口服碳水化合物对硬膜外分娩镇痛产妇产程中舒适度的影响

目的观察口服碳水化合物对接受硬膜外分娩镇痛产妇产程中舒适度的影响。方法选择接受硬膜外分娩镇痛的单胎、头位、足月初产妇90例,年龄24~39岁,BMI 21~39kg/m~2,ASAⅡ级,随机分为两组:口服碳水化合物组(CHO组,n=46)和对照组(C组,n=44)。在接受分娩镇痛后,CHO组饮用术能,C组饮用无渣液体,第三产程后两组均停止饮用液体。记录两组饮用时长、液体总量,计算两组液体供能;记录产程时长、分娩方式、PCEA镇痛泵按压次数、药物总量和产程中呕吐的发生情况;记录分娩镇痛后即刻以及第三产程结束即刻饥饿、口渴、疲劳程度NRS评分。结果CHO组饮用液体总量少于C组,但差异无统计学意义[(129.5±28.8)ml vs(142.4±53.3)ml,P=0.15],CHO组液体供能明显多于C组[(312.2±69.5)kJ/h vs(153.9±96.7)kJ/h,P0.01]。两组液体饮用时长、产程时长、分娩方式、镇痛泵药物总量差异无统计学意义。CHO组镇痛泵按压次数明显少于C组[0.6(0~11.6)次vs 2(0~8.6)次,P=0.03]。CHO组产程中呕吐的比例明显低于C组[3例(6.5%)vs 10例(22.7%),P=0.03]。第三产程后即刻CHO组饥饿NRS评分[2(0~9)分vs 6(0~10)分,P0.01]、疲劳程度[3(2~8)分vs 4(1~7)分,P=0.04]明显低于C组。两组口渴NRS评分差异无统计学意义。结论口服碳水化合物作为接受硬膜外分娩镇痛产妇产程中的能量补充饮品可以降低产妇的饥饿疲劳程度,可降低产程中呕吐发生率,增加产妇的分娩舒适度。     

个体化镇痛时机对硬膜外分娩镇痛效果的影响

目的观察提前预置硬膜外导管,根据产妇需要开始镇痛的个体化镇痛模式对分娩镇痛效果的影响。方法这是一项标签开放的随机对照研究。选择单胎、足月、头位妊娠初产妇,年龄18~35岁,随机分为两组。个体化组产妇在产程开始(出现规律宫缩、宫颈接近消失)行硬膜外穿刺置管,当产妇有镇痛需求且NRS评分≥5分时给予硬膜外镇痛;对照组在宫口开大1 cm时行硬膜外镇痛。主要研究终点是分娩过程最严重疼痛NRS评分及分娩时NRS评分≥7分产妇比例。结果194例产妇完成研究,分娩过程中两组最严重疼痛程度NRS评分[个体化组9(8~10)分vs对照组9(8~10)分,P=0.201]及分娩时NRS评分≥7分产妇比例[个体化组94例(96.9%)vs对照组89例(91.8%),P=0.121]差异均无统计学意义。两组不良事件发生率差异无统计学意义。结论对于单胎、足月、头位且产科评估可试行阴道分娩的产妇,根据产妇需求实施硬膜外分娩镇痛的效果与传统的镇痛时机(宫口开放1 cm)相当。     

