硬脊膜穿刺硬膜外阻滞与标准硬膜外阻滞对择期剖宫产术麻醉起效时间的影响：一项随机临床试验

以下文章来源于罂粟花 ，作者anesthGH

本文由“罂粟花”授权转载  

硬脊膜穿刺硬膜外阻滞与标准硬膜外阻滞对择期剖宫产术麻醉起效时间的影响：一项随机临床试验

重要性和目的

硬脊膜穿刺硬膜外阻滞(DPE)和标准硬膜外阻滞是椎管内分娩镇痛的常见方式。较少有研究报道DPE在剖宫产术麻醉中的应用。为比较DPE与标准硬膜外阻滞在剖宫产术中的应用效果，本试验将对DPE 是否能提供更快、更好的阻滞效果进行探讨。

试验设计、地点和受试对象

这项随机双盲临床试验于2019年4月至2022年10月在一所三级教学医院(阿肯色大学医学院)进行。受试对象包括18岁及以上拟行择期剖宫产的单胎妊娠妇女。  

干预措施

将受试对象随机分为DPE组或标准硬膜外组。术前通过硬膜外导管使用低浓度布比卡因和芬太尼维持感觉阻滞平面于T10平面。

主要结局指标和测量方法

主要结局指标是从氯普鲁卡因给药到手术麻醉(T6感觉阻滞平面)的时间。次要结局指标是硬膜外麻醉的质量，由以下因素综合定义: (1)进入产房后，术前双侧麻醉平面未能达到T10平面，(2)氯普鲁卡因给药15分钟内麻醉平面未能达到T6平面，(3)术中镇痛要求，(4)重复椎管内穿刺，(5)转为全身麻醉。  

结果

140例(平均年龄[标准差]，30.1 [5.2]岁)妇女中，70例随机分至DPE组，70例随机分至标准硬膜外组。与标准硬膜外组相比，DPE组麻醉起效作时间更快(中位数[四分位数间距] ，422[290-546]秒比655[437-926]秒; 中位数差[四分位数间距]，233[104-369]秒)。DPE组低质量麻醉综合率为15.7% (70名女性中有11名) ，标准硬膜外组为36.3% (66名女性中有24名)(OR为0.33；95% CI 为0.14-0.74; P =0.007)。  

结论

与标准硬膜外阻滞相比，DPE麻醉起效更快，阻滞质量能得到改善。需要进一步研究来证实这些研究结果在产时剖宫产中的应用。

原始文献来源：

Sharawi N, Williams M, Athar W, Martinello C, Stoner K, Taylor C, Guo N, Sultan P, Mhyre JM. Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open. 2023 Aug 1;6(8):e2326710.    

英文原文

Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery

Importance: Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. Objective: To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. Design, Setting, and Participants: This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Interventions: Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. Main Outcomes and Measures: The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Results: Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Conclusions and Relevance: Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery.

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编辑：MiSuper.米超

校对：Michel.米萱

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