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低浓度利布合剂硬膜外麻醉行剖宫产术的临床观察

时间:2010-08-24 11:33:17  来源:  作者:

A Clinical Study of Low-does Lidocaine Plus Bupivacaine Mixture in Epidural Anesthesia for Caesarean Section<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 

王铁桥

开封市第一中医院麻醉科, 开封 475001

Tie-qiao Wang

Department of Anesthesiology, Kaifeng Hospital of Traditional Chinese medicine, Affiliate of Henan Traditional Chinese Medicine Univerisity, Kaifeng 475001, China

 

ABSTRACT

Objective:To observe the effects and side effects of low-does lidocaine plus bupivacaine mixture in epidural anesthesia for caesarean section.

Methods:Sixty parturients (ASA I~II) scheduled for elective cesarean section were randomly allocated into two groups: Patients in group BL were given 0.75% bupivacaine plus 2% lidocaine mixture, or in group L were given 2% lidocaine with 5mg/ml epinephrine in each group, each group included 30 patients. In all patients epidural space L2-3 was punctured and the catheter was put upward 3~4cm. Local anaesthetic agents were administered until a complete sensory block was established extending upper the eighth thoracic nerves (T8). BP , ECG , SpO2, sensory block and motor block, neonatal outcome and side effects were observed and recorded during operation.

Results:There were no significant difference in ECG, SpO2, the maximum cephalic sensory block spread, and Apgar scores for neonatus. The onset time of analgesia to T8 were shorter in group BL than group L (P<0.05). The scores of intraoperative pain were significantly better in group BL than that in group L (P<0.005). Motor nervous block were weaker in group BL. At 10 min after epidural block, SBP and DBP were decreased significantly (P<0.05). There were no significant difference in the side effects (tachycardia, nausea, vomiting and shivering).

Conclusions:Epidural administration of low-does lidocaine plus bupivacaine mixture can be applied safely and effectively to cesarean section, has no complications for neonatus .

Key words:Bupivacaine; Epidural anesthesia; Cesarean section

 

布比卡因是一种酰胺类长效局部麻醉药,其麻醉持续时间比利多卡因长 2~3倍,弥散度与利多卡因相仿,对呼吸和循环的影响小,常用量时对中枢神经及心血管的毒性发生率低。为增强剖宫产术硬膜外麻醉镇痛效果,我们采用低浓度的布比卡因与利多卡因混合注入硬膜外腔,收到良好效果,现就镇痛情况及对母婴影响进行对比观察。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 

一、资料和方法

1. 研究对象 

选择60例ASA I-II级无产科并发症,择期行剖宫产术患者,随机分成二组,每组30例; 利布(BL)组配成1%利多卡因与0.15%布比卡因合剂;利多卡因(L)组为单纯2%利多卡因两组局麻醉药中均含盐酸肾上腺素5mg/ml 。

2. 麻醉方法

入手术室前30min均肌注阿托品0.5mg、苯巴比妥钠100mg,入室后先静脉输入乳酸林格氏液,同时取L2-3椎间隙行硬膜外穿刺,向头侧置管3~4cm,平卧后注入试验剂量1%利多卡因3ml,观察5min无全脊麻现象后,L组每隔5min注入2%利多卡因4~5ml; BL组每隔5min注入低浓度利布合剂5ml至麻醉平面上界达T8水平。麻醉期间血压下降超过基础值的30%或低于90mmHg即静注麻黄碱6~10mg、心率低于60bpm即静注阿托品0.1mg。

3. 监测  

常规观察氧饱和度、血压、心率及心电图。记录阻滞平面达T8所需时间,术中每15分钟测定一次平面的上界、直至术终。产妇术中疼痛分为四级[1]: 优: 产妇完全无痛,腹肌松软,病人安静;良: 稍感疼痛,可耐受,腹肌松软;中: 疼痛较重,需要辅助用药;差: 疼痛剧烈,不能忍受需改麻醉。在切皮前和术终采用改良的Bromage分级评估下肢运动能力[2]: 0级: 无运动阻滞,能自如抬起大腿; 1级: 不能抬起大腿; 2级: 不能曲膝;3级: 不能弯曲踝关节。记录新生儿出生即刻,5min、10min 时Apgar评分。记录恶心、呕吐、低血压等不良反应。