低背景剂量联合大剂量PCA在产妇硬膜外分娩镇痛中的应用

目的观察在持续输注联合硬膜外自控给药模式下低背景剂量持续输注联合大剂量PCA的参数设置对分娩镇痛临床效果的影响。方法选择自愿接受分娩镇痛足月、单胎和头位初产妇120例,年龄25~35岁,体重58~86kg,ASAⅠ或Ⅱ级,随机分为两组:常规组(A组)和低背景剂量组(B组)。在宫口扩张2~3cm时采用硬膜外分娩镇痛。每组均事先配置硬膜外注射混合液0.1%罗哌卡因+2μg/ml芬太尼100ml。A组为常规组,背景剂量6ml/h,PCA 5ml,间隔40min;B组为低剂量组,背景剂量2ml/h,PCA 10ml,间隔为40min。记录产妇镇痛前、镇痛后10min、30min、1h、2h、宫口开全时和分娩时VAS评分及改良Bromage评分;记录PCA追加次数;记录爆发痛例数;记录硬膜外混合液的用量;记录镇痛时间、产程时间、分娩方式;记录不良反应的发生情况和新生儿Apgar评分。结果镇痛期间两组产妇VAS评分差异无统计学意义;接受镇痛期间B组混合液用量(40.5±7.5)ml;明显少于A组(60.3±12.0)ml(P0.05);B组PCA实际追加次数(1.6±0.9)次明显少于A组(3.0±1.8)次(P0.05)。两组产妇的产程、镇痛时间、爆发痛例数、不良反应发生率、产妇分娩方式和新生儿Apgar评分差异无统计学意义。结论采用低背景剂量(2ml/h)联合大剂量PCA(10ml,间隔40min)的硬膜外自控镇痛参数设置不仅没有降低镇痛效果,还可减少硬膜外腔用药总量。     

全产程分娩镇痛与第一产程分娩镇痛对妊娠高血压综合征产妇产程的影响

目的比较全产程分娩镇痛与第一产程分娩镇痛用于合并妊娠高血压综合征产妇的安全性及有效性。方法选择2015年3~11月于北京妇产医院分娩的产妇196例,年龄22~35岁,ASAⅠ或Ⅱ级。所有产妇均为初产、单胎和足月妊娠,诊断妊娠高血压综合征。随机将入选产妇分为全产程分娩镇痛组(T组)和第一产程活跃期分娩镇痛组(F组)。T组在出现子宫规律收缩后进行分娩镇痛,持续应用镇痛泵至第三产程结束;F组在出现子宫规律收缩且进入第一产程活跃期(子宫口开至3cm)后进行分娩镇痛,子宫口开全后,由生理盐水代替泵内麻醉药物至第三产程结束。记录镇痛前、镇痛后10、60min、宫口开全、第二产程屏气用力和胎头娩出时的MAP和VAS评分;记录应用缩宫素例数和第二产程屏气用力时Bromage评分;记录第一、第二、第三产程时间、分娩方式、子痫和产后出血情况。结果第二产程屏气用力时,T组MAP明显低于F组[(106.0±7.0)mm Hg vs.(115.4±7.3)mm Hg,P0.05],VAS评分明显低于F组[(2.0±1.1)分vs.(5.1±1.2)分,P0.05];胎头娩出时,T组MAP明显低于F组[(106.2±7.2)mm Hg vs.(116.0±7.6)mm Hg,P0.05],VAS评分明显低于F组[(1.9±1.2)分vs.(5.2±1.3)分,P0.05];T组应用缩宫素例数明显多于F组[50(51%)vs.35(35%),P0.05]。两组Bromage评分、产程时间、分娩方式和相关不良反应差异无统计学意义。结论全产程分娩镇痛可安全有效地应用于合并妊娠高血压综合征的产妇。     

不同硬膜外镇痛模式对肥胖产妇镇痛效果和分娩方式的影响

目的比较两种硬膜外镇痛模式对肥胖产妇镇痛效果和分娩方式的影响。方法回顾性分析2013—2016年本院肥胖产妇586例,年龄21～43岁,BMI 30～41 kg/m~2,ASAⅡ或Ⅲ级,按照镇痛模式分为两组,每组105例:连续硬膜外输注组(CEI组)和间歇脉冲硬膜外输注组(IEB组)。两组均事先配置硬膜外注射混合液0.08%罗哌卡因+0.45μg/ml舒芬太尼200 ml。CEI组:背景剂量6 ml/h,PCEA剂量6 ml,注药速率为60 ml/h,锁定时间30 min;IEB组:脉冲频率每小时1次,剂量6 ml,注药速率400 ml/h,PCEA剂量6 ml,锁定时间30 min。应用SPSS 22.0中倾向性评分匹配(PSM)模块,采用1∶1最近邻匹配法、设定卡钳值为0.01进行倾向性匹配分析。记录镇痛前、镇痛后10、30 min和宫口开全时NRS评分;记录产程时间、分娩方式;记录镇痛药物总量、PCEA追加次数、PCEA有效次数和新生儿1、5 min Apgar评分;记录镇痛期间不良反应的发生情况。结果宫口开全时IEB组NRS评分明显低于CEI组[(3.8±0.7)分vs (4.2±0.7)分,P0.05]。IEB组三个产程时间明显长于CEI组(P0.05),PCEA追加次数及PCEA有效次数明显少于CEI组(P0.05)。两组分娩方式、镇痛药物总量、新生儿Apgar评分和不良反应发生率差异无统计学意义。结论 IEB模式为肥胖产妇提供良好的镇痛效果,不影响分娩方式,可安全有效地用于肥胖产妇联合PCEA进行分娩镇痛。     

