瑞芬太尼用于剖宫产术全身麻醉的适宜剂量

发布时间：2018-06-10 06:44

本文选题：瑞芬太尼 + 剖宫产　；参考：《新乡医学院》2017年硕士论文

【摘要】：背景临床上剖宫产手术大多采用椎管内麻醉,对产妇和新生儿的影响小,但对于有椎管内禁忌症的患者,全身麻醉是一个合适的选择。瑞芬太尼作为一种其镇痛作用好,起效时间短,代谢速率快,无蓄积的短效药物,但对呼吸和循环系统呈剂量依赖性的抑制,且易透过胎盘进入胎儿体内,造成胎儿娩出后呼吸和循环的抑制。本研究使用瑞芬太尼实施产科全身麻醉诱导,检测它在母体,新生儿脐动静脉中的血药浓度,评估其对新生儿呼吸和Apgar评分的影响,探讨其在临床上的应用前景。目的本研究拟通过对行全身麻醉剖宫产手术的产妇采用不同剂量的瑞芬太尼进行诱导,评价其对产妇的血流动力学,新生儿的呼吸和Apgar评分以及血气指标的影响,同时测定产妇和脐带血的瑞芬太尼血药浓度,探讨瑞芬太尼在全麻剖宫产中的适宜诱导剂量。方法拟行全身麻醉下剖宫产的择期产妇90例,均为初产妇,年龄在20~45岁之间,手术切口为Ⅰ、Ⅱ类切口;体重在60~84kg之间,心、肺、肝、肾未见明显异常,无妊娠期疾病史,有椎管内麻醉禁忌症的(如有凝血功能障碍,严重腰椎病变等),术前未见循环功能障碍,胎儿术前胎心正常,无宫内窘迫。采用随机数字表法,依据瑞芬太尼使用的剂量不同将患者随机分为3组(n=30):A组(1.0μg/kg+丙泊酚1.5mg/kg+罗库溴铵0.6mg/kg组),B组(1.5μg/kg+丙泊酚1.5mg/kg+罗库溴铵0.6mg/kg组),C组(2.0μg/kg+丙泊酚1.5mg/kg+罗库溴铵0.6mg/kg组)。三组患者采用丙泊酚+罗库溴铵+瑞芬太尼行全麻诱导,在胎儿娩出后三组麻醉维持均采用靶控输注丙泊酚和瑞芬太尼以及间断静脉注射罗库溴铵维持麻醉。潮气量设置8ml/kg,吸入氧流量为2.0L/min,吸入氧浓度为80%,吸呼比为1:2,呼吸频率为12次/分。记录患者的年龄、体重、身高、孕周、术前胎心率、胎儿娩出时间等一般资料;于入室后麻醉诱导开始前(T1)、切皮时(T2)、气管插管后(T3)记录产妇的血流动力学指标如心率(HR)、收缩压(SBP)、舒张压(DBP);在气管插管后即刻(T3)、胎儿娩出结扎脐带后即刻(T4)抽取产妇桡动脉血5ml测定瑞芬太尼的血药浓度;同时在胎儿娩出结扎脐带后即刻(T4)取胎盘侧脐带中脐静脉血5ml,脐动脉血5ml测定瑞芬太尼血药浓度,同时进行脐动脉血的血气指标分析:如PH值、脐动脉血二氧化碳分压(Pa CO2)、脐动脉血氧分压(PaO_2);分别在娩出后1min、5min、10min三个时间点进行Apgar评分及观察并统计新生儿的呼吸抑制情况,新生儿的面罩给氧,气管插管及纳洛酮的处理情况。结果1一般情况A、B、C三组患者的身高、孕周、体重、年龄、、术前胎心率,胎儿娩出时间的比较,差异无统计学意义(P0.05);2血流动力学指标2.1收缩压(SBP):A、B、C三组患者麻醉诱导前,组间比较,差异无统计学意义(P0.05);A组T2、T3与T1比较,差异有统计学意义(P0.05);与A组比较,B、C两组T2、T3时,差异有统计学意义(P0.05);B、C两组T2、T3与T1比较,以及两组间比较时,差异无统计学意义(P0.05);2.2舒张压(DBP):A、B、C三组患者麻醉诱导前,组间比较,差异无统计学意义(P0.05);A组T2、T3与T1比较,差异有统计学意义(P0.05);与A组比较,B、C两组T2、T3时,差异有统计学意义(P0.05);B、C两组T2、T3与T1比较,以及两组间比较时,差异无统计学意义(P0.05)。2.3心率(HR):A、B、C三组患者麻醉诱导前,组间比较,差异无统计学意义(P0.05);A组内,T2与T1、T3与T1组内比较,差异有统计学意义(P0.05);B、C两组T2、T3时与A组相比,差异有统计学意义(P0.05);B、C两组组内,T2与T1、T3与T1组内比较,以及两组间比较时,差异无统计学意义(P0.05);3脐动脉血气分析A、B、C三组患者组间比较PH值、脐动脉血氧分压(PaO_2)、脐动脉血二氧化碳分压(Pa CO2),差异无统计学意义(P0.05)。4脐带血瑞芬太尼浓度4.1脐静脉(UV)血瑞芬太尼浓度:A、B、C三组患者分别为0.63±0.14ng/ml、0.99±0.24ng/ml、1.39±0.29ng/ml;4.2脐动脉(UA)血瑞芬太尼浓度:A、B、C三组患者分别为0.32±0.09ng/ml、0.60±0.36ng/ml、0.89±0.41ng/ml;4.3 UA/UV:A、B、C三组患者分别为0.62±0.06、0.65±0.21、0.64±0.33。5产妇桡动脉血瑞芬太尼浓度A、B、C三组T3、T4时的血药浓度是1.41±0.51ng/ml、2.14±0.88ng/ml、2.97±1.09ng/ml和0.89±0.38ng/ml、1.38±0.20ng/ml、1.89±0.40ng/ml。6 Apgar评分A、B、C三组在胎儿娩出后1min、5min、10min进行比较,差异无统计学意义(P0.05);A组未出现呼吸抑制,B组出现1例轻度呼吸抑制,经拍足刺激等措施后呼吸很快正常,C组出现2例轻度呼吸抑制,经拍足刺激等措施后呼吸很快正常,新生儿在出生后5min、10min时未出现呼吸抑制。结论通过对不同诱导剂量瑞芬太尼在全麻剖宫产中的比较,诱导剂量为1.5μg/kg和2.0μg/kg时,产妇的血流动力学稳定、新生儿呼吸无明显抑制,Apgar评分以及脐动脉血的血气指标无明显影响,可推荐作为在全麻剖宫产中适宜的诱导剂量。
[Abstract]:The effect of intraspinal anaesthesia mostly in the clinical cesarean section is small, but for the patients with intraspinal contraindication, general anesthesia is a suitable choice. Remifentanil is a good analgesic, short acting time, fast metabolic rate and no accumulation of short effective drugs, but the respiratory and circulatory system is present. Dose-dependent inhibition, and easy to enter the fetus through the placenta, resulting in the inhibition of respiration and circulation after delivery of the fetus. This study used remifentanil to induce general obstetric