A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after cesarean section

BackgroundAdding intrathecal opioids to intrathecal local anesthetics to decrease their doses and provide hemodynamic stability are major goals during spinal anesthesia in cesarean section. Different opioids were used to select the one with the longest duration of analgesia and the least side effects. In this study, intrathecal nalbuphine was compared with intrathecal fentanyl as an adjuvant to hyperbaric bupivacaine in cesarean section.Patients and methodsSixty female patients of ASA grades I and II presented for elective cesarean deliveries with spinal anesthesia were randomly allocated to 2 equal groups; Group F: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml fentanyl (25 μg); Group N: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml nalbuphine (0.8 mg). The onset of sensory and complete motor blockade, time of sensory blockade, duration of analgesia and motor blockade, fetal Apgar score, visual analog scale score, oxygen saturation, adverse effects and hemodynamic parameters were recorded intra-operatively and up to 4 h post-operatively. The effective analgesic time was recorded.ResultsThe onset of complete motor block was significantly more rapid in fentanyl group than in nalbuphine group. The duration of post-operative analgesia was more prolonged in nalbuphine group but the difference was insignificant. No significant difference was found between both groups as regards the duration of sensory block, motor block, duration of analgesia, fetal Apgar score, visual analog scale score, hemodynamic parameters and oxygen saturation. Adverse effects were less common in nalbuphine group but the difference was insignificant.ConclusionEither intrathecal nalbuphine 0.8 mg or intrathecal fentanyl 25 μg combined with 10 mg bupivacaine provides good intra-operative and early post-operative analgesia in cesarean section.     

Postural change from lateral to supine is an important mechanism enhancing cephalic spread after injection of intrathecal 0.5% plain bupivacaine for cesarean section

BackgroundSpinal anesthesia is widely used for cesarean section, but the factors that affect the spread of the block in pregnant patients are still not fully explained. This study was designed to investigate the effect of postural changes on sensory block level.MethodsThirty patients scheduled for elective cesarean section under combined spinal–epidural anesthesia were randomly allocated into three groups. After intrathecal injection of 0.5% plain bupivacaine 7.5 mg, patients in group S were immediately placed in the supine position with left tilt, patients in group L5 were kept lateral for 5 min and then turned to the supine position with left tilt, and patients in group L10 were kept lateral for 10 min and then turned to the supine position with left tilt.ResultsAt 5 min, median cephalad level of sensory block was lower in groups L5 and L10 compared with group S (corrected P<0.001); at 10 min, median cephalad sensory block level was lower in group L10 compared with group S (corrected P<0.001) and group L5 (corrected P<0.001), and lower in group L5 compared with group S (corrected P=0.033); at 15 min, median cephalad level of sensory block was lower in group L10 compared with group S (corrected P=0.003) and group L5 (corrected P=0.015).ConclusionsIn our population, using 0.5% plain bupivacaine 7.5 mg, postural change from the lateral position to the supine position is an important mechanism enhancing cephalic spread of spinal anesthesia during late pregnancy.     

椎管内给药预防剖宫产术中寒战的Meta分析

目的 评价椎管内给药预防剖宫产术中寒战的有效性与安全性.方法 检索Cochrane图书馆、PubMed、Embase,检索时间从建库至2015年8月.收集椎管内给药预防剖宫产术中寒战的临床随机对照试验(RCTs).采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan 5.3软件对收集的资料进行Meta分析.结果 纳入10项研究,共677例,其中试验组390例,对照组287例.与对照组比较,分别体现在芬太尼、哌替啶可减少术中寒战的发生,合并效应的比值比(odda radio,OR和95％可信区间(95％confidence interval,95％CI)为(OR =0.29,95％CI 0.14～0.59)、(OR =0.09,95％CI 0.04～0.18)、舒芬太尼椎管内给药与对照组比较,并不能减少术中寒战的发生(OR=1.74,95％CI 0.33～9.02).结论 芬太尼、哌替啶椎管内给药可有效且安全预防剖宫产术中寒战的发生,而舒芬太尼椎管内给药可能并不能减少术中寒战的发生;在椎管内给予上述药物时应注意药物相关并发症.     