硬膜外分娩镇痛对脐动脉血心钠素和内皮素-1的影响

目的评价硬膜外分娩镇痛对脐动脉血心钠素(ANP)和内皮素-1(ET-1)的影响。方法选择初产妇60例,年龄22~35岁,身高155~170cm,体重60~75kg,孕周37周,单胎头位,宫缩正常,ASAⅠ或Ⅱ级,依据产妇自愿原则顺序入组,并据此分为E组和C组,每组30例。E组宫口开至2~3cm时,在L2~3椎间隙行硬膜外穿刺,置入硬膜外导管,1%利多卡因3~5ml作为试验剂量,观察5min后采用患者自控硬膜外镇痛,0.1%罗哌卡因与舒芬太尼0.5μg/ml混合液100ml加入电子镇痛泵,负荷剂量为10ml,背景维持量为6ml/h,单次剂量为5ml,锁定时间15min。C组产妇自愿放弃镇痛措施。记录第一产程时间、第二产程时间、VAS评分、不良反应情况、脐动脉血气分析和新生儿Apgar评分,酶联免疫吸附法测定脐动脉血ANP和ET-1浓度。结果 E组在镇痛后分娩过程中VAS评分明显低于C组(P0.05),且镇痛后各时点VAS评分均低于3分。两组第一产程、第二产程、脐动脉血气分析和新生儿Apgar评分差异无统计学意义。E组脐动脉血ANP和ET-1浓度明显高于C组(P0.05);两组脐动脉血ANP/ET-1浓度比值差异无统计学意义。两组未发生运动阻滞、低血压和恶心呕吐等不良反应。E组有1例出现瘙痒,1例出现耳鸣。结论硬膜外分娩镇痛能够改善胎盘循环,增加脐动脉血ANP和ET-1浓度。     

不同浓度罗哌卡因用于全产程硬膜外分娩镇痛的疗效观察

目的比较不同浓度罗哌卡因用于不同产程硬膜外分娩镇痛的效果。方法选择要求硬膜外分娩镇痛的初产妇360例,随机分为3组(n=120)。所有患者在完成硬膜外腔置管后,硬膜外腔注射负荷剂量局麻药(0.1%罗哌卡因+2μg/ml芬太尼),阻滞平面达T_(10)后接PCA泵行PCEA。A组PCA采用0.1%罗哌卡因+2μg/ml芬太尼,宫口开全时停止PCA。B组PCA采用0.1%罗哌卡因+2μg/ml芬太尼全产程镇痛。C组PCA采用0.08%罗哌卡因+2μg/ml芬太尼全产程镇痛。观察产妇镇痛前(T_0)、镇痛后1小时(T_1)、2小时(T_2)、3小时(T_3)、宫口开全时(T_4)、分娩时(T_5)、会阴部修复时(T_6)VAS评分;采用Bromage评分评价运动阻滞程度;记录产程时间、镇痛时间、分娩方式、新生儿Apgar评分、满意度评分及不良反应的发生情况。结果与T_0时比较,B、C两组产妇T_1~T_6时点VAS评分较低,A组T_1~T_5时点VAS评分较低(P0.05)。与A组比较,B、C两组产妇T_6时点VAS评分较低;产妇对分娩镇痛效果满意度较高(P0.05)。3组产妇第一产程时间、第一产程镇痛时间、第二产程时间、分娩方式、新生儿Apgar评分、Bromage评分及不良反应差异无统计学意义(P0.05)。结论全产程硬膜外分娩镇痛效果优于第一产程分娩镇痛,而0.08%罗哌卡因复合芬太尼用于全产程分娩镇痛具有较好的效果与安全性。     