anesthesia, to detect its blood concentration in the maternal and neonatal umbilical vein, to evaluate its effect on newborn infants' respiration and Apgar score, and to explore its clinical effects. The purpose of this study is to evaluate the effect of different doses of remifentanil on the maternal hemodynamics, the neonatal respiration and Apgar score and the blood gas index, and to determine the blood concentration of remifentanil in maternal and umbilical cord blood and to explore rifen Tai. Methods the suitable induction dose in caesarean section of general anesthesia. Methods 90 cases of cesarean section were given under general anesthesia, all of which were primipara. The age was between 20~45 years, the incision was I, the incision of class II, the body weight was between 60~84kg, heart, lung, liver and kidney, there was no history of pregnancy disease, and the contraindications of intraspinal anesthesia (such as clotting) The patients were randomly divided into 3 groups (n=30): A group (1 g/kg+ propofol 1.5mg/ kg+ rocuronium 0.6mg/kg group), and B group (1.5 u g/kg+ propofol 1.5mg/kg+ Luo). The 0.6mg/kg group (group 0.6mg/kg), group C (2 mu g/kg+ propofol 1.5mg/kg+ rocurbrominium). The three groups were induced by propofol + rocuronium + with general anesthesia. After the birth of the fetus, the three groups of anesthesia were maintained by target controlled infusion of propofol and Reventa Ni and intermittent intravenous injection of rocuronium. The tidal volume was set to 8ml/k. G, inhaled oxygen flow was 2.0L/min, inhaled oxygen concentration was 80%, respiration rate was 1:2, respiratory frequency was 12 times per cent. General data of age, weight, height, gestational age, fetal heart rate, fetal delivery time were recorded, before induction of anesthesia induction (T1), skin cutting (T2), and endotracheal intubation (T3), the hemodynamic indexes of parturients were recorded. Rate (HR), systolic pressure (SBP) and diastolic pressure (DBP); immediately after endotracheal intubation (T3), and immediately after the fetal delivery was ligation of the umbilical cord (T4), the blood concentration of remifentanil was measured by 5ml in the radial artery blood of the parturients (T4); at the same time, the umbilical vein blood 5ml of the placental side umbilical cord was taken immediately after the umbilical cord was ligated and the umbilical artery blood was used to determine the concentration of remifentanil in the umbilical artery. The blood gas index of umbilical artery blood was analyzed, such as pH value, Pa CO2 of umbilical artery blood (Pa), umbilical artery blood oxygen partial pressure (PaO_2), Apgar score of 1min, 5min, 10min after delivery, and observation of neonatal respiratory depression, neonatal mask oxygenation, tracheal intubation and naloxone treatment. Results 1 A, B, C three groups of patients with height, gestational age, weight, age, preoperative fetal heart rate, fetal delivery time comparison, the