A two-dose epidural morphine regimen for cesarean section patients: therapeutic efficacy

A single dose of epidural morphine (EM) usually produces 24 h of post-cesarean section (CS) analgesia and patients require supplemental analgesics beyond this period. This study assesses if a second dose of EM administered 24 h after the first one offers superior therapeutic efficacy compared to conventional analgesics. Patients (n = 100) were randomized to receive one or two doses of epidural morphine. In all patients, EM 5 mg was administered after delivery. After 24 h patients received epidurally either normal saline (n = 50, Group 1) or morphine 5 mg (n = 50, Group 2). An independent observer used a visual analogue scale to assess nausea, itching, and analgesia 24 h after each injection. Results were expressed as mean +/- 1 s.e. mean and analyzed using nonparametric methods. The second dose of EM produced a significantly lower incidence and severity of nausea and itching than did the first dose (P < 0.01) in Group 2 with no difference in analgesia. The second day postoperative pain score in Group 1 was significantly greater than the first day score in the same group, and significantly greater than the severity score in Group 2. Only 36% of patients receiving two doses of EM required supplemental analgesics beyond 48 h compared to 76% of those receiving one dose (P < 0.01). No serious complications were noted. In summary, the use of a second dose of EM for post-CS analgesia produces better analgesia and reduces the need for oral analgesics. The second dose produced fewer side-effects, probably due to acute tolerance to morphine.     

剖宫产术患者不同比重罗哌卡因腰麻半数有效剂量的比较

目的 比较剖宫产术患者不同比重罗哌卡因腰麻的半数有效剂量(ED50).方法 择期脊椎-硬膜外联合麻醉下行剖宫产术的单胎足月初产妇40例,年龄20～40岁,采用随机数字表法,将其随机分为2组(n=20):重比重罗哌卡因组(HR组)和轻比重罗哌卡因组(LR组).经L2.3间隙行蛛网膜下腔穿刺,2组第1例患者局麻药的初始剂量均为9mg,HR组和LR组分别给予0.5％重比重和0.5％轻比重罗哌卡因,根据腰麻是否有效按照序贯法确定下一例患者的剂量,剂量间隔为1mg.采用概率单位法计算不同比重罗哌卡因腰麻的ED50及其95％可信区间(CI).结果 0.5％重比重和0.5％轻比重罗哌卡因腰麻的ED50分别为9.34 mg(95％CI 8.34～10.46 mg)和9.64 mg(95％CI 8.90～10.44 mg),二者ED50比较差异无统计学意义(P＞0.05).结论 剖宫产术患者0.5％重比重和0.5％轻比重罗哌卡因腰麻的ED50分别为9.34和9.64 mg,比重因素对罗哌卡因腰麻效果无影响.     

Sevoflurane anesthesia for elective cesarean section

Sevoflurane anesthesia was given to sixteen women who had been scheduled for elective cesarean section. The maternal systolic blood pressure significantly decreased during the anesthesia induction. Both the anesthesia induction and emergence were smooth and rapid. These findings were supported partially by the pharmacokinetic analysis of sevoflurane concentration in the maternal artery and expired gas mixture. Spontaneous uterine contractions were good in 12 patients, fair in two and poor in two. The measured blood loss was 752 ± 257ml including amniotic fluid. No blood transfusion was given to any patient. The median value of the Apgar score at one minute was seven (range three to nine). No neonate was intubated for resuscitation. No abnormal maternal laboratory data were found, including liver and kidney function tests and blood cell counts one week after the operation. No adverse effect of sevoflurane on the neonate was found one week after the delivery and three months after the discharge.(Asada A, Fujimori M, Tomoda S et al.: Sevoflurane Anesthesia for elective cesarean section. J Anesth 4: 66–72, 1990)     