罗比卡因硬膜外分娩镇痛的临床研究

目的:研究低浓度罗比卡因病人自控硬膜外镇痛(PCEA)行分娩镇痛的效果.方法:选择109例ASAⅠ～Ⅱ级、头位、单胎足月妊娠的初产妇行PCEA(分娩镇痛组).另选100例条件相仿但不给予硬膜外阻滞的自然分娩产妇为对照组.分娩镇痛组给予0.1%罗比卡因+芬太尼(1μg/ml),PCEA基础注药速率为6ml/h,冲击量为2ml,锁定时间为10分钟.进行视觉模拟镇痛评分(VAS)和下肢运动神经阻滞评分(MBS).记录产程时间、生产方式.监测胎儿心率(FHR)、新生儿Apgar评分和SpO2.结果:分娩镇痛组用药后15～30分钟均感到无痛或只感到轻度可耐受的疼痛(VAS评分0.6±0.8).分娩镇痛组产妇MBS在镇痛前后无统计学差异(P＞0.05),所有产妇均能下床活动.分娩镇痛组产妇第一产程时间为464.9±173.5分钟,短于对照组第一产程时间(P＜0.05).分娩镇痛组第二产程时间为48.4±21.8分钟,对照组为46.7±20.6分钟,两组无统计学差异(P＞0.05).分娩镇痛组新生儿1、5分钟Apgar评分和SpO2与对照组无统计学差异(P＞0.05).结论:低浓度罗比卡因分娩镇痛效果确切,对运动神经阻滞轻,不影响产程及新生儿,是目前分娩镇痛较理想的方法.     

单纯罗哌卡因与罗哌卡因复合舒芬太尼在硬膜外分娩镇痛中的比较

目的比较单纯罗哌卡因与罗哌卡因复合舒芬太尼在硬膜外分娩镇痛中的有效性和安全性。方法选择要求硬膜外分娩镇痛的产妇481例,年龄18~45岁,ASAⅠ级,随机分为两组,硬膜外分别给予0.125%罗哌卡因(R组,n=241)或0.125%罗哌卡因复合0.3μg/ml舒芬太尼(RS组,n=240)。记录产程中NRS疼痛评分及VAS镇痛满意度评分,产妇Bromage运动评分及不良反应情况,以及新生儿Apgar评分及脐带血气分析。结果最终纳入产妇346例,R组164例,RS组182例。第一产程NRS评分RS组2.2分(IQR 1.8~2.7分),明显低于R组2.4分(IQR 2~2.8分)(P0.001),第二产程两组NRS评分差异无统计学意义。两组VAS镇痛满意度差异无统计学意义。分娩镇痛相关不良反应发生率RS组47.2%,R组37.7%,两组差异无统计学意义。RS组1 min的Apgar评分≤7分的比例为5.5%,明显高于R组1.2%(P0.05)。结论单纯罗哌卡因用于硬膜外分娩镇痛与罗哌卡因复合舒芬太尼效果相似,但产妇不良反应更少,新生儿1 min的Apgar评分≤7分的比例更低。     

