Comparison of Patient-controlled Epidural Analgesia with Different Concentrations of Ropivacaine and Fentanyl after Cesarean Section<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

岳红丽  医学硕士　　马　宁  医学博士　　李树人　　教授
首都医科大学附属北京友谊医院麻醉科，北京  100050

Hongli yue，Ning Ma，Shuren Li
Department of Anesthesiology, Beijing Frienship Hospital, Capital University of Medical Sciences, Beijing, 100050

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ABSTRACT

　　Objective: To evaluate the proper concentration of ropivacaine（Ropi）during patient-controlled epidural analgesia (PCEA) after cesarean section by comparing the effects of varied concentrations of Ropi and fentanyl(F).
　　Methods: 160 ASA I-II primiparaes undergoing cesarean section (two anesthetic methods: CEA or CSEA)were divided into 8 groups randomly to receive PCEA: CEA group (E₀: controlled group; E₁:0.0625%Ropi+2μg/ml F;E₂:0.1%Ropi+2μg/ml F；E₃：0.125% Ropi+2μg/ml F).CSEA group(S₀:controlled group; S₁:0.0625%Ropi+2μg/ml F; S₂:0.1%Ropi+2μg/ml F; S₃:0.125% Ropi+2μg/ml F).Visual analogue scores of pain in 0～2h、2～4h、4～8h、8～16h、16～24h and 24～48h, degree of motor block, PCA total demands and effective demands, consumption of Ropi and F, occurrence of nausea, vomiting and other side effects among groups were observed postoperatively. Results: The exhausting time and post-delivery indexes among groups were similar. Accompanied with the increase of concentration, the total dosage of Ropi increased, whereas the consumption of F, PCA total demands and effective demands decreased (P<0.05).In CEA groups, the pain scores in static status and movement gradually decreased (P<0.05), and the lower extremity strength were regained in 4h(P<0.05).In CSEA groups, accompanied with the concentration of Ropi increased, the pain scores in static status and movement gradually decreased(P<0.05)except for the 0～2h phase, but the difference between 0.1% and 0.125% was not significant(P>0.05);The recovery of lower extremity strength was delayed and there were marked differences among groups (P<0.05).Compared with CEA, the VAS was lower in CSEA when administered with the same concentration of Ropi (P<0.05).
　　Conclusion: ①PCEA with 0.0625%,0.1or 0.125%Ropi and F 2μg/ml can produce analgesia to various degrees without serious side effects; ②When PCEA with Ropi and F was proceeded post-cesarean section, among three concentrations above, the suitable one is 0.125%Ropi+2μg/ml F after CEA whereas 0.1%Ropi+2μg/ml F after CSEA.
　　Key Words: Concentration; Ropivacaine; PCEA; Cesarean section

　　剖宫产术后镇痛有别于一般手术的术后镇痛，除充分有效的镇痛外，还应考虑药物对子宫收缩的影响、药物在乳汁中的分泌。另外，产妇希望产后保持清醒，能与新生儿密切接触，以行母乳喂养。近年来，随着PCA技术和新的局麻药罗哌卡因在国内临床的应用，PCEA成为剖宫产术后镇痛研究的一个热点。
　　本研究拟对比观察不同浓度的罗哌卡因联合芬太尼行剖宫产术后PCEA镇痛，比较其镇痛效果、副作用及药物用量和对产妇术后恢复的影响。