布比卡因复合右美托咪定在剖宫产术蛛网膜下腔麻醉中的安全性和有效性

目的探讨布比卡因复合右美托咪定在剖宫产术蛛网膜下腔麻醉(腰麻)的安全性和有效性。方法择期腰麻下行剖宫产术的产妇150例,年龄20～35岁,体重60～85 kg,随机分为三组,B组:0.5%布比卡因9 mg;FB组:0.5%布比卡因7.5 mg+芬太尼20μg;DB组:0.5%布比卡因7.5 mg+右美托咪定5μg。记录产妇感觉和运动阻滞起效时间、持续时间,以及低血压、寒战、恶心呕吐等不良反应发生情况。结果 B组、FB组和DB组感觉阻滞起效时间分别为(14.8±2.9)s、(15.5±2.2)s和(12.3±1.6)s,DB组明显短于B组和FB组,B组明显短于FB组(P0.05)。B组、FB组和DB组感觉阻滞持续时间分别为(122.3±23.5)min、(108.7±21.4)min和(147.3±18.0)min,DB组明显长于B组和FB组,B组明显长于FB组(P0.05)。B组、FB组和DB组运动阻滞起效时间分别为(3.4±1.1)min、(3.2±0.8)min和(2.8±0.7)min,DB组明显短于B组和FB组(P0.05)。B组、FB组和DB组运动阻滞持续时间分别为(162.1±24.5)min、(141.3±21.9)min和(188.5±21.7)min,DB组明显长于B组和FB组,B组明显长于FB组(P0.05)。DB组产妇低血压、寒战、术中及术后恶心呕吐的发生率均明显低于B组(P0.05),且DB组低血压发生率明显低于FB组(P0.05)。结论剖宫产术中布比卡因复合右美托咪定的腰麻效果优于复合芬太尼,且安全性更高。     

A triple-blinded randomized trial comparing spinal morphine with posterior quadratus lumborum block after cesarean section

BackgroundThis study aimed to compare the postoperative analgesic effects of ultrasound-guided posterior quadratus lumborum block with spinal morphine, after cesarean section, using the visual analogue scale pain score.MethodsOne-hundred-and-seventy-six pregnant women scheduled for elective cesarean section with spinal anesthesia were randomly allocated into four groups to receive spinal morphine 0.1 mg (group M⁺); spinal saline (M⁻); posterior quadratus lumborum block using either 0.3% ropivacaine (0.45 mL/kg each side, maximum 150 mg) group pQ⁺); or saline (pQ⁻). All patients received 11–13 mg hyperbaric bupivacaine 0.5% and 10 μg fentanyl. Intravenous droperidol, fentanyl and acetaminophen were administered during surgery. Bilateral posterior quadratus lumborum block was performed immediately after surgery. Postoperative pain was assessed at 0.5, 1, 2, 4, 6, 18 and 24 h after surgery, and the pain score 6 h after surgery was the primary endpoint.ResultsOne-hundred-and-forty-six patients were included in the final analysis. Pain scores 6 h after surgery, both at rest and when moving, were significantly different when comparing the M⁺pQ⁺ group with the M⁻pQ⁺ or M⁻pQ⁻ groups, and when comparing the M⁺pQ⁻ group with the M⁻ pQ⁺ or M⁻ pQ⁻ groups (all P <0.05). There was no significant difference between the M⁺pQ⁺ and M⁺pQ^– groups, or between the M⁻pQ⁺ and M⁻pQ⁻ groups.ConclusionSpinal morphine improved postoperative analgesia but the combination of posterior quadratus lumborum block with spinal morphine did not lead to further improvement.     

剖宫产后适宜节育措施初探

应用历史前瞻性研究方法,调查360例剖宫产(CS)后5年的避孕、人工流产及发病情况,并与同期自然分娩(ND)401人作对照。结果显示:宫内节育器(IUD)使用最为普遍,其中以Tcu Vcu效果最好,阴道药具及甾体避孕药等因使用不当而效果较差。CS组惰性金单环的带器妊娠率(5.4％)明显高于ND组(2.4％),Tcu Vcu带器妊娠率很低,分别为1.6％及1.5％。CS组宫外孕发生率1.7％,对照组为0(P<0.05)。多因素回归分析显示,子宫周围粘连及产褥感染为宫外孕的主要危险因素,RR分别为3.02及7.84。提示CS后以选择活性非O形IUD为宜,子宫活动度受限者不宜用IUD,用综合性节育措施应加强技术指导。     

双叶产钳在剖宫产术中的应用

目的探讨产钳在剖宫产术中娩头困难的应用价值。方法将80例剖宫产术中抬头高浮随机分为两组,观察组:应用双叶产钳助产,对照组:未使用产钳。结果观察组胎头娩出时间(21±4)s短于对照组(28±6)s,两组差异有统计学意义(P<0.05);观察组新生儿Apgar评分(9.45±0.68)分,对照组为(8.92±1.02)分,两组差异有统计学意义(P<0.05);术中出血量观察组为(259±54)ml,对照组为(288±99)ml,两组差异有统计学意义(P<0.05);两组均无子宫切口撕裂及新生儿产伤。结论剖宫产术中抬头高浮使用双叶产钳可明显缩短娩胎时间、减少新生儿窒息、减少术中出血,且无子宫切口撕裂,值得推广。     