地塞米松对硬膜外分娩镇痛产妇发热的影响

目的探索硬膜外给予地塞米松对硬膜外分娩镇痛后产妇发热的影响。方法选择实施分娩镇痛的单胎足月初产妇200例,年龄22～38岁,BMI 20～35 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法将产妇分为两组:地塞米松组(D组)和对照组(C组),每组100例。两组均采用程控硬膜外间歇脉冲给药的方式实施分娩镇痛,D组在给予硬膜外首次剂量(0.08%罗哌卡因+舒芬太尼0.4μg/ml,共12 ml)后,经硬膜外给予地塞米松10 mg(2 ml);C组在给予相同硬膜外首次剂量后经硬膜外给予生理盐水2 ml。测量并记录分娩镇痛开始前、分娩镇痛开始后1、2、3、4、5 h和胎儿娩出时产妇鼓膜温度。记录分娩镇痛开始前、分娩镇痛开始后1、2、3、4、5 h和第一产程结束时的Bromage评分、VAS疼痛评分。记录产间发热例数、分娩转剖宫产例数,记录镇痛时间、产程时间、新生儿出生后1、5、10 min Apgar评分,记录其他不良反应的发生情况。结果 D组发热率明显低于C组(P0.05)。两组分娩转剖率、镇痛时间、产程时间、新生儿出生后1、5、10 min Apgar评分和各时点VAS疼痛评分差异无统计学意义,两组均未发生下肢运动神经阻滞及其他不良反应。结论镇痛初始经硬膜外给予地塞米松10 mg能明显降低产妇硬膜外分娩镇痛后发热率,且不影响母婴安全。     

硬膜外分娩镇痛对分娩方式影响的回顾性分析

目的 评价硬膜外分娩镇痛对分娩方式的影响.方法 将我院2005年1月至2006年12月的临床分娩资料,按年和月分别统计硬膜外分娩镇痛率、顺产率、产钳率和剖宫产率;收集接受硬膜外分娩镇痛而以剖宫产结束分娩的产妇资料.分娩镇痛的方法是待产妇宫口开至2 cm以上时采用0.15%罗哌卡因或0.1%罗哌卡因复合2 mg/L芬太尼硬膜外镇痛,首剂负荷量10ml～12ml,背景量5 ml/h～8 ml/h,患者自控镇痛量1ml～5 ml,锁定时间15 min,宫口开全停泵.结果 与2005年比较,2006年硬膜外分娩镇痛率升高(21.90%对33.8%,P＜0.05),顺产率升高(51.7%对55.2%,P＜0.05),剖宫产率降低(43.9%对40.1%,P＜0.05),产钳率无明显变化(4.4%对4.7%,P＞0.05).随着每月硬膜外分娩镇痛率由8.4%升至41.2%时,剖宫产率由46.9%降至37.6%,两者之间呈负相关(r=0.678,P＜0.05).两年共完成硬膜外分娩镇痛5 461例,其中1125例(20.6%)以削宫产结束分娩,原因分别为胎儿窘迫371例(33.0%),头盆不称323例(28.7%),持续性枕后位或枕横位219例(19.5%),活跃期停滞141例(12.5%),发烧44例(3.9%),其他原因26例(2.3%).结论 硬膜外分娩镇痛为畏惧产痛而要求削宫产的产妇提供了自然分娩的机会,在一定程度上能够降低剖宫产率、提高自然分娩率;但接受硬膜外分娩镇痛而以剖宫产结束分娩的产妇,剖宫产的原因是否与分娩镇痛有关还需进一步研究.     

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre,double-blind,randomised study†

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml^-1. The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.     

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml^-1; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA–group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.     

