椂闂�)杩涜�岃�板綍,骞跺悓鏃惰�傛担�

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