腰-硬联合麻醉剖宫产术中预注去氧肾上腺素与麻黄碱对母婴的影响

摘要

目的 探讨腰-硬联合麻醉剖宫产术中预注去氧肾上腺素与麻黄碱对母婴的影响,以期寻找最佳预防低血压方法.方法 选取医院2014年1月至2015年12月妇产科收治择期剖宫产孕妇120例,随机单盲取法分为A、B、C三组各40例,C组为对照组,给予6%羟乙基淀粉预扩容;A组在C组基础上预注麻黄碱,B组在C组基础上预注去氧肾上腺素.观察三组产妇术中临床资料,进入手术室计为基础值(T0),麻醉后5min(T1),胎儿娩出时(T2)三个时间点心率(HR)、心脏排血量(CO)及平均动脉压(MAP)血流动力学指标变化;比较胎儿娩出后,三组新生儿脐动静脉血pH值、BE值、二氧化碳分压(PCO2)、血氧分压(PO2)变化及分娩后1min、5min新生儿Apgar评分.结果 三组均顺利完成剖宫产,三组产妇子宫切开至胎儿娩出时间(U-DI)、失血量、尿量、液体输入量、感觉阻滞平面、麻醉至胎儿娩出时间及手术时间比较差异无统计学意义(P>0.05).B组T1时CO低于T0时,差异有统计学意义(P<0.05).B组T1时MAP为(92.87±11.46)mmHg,C组T1时MAP为(87.63±10.85)mmHg,差异有统计学意义(P<0.05).A组T1时HR高于C组同期,差异有统计学意义(P<0.05).C组T1、T2时HR高于T0时,差异有统计学意义(P<0.05),T1时MAP低于T0时,差异有统计学意义(P<0.05).A组追加血管活性物产妇6例,B组追加5例,A、B组术中追加血管活性物产妇对比,差异无统计学意义(P>0.05).三组新生儿脐动静脉血气指标pH值、PCO2、PO2及1minApgar评分对比,差异有统计学意义(P<0.05).B组脐带动静脉血PCO2、PO2指标均低于C组,A组脐动静脉血PCO2、PO2指标均高于B组,1min Apgar评分高于C组同期,1min Apgar评分低于B组同期,差异均有统计学意义(P<0.05).A组脐动静脉pH值低于C组与B组,B组头晕、胸闷、恶心呕吐发生率低于A组、C组,A组、B组低血压发生率低于C组,差异均有统计学意义(P<0.05).结论腰-硬联合麻醉剖宫产术中预注去氧肾上腺素或麻黄碱均可有效降低低血压发生,但预注去氧肾上腺素对母婴影响较小,不良反应少,值得临床推广.%Objective To study the effects of phenylephrine and ephedrine pre-injection during cesarean section with Combined Spinal-Epidural Anesthesia (CSEA) on mother and infant,in order find the best way to prevent hypotension.Methods 120 cases of elective cesarean section gravidas received from January 2014 to December 2015 in Obstetrics and Gynecology of our hospital were selected and divided into A,B and C groups,each 40 cases,according to random single blind method.Group C was control group and 6% hydroxyethyl starch was used for volume pre-expansion.Group A was pre-injected with ephedrine in addition to 6% hydroxyethyl starch and group B was pre-injected with phenylephrine in addition to 6% hydroxyethyl starch.Intra-operation clinical data of puerperae in three groups were observed,T0 for the point of entering operating theatre,T1 for the point 5min after anesthesia and T2 for the point of the delivery of baby.Changes of hemodynamic indexes,such as heart rate (HR),cardiac output(CO) and mean arterial pressure (MAP) on these three time points,changes of neonatal arterial and venous cord blood pH,BE,partial pressure of carbon dioxide (PCO2) and partial pressure of blood oxygen (PO2) and neonatal Apgar scores 1 and 5minutes after delivery were observed.Results Puerperae of the three groups all successfully completed cesarean section and the differences of uterine incision-to-delivery interval (U-DI),blood loss,urinary volume,liquid input,sensory block level,anesthesia to fetal childbirth time and operation time among the three groups were not statistically significant (P>0.05).CO of group B at T1 was lower than that at T0,the difference being statistically significant(P<0.05).MAP of group B at T1 was (92.87 ± 11.46) mmHg and MAP of group C at T1 was (87.63 ± 10.85) mmHg,the difference being statistically significant(P<0.05).HR of group A at T1 was higher than HR of group C at T1,the difference being statistically significant(P<0.05).HR of group C at T1 and T2 was higher than that at T0,the difference being statistically significant(P<0.05).MAP of group C at T1 was lower than that at T0,the difference being statistically significant(P<0.05).In group A,there were 6 puerperae who received additional vasoactive agent and in group B,there were 5 puerperae who received additional vasoactive agent,comparing the number of puerperae who received additional vasoactive agent during operation in group A and B,there being no statistically significant difference(P>0.05).Comparing the neonatal arterial and venous cord blood pH,PCO2,PO2 and 1min Apgar scores of the three groups,the differences being statistically significant(P<0.05).Arterial and venous cord blood pH,PCO2 and PO2 of group B were all lower than those of group C,arterial and venous cord blood pH,PCO2 and PO2 of group A were all higher than those of group B,1min Apgar score of group A was higher than that of group C and lower than that ofgroup B,the differences being statistically significant(P<0.05).Arterial and venous cord blood pH of group Awas lower than group B and C,incidence of dizziness,chest distress,nausea and vomiting of group B was lower than group A and C,hypotension incidence of group A and B was lower than group C,the differences allbeing statistically significant(P<0.05).Conclusion Pre-injection of phenylephrine or ephedrine during cesarean section with CSEA can effectively reduce the incidence of hypotension,but in comparison,pre-injection of phenylephrine has little effect on mother and infant and less adverse reactions,worthy of promotion.