4. 统计学分析

计量资料以均数±标准差表示,采用t检验分析,计数资料用x2检验。

二、结果<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

两组病人年龄、身高、体重、利多卡因用量、麻醉阻滞平面见表1。2%利多卡因用量BL组少于L组,有极显著差异(P < 0.01); 感觉阻滞平面BL组最高在T4-T8,中位数T6,最低达S5,L组最高在T5-T8,中位数T7,最低达S5,(P > 0.05);麻醉达T8所需时间,BL组平均14.06min,L组17.20min,两组比较差异显著(P < 0.05)。

下肢运动神经阻滞见表2。组间比较切皮前无差异(P > 0.05); 术终有显著差异(P < 0.05)。

血流动力学改变见表3。麻醉后10~15min两组收缩压、舒张压均有不同程度下降,与麻醉前比较(P < 0.05),心率改变两组无显著差异。

  不良反应见表4。

两组病人术中各期镇痛效果见表5。L组有20例切皮时静注芬氟合剂2ml,5例胎儿娩出前静注芬氟合剂2ml,4例分离膀胱子宫腹膜反折时加辅助局麻,胎儿娩出后静注氯胺酮全麻;BL组有3例分离膀胱子宫腹膜反折时静注芬氟合剂2ml强化麻醉。镇痛效果两组比较(P < 0.005),BL组优于L组。

对新生儿Apgar评分: 胎儿娩出即刻除3例因脐带绕颈1~2周评7分,5min后为10分外,其余两组57例均为10分。

 

三、讨论

因布比卡因为长效的酰胺类局麻药,对中枢神经及心血管的毒性低,硬膜外腔及鞘内给药时镇痛效果显著,在产科剖宫产和分娩镇痛时日益广泛使用。我们采用0.15%布比卡因和1%利多卡因(内含1: 20万的盐酸肾上腺素)用于产科剖宫产术,与单纯应用2%利多卡因麻醉组对照,明显提高了剖宫产的镇痛效果(P < 0.005),并使腹肌松软、阻滞完善,手术时间35-50min,2%利多卡因总量BL组12.5±0.77ml少于L组13.8±1.01ml,两组相比差异显著(P  < 0.01);感觉阻滞平面达T8所需时间BL组平均14.06min快于L组17.02min(P < 0.05);运动神经阻滞程度BL组强于L组;阻滞不全发生率利多卡因组明显;低血压多发生于10min以后,两组发生率分别为30%和66.7%,以利多卡因组发生率高(P < 0.05),通过加快输液及静注少量的麻黄碱等措施即可纠正。心率的变化两组无明显差异(P > 0.05)。心动过速与产妇的生理特点有关,心动过缓时,静脉分次给予0.1mg阿托品即可。

剖宫产术的麻醉除要求镇痛效果好外,还应保证所用方法和药物对胎儿不产生呼吸抑制作用,对两组病例的新生儿评分(Apgar法),无明显差异,表明低浓度的布比卡因和利多卡因合剂用于硬膜外宫产术对新生儿同样是安全的。由于布比卡因的离解值(pka)高(8.1),组织扩散不广,分子量288,具有高蛋白结合和高脂溶性特性,限制了血管外吸收[3],进入胎盘药物少,脐静脉血比率为0~0.36,提示只有微量布比卡因通过胎盘[4]。并且布比卡因不易积累,对母婴影响较少,安全性可靠。

总之,0.15%布比卡因与1%利多卡因合剂用于硬膜外剖宫产手术的麻醉,具有用药量少,浓度低,镇痛效果好,腹肌松软,阻滞完善,产妇舒适,母婴安全,副作用少等特点,可作为剖宫产的麻醉方法之一。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 

参考文献

1. 张志民,曹瑞彬. 局麻药中加芬太尼用于剖腹产硬膜外阻滞的临床观察。中华麻醉学杂志, 1990, (疼痛治疗专刊):17

2. 徐惠芳. 阿汽类镇痛药的临床应用技术。中华麻醉学杂志,2001; 21: 599- 601.

3. 汤家镌. 布比卡因在产科麻醉中的毒性作用,国外医学麻醉学与复苏分册,1987; 8(4):255.

4. 何孔源. 无痛分娩法的临床应用与观察。中华麻醉学杂志, 1987; 9(2): 104.

 

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