左布比卡因复合右美托咪定在分娩镇痛中的应用及对母儿的影响

目的 研究左布比卡因复合右美托咪定(dexmedetomidine,Dex)在分娩镇痛中的应用及对母儿的影响. 方法 120例单胎、头位、初产妇,采用随机数字表法分为两组(每组60例),观察组(A组)应用左布比卡因复合Dex,对照组(B组)应用左布比卡因复合舒芬太尼,两组均采用硬膜外麻醉方式.产妇行硬膜外穿刺,两组分别给予0.1％左布比卡因+0.5 mg/L Dex复合液和0.1％左布比卡因+0.5 mg/L舒芬太尼复合液各5 ml.连接泵镇痛,泵速设置为8ml/h,患者自控镇痛(patient controlled analgesia,PCA)追加5 ml/次,锁定15 min.观察两组产妇生命体征、VAS评分、Bromage评分、Ramsay评分、产程、产后出血及新生儿Apgar评分. 结果 与麻醉前(T0)比较,麻醉后30 min(Tt)两组产妇MAP[A组,(81.8±4.7) mmHg(1 mmHg=0.133 kPa)比(93.0±6.2) mmHg;B组,(86.3±5.4)mmHg比(93.8±7.0) mmHg]、HR[A组,(70±10)次/min比(90±10)次/min;B组,(76±8)次/min比(88±8)次/min]均降低(P＜0.05).VAS评分,在T0、T1、活跃期1 h(T2)、第二产程1 h(T3)时,A组分别为(8.6±1.1)、(1.3±0.7)、(1.7±0.6)、(3.5±0.7)分,B组分别为(8.8±1.2)、(3.0±0.3)、(3.0±0.5)、(3.2±0.8)分,两组差异有统计学意义(P＜0.05).Ramsay评分在T1～T3时点,B组[(3.0±0.2)、(4.0±0.3)、(4.0±0.1)分]与A组[(2.0±0.3)、(2.0±0.2)、(2.0±0.1)分]比较,差异有统计学意义(P＜0.05).两组Bromage评分、产程时间、妊娠结局、产后出血及新生儿Apgar评分比较,差异无统计学意义(P＞0.05). 结论 左布比卡因复合Dex用于分娩镇痛安全、有效、舒适.     

两种硬膜外分娩镇痛给药方式效果比较

目的观察两种硬膜外分娩镇痛给药方式对产妇镇痛满意度的影响。方法将60例ASAⅠ~Ⅱ级有分娩镇痛要求的初产妇随机分为Ⅰ组和Ⅱ组各30例,两组均在成功实施硬膜外阻滞后,将硬膜外导管与镇痛泵相连;Ⅰ组设定无背景剂量,Ⅱ组设定背景剂量5 ml/h;均设置单次剂量5 ml,锁定时间15 min。结果两组产妇在分娩镇痛期间的BP、HR、RR、SpO2、胎心率及宫缩强度均在正常范围,各记录时点的VAS评分、不良反应发生率及产妇满意度两组差异无统计学意义(均P>0.05);Ⅰ组行PCEA单次剂量追加例数和按压次数均显著多于Ⅱ组(均P<0.01),使用罗哌卡因和舒芬太尼药量显著少于Ⅱ组(均P<0.01)。结论两种给药方式均能使产妇达到较高满意度,有背景剂量的给药方式接近理想分娩镇痛效果。     

The incidence of breakthrough pain associated with programmed intermittent bolus volumes for labor epidural analgesia: a randomized controlled trial

BackgroundIn this randomized, blinded study, we evaluated the effects of different programmed intermittent epidural bolus (PIEB) volumes for labor analgesia on the incidence of breakthrough pain and other analgesic outcomes.MethodsNulliparous women with term cephalic singleton pregnancies who requested labor analgesia had epidural analgesia initiated with 10 mL 0.1% ropivacaine with sufentanil 0.3 μg/mL. The pump was programmed to deliver a 4, 6 or 8 mL bolus every 45 min (groups 4, 6 or 8, respectively). The primary outcome was the incidence of breakthrough pain, defined as inadequate analgesia after two patient-controlled epidural analgesia administrations in a 20-min period. Secondary outcomes included ropivacaine consumption, time of the first patient-controlled epidural analgesia request, duration of the second stage of labor, and incidence of motor block.ResultsAmong 210 women randomly allocated the incidence of breakthrough pain was 34.9%, 19.7%, and 13.1%, for groups 4, 6 and 8, respectively (P=0.011). The incidence of breakthrough pain in group 8 was lower than in group 4 (P=0.006). The median (interquartile range) hourly ropivacaine consumption was 8.2 mg/h (7.1–11.3), 10.4 mg/h (9.2–13.0), and 12.0 mg/h (11.2–13.8) in groups 4, 6 and 8, respectively (P <0.001). Group 8 had a longer duration of effective analgesia and longer second stage of labor than group 4. There was no significant difference between groups in the incidence of motor block.ConclusionThe larger PIEB volumes were preferred for epidural labor analgesia compared with a smaller volume because of improved analgesia without clinically significant increases in adverse effects.     

