[罂粟摘要]硬脊膜穿刺硬膜外麻醉、腰硬联合麻醉在剖宫产中的比较:一项随机对照试验

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硬脊膜穿刺硬膜外麻醉、腰硬联合麻醉在剖宫产中的比较:一项随机对照试验

贵州医科大学  麻醉与心脏电生理课题

翻译:  马艳燕

编辑:  严旭

审校: 曹莹

目的：

以导管为基础的技术有复杂的作用机制，有时用于产科麻醉，如腰硬联合麻醉(CSE)。硬膜外穿刺(DPE)麻醉在剖宫产手术(CS)中的应用尚未得到很好的研究。本研究将相对新颖的DPE技术与硬膜外麻醉(EA)和CSE麻醉进行了比较。

患者和方法：

我们随机分配了150名接受择期CS的产妇，分别接受DPE，EA或CSE麻醉。主要结果是T5平面感觉阻滞起效的时间，使用Cox比例风险模型进行评估。次要结果包括感觉阻滞的中位数时间、阻滞质量、患者和外科医生的满意度、APGAR评分和其他副作用。

结果：

与EA麻醉相比，DPE麻醉起效时间更快（风险比2.47 [95%CI 1.56-3.90]，校正P<0.001），达到手术水平的中位数时间更短（16 [IQR 14-18] min vs 19 [15.5–21]min，校正P<0.001）；术中疼痛发生率更低（7/48 vs 17/47，校正P=0.046），患者满意度评分的中位数更高（9 [IQR 9–10] vs 8 [8–9.5]，校正P = 0.004）。CSE组麻醉起效时间快于其他两组，但低血压发生率更高（P < 0.001），去氧肾上腺素需求量更大（P <0.001）。

结论：

与EA麻醉相比，DPE麻醉起效更快，阻滞质量更好，而且对母体血流动力学参数影响小于CSE麻醉。这些结果表明，硬膜穿刺在提高CSE麻醉期间硬膜外补充的有效性方面具有重要作用，并为提高DPE技术用于剖宫产手术的麻醉效果满意度提供了启示。

原始文献来源：

Chun EH, Cho S, Woo JH, Kim YJ. A randomized double-blind comparison of the double-space technique versus the single-space technique in combined spinal-epidural anesthesia for cesarean section. BMC Anesthesiol. 2020 Jan 30;20(1):29. doi: 10.1186/s12871-020-0948-7.

英文原文：

Comparison of Dural Puncture Epidural, Epidural  and Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Controlled T rial

Purpose: Catheter-based techniques such as combined spinal-epidural (CSE) anesthesia which are sometimes indicated for obstetric anesthesia have a complex mechanism of action. The application of the dural puncture epidural (DPE) anesthesia for cesarean section (CS) has not been well investigated. The present study compared the relatively novel DPE technique with epidural (EA) and CSE anesthesia.

Patients and Methods: We randomly assigned 150 parturients who underwent elective CS to receive DPE, EA or CSE anesthesia. The primary outcome was the onset of sensory anesthesia to the T5 dermatome assessed using the Cox proportional hazards model. Secondary outcomes included median time to sensory block, quality of block, patient and surgeon satisfaction, APGAR scores and other side effects.

Results: For DPE anesthesia versus EA anesthesia, the onset of anesthesia was faster (hazard ratio 2.47 [95% CI 1.56 to 3.90], adjusted P < 0.001) and the median time to surgical level was shorter (16 [IQR 14–18] min versus 19 [15.5–21] min, adjusted P <0.001); the incidence of intraoperative pain was lower (7/48 versus 17/47, adjusted P = 0.046) and the median patient satisfaction score 

was higher (9 [IQR 9–10] versus 8 [8–9.5], adjusted P = 0.004). In the CSE group, the onset of anesthesia was faster than in the other two but the incidence of hypotension was higher (P < 0.001) and the phenylephrine requirement was greater (P < 0.001).

Conclusion: DPE anesthesia had a faster onset and better quality of block than EA anesthesia and provided less influence to maternal hemodynamic parameters than CSE anesthesia for CS. These results suggest that the dural puncture plays a significant role in enhancing the effectiveness of epidural top-ups during CSE anesthesia and indicates enlightenment that contributes to the satisfaction of anesthetic effect in DPE technique labor analgesia transferred to CS.

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