【作者】 刘勇；

【导师】 吕志平；

【作者基本信息】 中南大学 ， 临床麻醉学， 2011， 硕士

【摘要】 目的：比较病人腰麻硬膜外联合阻滞(CSEA).氧化亚氮吸入和瑞芬太尼静脉泵入用于分娩镇痛的临床效果,进一步明确不同分娩镇痛模式给产妇、胎儿、和新生儿带来的影响。方法：选择无产科和椎管内神经阻滞禁忌症的阴道分娩,头位单胎足月初产妇(ASAI或Ⅱ级)120例,随机均分为四组：舒芬太尼复合罗哌卡因CSEA组(A组)、氧化亚氮吸入组(B组)、瑞芬太尼静脉泵入组(C组)和无镇痛干预作为对照组(D组),四组都无头盆不称、妊娠合并症及妊娠并发症,经产科医师检查能从阴道分娩。当宫口开至3cm时,A组在蛛网膜下隙注入罗哌卡因1.5mg+舒芬太尼2.5μg+0.9%生理盐水2m1。然后硬膜外给予1.1%罗哌卡因和0.187μg/ml舒芬太尼行硬膜外病人自控镇痛(PCEA)。首剂7m1,基础注药速度为6m1/h,冲击量为6 m1,极限量为27 m1/h,锁定时间为15min,宫口开全后停用麻醉药。B组应用氧化亚氮吸入(50%氧化亚氮和50%的氧气)镇痛,C组应用瑞芬太尼PCA泵入,D组为对照组,无镇痛干预。记录产妇视觉模拟疼痛评分(VAS)、下肢运动神经阻滞评分(MBS)、生命体征、产妇满意度、不良反应、并发症、产程时间、催产素用量、分娩方式、产后出血量、SPO2下降、胎儿和新生儿情况。结果：三种镇痛方法均能提供安全有效的分娩镇痛,产痛程度比较A组<C组<B组<D组(P<0.05)；A组和B组产程时间缩短,C组稍延长,A组活跃期(127.54±60.69)min,短于B组的(166.76±59.53)min、C组(258.67±71.94)min和D组(207.59±68.40)min(P<0.05),四组第二产程时间差异无统计学意义(P>0.05)；A、B、C组剖宫产率分别为13.3%、16.7%、20.0%明显低于D组43.3%(P<0.05),A、B、C三组阴道助产率无增加(P>0.05);MBS四组差异无统计学意义(P>0.05),所有产妇都能下床活动；胎儿宫内窘迫率、新生儿窒息率、产后出血率四组比较差异无统计学意义(p>0.05)；产妇满意度A、B、C三组均较D组高,其中A组高于B组和C组(P<0.05)。结论：(1)舒芬太尼混合罗哌卡因,腰麻硬膜外联合阻滞+病人自控硬膜外分娩镇痛,氧化亚氮吸入分娩镇痛与瑞芬太尼病人自控分娩镇痛均能使产妇疼痛减轻,同时使剖宫产率下降,使胎儿、新生儿、产妇安全。(2)本实验条件下瑞芬太尼静脉自控分娩镇痛不缩短产程。(3)与氧化亚氮和瑞芬太尼分娩镇痛相比,CSEA效果更确切,产程更加缩短,同时使病人分娩过程更舒适,因此更适合于分娩镇痛。更多还原

【Abstract】 Objective:To evaluate the clinical effect of combined spinal-epidural epidural anesthesia, nitrous oxide inhalation and remifentanil patients-controlled analgesia (PCA) on the duration of labor analgesia and to further clarify the influence to the maternal, fetal and neonate in the different labor analgesia mode.Methods:120 women (ASAI or GradeⅡ) without contraindications of obstetrics and spinal block and with first single baby head-located down were selected and classified into four groups randomly:A: Sufentanil+Ropivacaine combined spinal epidural anesthesia (CSEA); B: Nitrous oxide inhalation; C:Remifentanil Intravenous infusion; D: Control group without analgesia. All the women had no head disproportion, pregnancy complications, and were diagnosed through vaginal delivery by the obstetrician. When the cervix was open by 3cm, group A was subjected to ropivacaine 1.5 mg+sufentanil 2.5μg+0.9% saline 2 ml through subarachnoid injection.(?)1.1% epidural ropivacaine and 0.187μg/ml sufentanil were added to patients-controlled epidural analgesia (PCEA). The first dose is 7 ml/h, the basical injection speed is 6 ml/h, the bolus of volume is 6 ml, the maximum speed is 27 ml/h and local time is 15 min. Group B was subject to nitrous oxide (50% nitrous oxide and 50% oxygen). Group C was subjected to remifentanil PCA pump. Group D was the control group with no analgesia intervention. All the treatment were stopped when cervix was open completely. Visual analogue pain score (VAS), maternal lower limb motor block score (MBS), vital signs, patients satisfaction, side effects, complications, labor time, the amount of oxytocin, mode of delivery, postpartum hemorrhage, fetal and newborn child situation were recorded.Results:Three methods of analgesia could provide safe and effective analgesia. The degree of pain in order was the group A, group C, group B and group D. The labor time were shorted in the group A and B compared with the group C. The active phase of group A was shorter than that of the group B, group C and group D (127.54±60.693 min vs 166.76±59.530 min,258.67±71.940 min and 207.59±68.039 min, all P<0.05). The expulsive stages had no significant difference in all groups. Compared with the group D (43.3%), the rates of uterine-incision delivery were decreased significantly (respectively 13.3%、16.7%and 20.0%,all P<0.05). MBS had no significant difference in all groups (all P>0.05). All maternal women after labor could go around in the room in three groups. The rates of fetal distress in uterus, apnoea neonatorum and postpartum hemorrhage had no significant difference in all groups (all P>0.05). Compared with group D, the satisfaction degree of postnatal recovery in group A, B and C were increased significantly (all P<0,05). Compared with group B and C the satisfaction degree of postnatal recovery in group A was increased significantly (P<0.05).Conclusions:CSEA+ PCEA with Sufentanil and Ropivacaine combined, nitrous oxide inhalation and remifentanil PCA all relive significantly the puerperal pain, decrease significantly the cesarean rate, and also provid safety for puerperal, fetal and newborn child.In this experimental conditions, remifentanil PCA doesn’t shorten labor time. CSEA is more effective by shortening the birth process and more suitable for labor analgesia compared to remifentanil and nitrous oxide analgesia.更多还原