Patient-controlled epidural analgesia during labor using ropivacaine and fentanyl provides better maternal satisfaction with less local anesthetic requirement

Purpose To test the hypothesis that patient-controlled epidural analgesia (PCEA) using ropivacaine and fentanyl provides better maternal satisfaction and less anesthetic requirement than conventional continuous epidural infusion (CEI) during labor, we studied 58 uncomplicated parturients (singleton, vertex presentation).Methods After establishing effective epidural analgesia with 11 ml of 0.2% ropivacaine, all parturients were randomly divided into one of two groups: the PCEA group (n = 29) or the CEI group (n = 29). In the PCEA group, the pump was initiated to deliver a basal infusion at 6 ml·h⁻¹ and a demand dose of 5 ml; the lockout interval was 10 min, and there was a 31 ml·h⁻¹ limit. The drugs used were 0.1% ropivacaine + fentanyl 2 µg·ml⁻¹. In the CEI group, epidural analgesia was maintained with the same solution as the PCEA group at a constant rate of 10 ml·h⁻¹. If parturients requested additional analgesia in the CEI group, we added 8 ml of epidural 0.2% ropivacaine without fentanyl.Results Parturients’ demographic data, such as duration of labor, mode of delivery, Apgar score, and umbilical arterial pH did not differ between the two groups. However, the hourly requirement of ropivacaine was significantly less in the PCEA group than in the CEI group (9.3 ± 2.5 vs. 17.6 ± 7.6 mg·h⁻¹; P < 0.05). Parturients’ satisfaction assessed by the Visual Analogue Scale tended to be higher in the PCEA group than in the CEI group. Side effects such as nausea, hypotension, and itching were similar for the two groups.Conclusion We found that PCEA was an effective means of providing optimal analgesia, with better satisfaction during labor and less local anesthetic requirement.     

A multicenter,randomized, controlled trial comparing bupivacaine with ropivacaine for labor analgesia

BACKGROUND: A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl. METHODS: This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 microg/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 microg/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes. RESULTS: There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients; P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively; P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively; P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean +/- SD: 76 +/- 23 vs. 72 +/- 23, respectively; P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean +/- SD: 71 +/- 25 vs. 66 +/- 26, respectively; P = 0.037). CONCLUSIONS: There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.     

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

IntroductionThe aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB) + patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI) + PCEA for maintenance labor analgesia after the introduction of PIEB at our institution.MethodsWe conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12 mL/h with PCEA (12 mL bolus, lockout 15 min); PIEB settings were a 9 mL bolus every 45 min with PCEA (10 mL bolus, lockout 10 min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses.ResultsFewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0–5] with CEI and 0[0–4] with PIEB. There was no difference in instrumental delivery rates.ConclusionsUsing PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.     

Automated regular boluses for epidural analgesia: a comparison with continuous infusion

BACKGROUND: Intermittent epidural bolus dosing is a method of drug delivery that can prolong the duration of labour analgesia induced by a combined spinal epidural (CSE). In this randomized, double-blinded study, we compared the analgesic efficacy of two drug delivery systems: regular intermittent epidural boluses and continuous epidural infusion and assessed the incidence of breakthrough pain after CSE. METHODS: With the approval of the Hospital Ethics Committee, we recruited 60 parturients into this randomized controlled trial. A CSE was performed with intrathecal fentanyl 25 mug in all patients. The parturients were then randomly allocated into two groups. The infusion group received a continuous epidural infusion of levobupivacaine 0.1% with fentanyl 2 microg/mL at a rate of 10 mL/h. The bolus group received 5-mL epidural boluses every half hour. The sample size was computed to detect a 40% reduction in the rate of breakthrough pain. RESULTS: The bolus group had a lower incidence of breakthrough pain than the infusion group (10% vs. 37%, P < 0.05). The bolus group also had significantly higher satisfaction scores for labour analgesia: 97+/-8 (mean+/-SD) vs. 89+/-7 (P < 0.05). CONCLUSION: Automated regular bolus delivery of epidural analgesia when compared with continuous infusion decreased the incidence of breakthrough pain and increased maternal satisfaction. In a busy obstetric unit, this may also serve to decrease the anesthetists' workload.