目的 探讨地塞米松与芬太尼对剖宫产产妇围术期寒战的影响.方法 选择首都医科大学附属北京安贞医院择期行剖宫产术产妇120例,采用随机数字表法分为芬太尼组、地塞米松组、对照组,各40例.芬太尼组患者蛛网膜下腔给予重比重0.5％罗哌卡因12.5 mg(2.5 ml)与芬太尼25 μg(0.5 ml)的混合溶液,地塞米松组、对照组蛛网膜下腔给予重比重0.5％罗哌卡因12.5 mg(2.5 ml)与0.9％氯化钠注射液(0.5 ml)混合溶液行蛛网膜下腔麻醉,胎儿剖出后地塞米松组静脉注射0.1 mg/kg地塞米松,芬太尼组、对照组给予同等容量的0.9％氯化钠注射液.采用疼痛视觉模拟量表(VAS)评分评估产妇疼痛程度;采用4级评分法评估寒战强度;记录并比较3组产妇手术时间、鼓膜温度、室温、最高感觉阻滞平面、寒战发生率、寒战发生强度以及不良反应发生情况.结果 芬太尼组、地塞米松组、对照组室温、手术时间、鼓膜温度及最高感觉阻滞平面比较,差异均无统计学意义(P＞0.05);芬太尼组、地塞米松组术中、术后及总寒战发生率均明显低于对照组[10.0％ (4/40)、20.0％(8/40)比32.5％ (13/40),0.0％(0/40)、2.5％ (1/40)比27.5％ (11/40),10.0％ (4/40)、22.5％ (9/40)比42.5％ (17/40),P＜0.05],其中芬太尼组术中及总寒战发生率低于地塞米松组(P＜0.05);芬太尼组、地塞米松组寒战发生强度明显低于对照组(P＜0.05),芬太尼组低于地塞米松组(P＜ 0.05);芬太尼组、地塞米松组恶心、呕吐发生率低于对照组[恶心:12.5％(5/40)、15.0％(6/40)比32.5％ (13/40),呕吐:5.0％ (5/40)、5.0％ (5/40)比15.0％(6/40),P＜0.05],芬太尼组瘙痒发生率高于地塞米松组、对照组[7.5％ (3/40)比0.0％ (0/40)、0.0％ (0/40),P＜0.01].3组低血压、呼吸抑制、心动过缓、低氧血症、低体温发生率差异无统计学意义(P＞0.05).对照组术中有5例,地塞米松组有3例产妇VAS评分≥4分,需要静脉给予芬太尼行疼痛治疗,芬太尼组无产妇VAS评分≥4分.结论 罗哌卡因蛛网膜下腔麻醉行剖宫产术时,静脉应用地塞米松或鞘内联合应用芬太尼都可使寒战发生率及强度降低,但鞘内应用芬太尼效果更好.%Objective To explore the effect of intravenous dexamethasone and intrathecal fentanyl in preventing perioperative shivering in cesarean section.Methods Totally 120 women undergoing elective cesarean section were enrolled and randomly divided into fentanyl group, dexamethasone group and control group.Subarachnoid anesthesia was given by intrathecal administration of 0.5％ hyperbaric ropivacaine [12.5 mg (2.5 ml)] combined with fentanyl [25 μg (0.5 ml)] in fentanyl group, 0.5％ hyperbaric ropivacaine [12.5 mg (2.5 ml)] combined with 0.9％ sodium chloride (0.5 ml) in dexamethasone group and control group;after delivery, dexamethasone group was intravenously administrated with dexamethasone (0.1 mg/kg), fentanyl group and control group were intravenously administrated with same volume of 0.9％ sodium chloride.The visual analog pain scale score (VAS) was used to evaluate the pain degree;four grades score method was used to evaluate the intensity of shivering.The duration of operation, tympanic temperature, room temperature, the highest sensory blockade plane, incidence and intensity of shivering, incidence of adverse reaction were compared among groups.Results The room temperature, duration of operation, tympanic temperature, the highest sensory blockade plane were not significantly different among groups (P ＞ 0.05).The incidences of intraoperative and postoperative shivering and total incidence of shivering in fentanyl group and dexamethasone group were significantly lower than those in control group [10.0％ (4/40), 20.0％ (8/40)vs 32.5％ (13/40), 0.0％ (0/40), 2.5％ (1/40)vs 27.5％ (11/40), 10.0％ (4/40), 22.5％ (9/40) vs 42.5％ (17/40)] (P ＜ 0.05);the incidence of intraoperative shivering and total incidence of shivering in fentanyl group were significantly lower than those in control group (P ＜ 0.05);the intensity of shivering was significantly lower in fentanyl group and dexamethasone group than that in control group, it was significantly lower in fentanyl group than that in dexamethasone group.The incidences of nausea and vomiting in fentanyl group and dexamethasone group were significantly lower than those in control group [12.5％ (5/40), 15.0％ (6/40) vs 32.5％ (13/40);5.0％ (5/40), 5.0％ (5/40) vs 15.0％ (6/40)] (P ＜0.05);the incidence of itching in fentanyl group was significantly higher than that in dexamethasone group and control group [7.5％ (3/40)vs 0.0％ (0/40), 0.0％ (0/40)] (P ＜0.01);the incidence of hypotension, respiratory depression, bradycardia, hypoxemia and hypothermia were not statistically different among groups (P ＞ 0.05).The VAS scores ≥4 scores in 5 cases of control group, 3 cases of dexamethasone group and none of fentanyl group.Conclusion Intrathecal ropivacaine combined with intrathecal fentanyl or combined with intravenous dexamethasone can effectively prevent shivering in elective cesarean section under spinal anesthesia, and the effect of former is more better.
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