资料和方法<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

一、病例选择
　　我院产科择期行剖宫产的足月初产妇，年龄23～35岁，ASA I～II级，妊娠后无镇痛药、镇静药用药史者。
　　排除标准：观察中不能配合的病人；因镇痛导管脱出镇痛不良而退出研究的病人。
二、病例分组
　　160例产妇，随机分为硬膜外组和腰麻-硬膜外联合阻滞组行剖宫产手术，每组根据术后镇痛用药再分为空白对照组及不同药物浓度组（每组=20例）。
1、CEA组（连续硬膜外阻滞组）：
　　E₀ 硬膜外空白对照组，
　　E₁ 0.0625%罗哌卡因+芬太尼（2μg/ml）,
　　E₂ 0.1%罗哌卡因+芬太尼（2μg/ml）,
　　E₃ 0.125%罗哌卡因+芬太尼（2μg/ml）；
2、CSEA组（腰麻-硬膜外联合阻滞组）：
　　S₀ 联合针空白对照组，
　　S₁ 0.0625%罗哌卡因+芬太尼(2μg/ml)，
　　S₂ 0.1%罗哌卡因+芬太尼(2μg/ml)，
　　S₃ 0.125%罗哌卡因+芬太尼(2μg/ml)。
三、实施步骤
　　1、术前向产妇及家属说明术后镇痛的目的、意义及可能发生的问题，征得产妇及家属同意签字。
　　2、在产妇进入手术室后常规监测心电图、无创血压和血氧饱和度，开放静脉（18G套管针），于麻醉前静滴乳酸林格溶液4～6ml/kg体重。
　　3、产妇左侧卧位，穿刺点为L2～3。随机实施硬膜外阻滞（CEA）或腰麻-硬膜外联合阻滞（CSEA）。CEA组行硬膜外穿刺，向头侧置管3.5cm；硬膜外腔应用2%利多卡因+1:200 000肾上腺素，将感觉阻滞平面控制在T6±1（针刺法）；术中不加用其他麻醉性镇痛药。CSEA组于蛛网膜下腔向尾或向地给予1%地卡因+10%葡萄粮+3%麻黄碱（1:1:1混合液）2ml，给药后常规置入硬膜外导管；调整感觉阻滞平面达T6±1（针刺法），根据阻滞效果决定是否追加硬膜外局麻药。
　　4、胎盘娩出后给产妇连接PCA泵（两个空白对照除外），按照分组情况行PCEA镇痛。持续输注药液2.5ml/h，单次PCA量为2.5ml，锁定给药间隔时间为20min。维持48小时镇痛。
　　5、分别于镇痛开始后2、4、8、16、24和48h观察并记录以下项目：①各时段镇痛效果：采用10cm视觉模拟评分法（VAS）间接评估（0=无痛，10=不能忍受的剧烈疼痛），各时段VAS评分均值表示，并分为静态VAS和动态VAS（宫缩、床上和下地活动时）；②采用改良Bromage评分评价下肢运动阻滞程度（0～5级：0=无肌肉收缩；1=可见肌肉轻微收缩而无肢体活动；2=肢体可在床平面移动，但不能抬起；3=肢体可抬离床面，能屈膝；4=能作抵抗一定阻力的运动；5=正常肌力）；③循环状态，监测病人2h、24h、48h的血压、心率；④产后恢复指标：记录术后宫底高度、子宫收缩情况、恶露量、乳汁分泌时间；⑤副作用：恶心、呕吐、瘙痒、低血压、尿潴留和胃肠功能恢复情况。
　　6、镇痛结束后随访，记录产妇的年龄、身高、体重、孕周、是否使用缩宫素及其剂量、总用药量、PCA总按压次数与有效按压次数。镇痛期间鼓励产妇早期下地活动。
四、统计学分析
　　数据均使用SPSS8.0统计软件包分析。计量数据以均值±标准差表示，P<0.05为有显著性差异。

参 考 文 献<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

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　　李树人，1936年生。现任首都医科大学麻醉教授，博士导师，北京友谊医院麻醉科主任医师。中华麻醉学公常委兼疼痛治疗学组组长，北京医师协会理事，北京医学会理事。留学于阿根迁。主持肾移相植、胰腺移植麻醉，急慢性疼痛治疗等多项研究，获卫生部科研进步奖一项，北京是科技术进步奖两项。主编、参编多部教科书和参考书。享受国务院特殊津贴。《中华麻醉学杂志》、《中国麻醉与镇痛杂志》、《临床麻醉学杂志》及本刊编常委。