difference is not statistically significant (P0.05); 2 hemodynamic index 2.1 systolic pressure (SBP): A, B, C three groups before anesthesia induction, the difference is not statistically significant (P0.05); A T2, T3 and differences, there is a statistical difference Learning significance (P0.05); compared with group A, B, C two groups T2, T3, the difference was statistically significant (P0.05); B, C two T2, T3 and T1, and the two groups compared, there was no statistically significant difference; 2.2 diastolic pressure, three groups of patients before anesthesia induction, the difference was not statistically significant Significance (P0.05); compared with group A, B, C two groups T2, T3, the difference was statistically significant (P0.05); B, C two T2, T3 and T1, and the difference between the two groups, there was no statistically significant difference between the three groups before anesthesia induction. Statistical significance (P0.05); B, C two groups T2, T3 compared with the A group, the difference was statistically significant (P0.05); B, C two groups, T2 and T1, and the two groups compared, the difference was not statistically significant; 3 umbilical artery blood gas analysis, three groups of patients compared with the pH, umbilical artery blood oxygen pressure, umbilical artery blood carbon dioxide Partial pressure (Pa CO2), the difference was not statistically significant (P0.05).4 umbilical cord blood remifentanil concentration 4.1 umbilical vein (UV) blood remifentanil concentration: A, B, C three groups were 0.63 + 0.14ng/ml, 0.99 + 0.24ng/ml, 1.39 + 0.29ng/ml; 4.2 umbilical artery (UA) blood remifentanil concentration: 0.32 + three, 0.60 +, 0.89 +; 4.3 UA/UV:A, B, and C three groups were 0.62 + 0.06,0.65 + 0.21,0.64 + 0.33.5 respectively, the concentration of remifentanil in radial artery was A, B, C three T3, and the concentration of blood drug was 1.41 + 0.51ng/ml, 2.14 +, 2.97 and 0.89, 1.38 +, 1.89 +. The difference was not statistically significant (P0.05); there were no respiratory inhibition in group A, 1 cases of mild respiratory depression in group B and 2 cases of mild respiratory depression in group C. The breathing was quickly normal after the measures of foot stimulation, and the newborn infants had no respiratory inhibition when 5min and 10min were born after birth. The conclusion passed through the conclusion. The comparison of the different induced doses of remifentanil in general anesthesia for caesarean section of the caesarean section of general anesthesia, the induced dose of 1.5 g/kg and 2 mu g/kg, the maternal hemodynamics is stable, the newborn respiration has no obvious inhibition, the Apgar score and the blood gas index of the umbilical artery blood have no obvious influence, can be recommended as the suitable induction dose in the general anesthesia cesarean section.
【学位授予单位】：新乡医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614.2

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