生理盐水硬膜外容量扩张对剖宫产蛛网膜下腔阻滞时0.75%罗哌卡因半数有效剂量的影响

目的探讨硬膜外注生理盐水10 ml进行硬膜外容量扩张(EVE)对剖宫产产妇0.75%罗哌卡因蛛网膜下腔阻滞(简称腰麻)半数有效剂量(ED_(50))的影响。方法足月单胎初产妇60例,体重50～80 kg, ASAⅡ级,孕期37周。采用随机数字表法将产妇分为两组:EVE组(E组)和对照组(C组),每组30例。两组均在超声引导下行L_(3-4)间隙腰麻,蛛网膜下腔给予0.75%罗哌卡因后,E组硬膜外推注生理盐水10 ml, C组不给予任何液体。序贯法0.75%罗哌卡因初始剂量为10 mg,根据上一例产妇的镇痛效果,上调或下调下一例产妇所需罗哌卡因剂量,上调或下调的浓度梯度为1 mg。观察腰麻效果,采用Probit回归分析计算罗哌卡因的ED_(50)及ED_(95)。结果 C组0.75%罗哌卡因腰麻的ED_(50)为12.050 mg(95%CI 11.215～12.953 mg),ED_(95)为13.683 mg(95%CI 12.816～15.692 mg);E组0.75%罗哌卡因腰麻的ED_(50)为9.915 mg(95%CI 9.321～10.471 mg),ED_(95)为11.548 mg(95%CI 10.878～13.255 mg)。结论剖宫产产妇0.75%罗哌卡因腰麻的ED_(50)为12.050 mg(95%CI 11.215～12.953 mg),硬膜外生理盐水10 ml容量扩张能使其用量减少约17.7%。     

剖宫产术病人硬膜外左旋布比卡因的胎盘转移

目的 评价剖宫产术病人硬膜外左旋布比卡因的胎盘转移情况.方法 择期硬膜外麻醉下剖宫产术病人60例.于L1,2或L2,3间隙进行硬膜外穿刺,穿刺成功后注射0.5%左旋布比卡因5ml(含1:20万肾上腺素)试验剂量,5 min后无脊麻征象后,追加9～12 ml,5 min后再追加1次.娩出时抽取脐动脉血样,进行血气分析;于娩出后l、5min行Apgar评分.选择30例病人,娩出时抽取母体静脉血样和脐静脉血样,采用高效液相色谱法测定血浆左旋布比卡因浓度.结果 在硬膜外注药结束后10～22 min60例胎儿娩出,新生儿Apgar评分均≥7分,脐动脉血Ph值均≥7.25.娩出时母体静脉血与脐静脉血血浆左旋布比卡因浓度分别为0.35 ±0.24、(0.24±0.21)μg/ml,脐静脉血与母体静脉血血浆左旋布比卡因浓度的比值为0.7 ±0.3.结论 宫产术病人硬膜外左旋布比卡因可通过胎盘,脐静脉血与母体静脉血左旋布比卡因浓度的比值为0.7.     

在剖宫产术时行子宫肌瘤切除的临床分析

目的探讨妊娠并发子宫肌瘤患者剖宫产术时行子宫肌瘤剔除术的可行性。方法选择我院的24例剖宫产术同时行子宫肌瘤剔除术的产妇为观察组,同期24例单纯剖宫产术的产妇为对照组,比较2组的术中及术后情况。结果术中出血量,观察组多于对照组,2组比较差异有显著性(P0.05),手术时间、产褥病率、手术前后Hb变化值、切口愈合、住院天数,2组比较差异无显著性(P0.05)。结论选择风险性小的妊娠并发子宫肌瘤患者在剖宫产术时行子宫肌瘤剔除术行肌瘤剥除术是安全可行的,并可减少患者再次手术的痛苦及风险。     

0.75%重比重布比卡因剖宫产腰硬联合麻醉的应用

目的探讨重比重布比卡因腰硬联合麻醉在剖宫产麻醉中的应用。方法选择120例剖宫产手术的产妇,ASAI-Ⅱ,行L2—3或L3—4间隙穿刺,穿刺成功后注入0.75%布比卡因重比重液1~2mL(7.5~15mg),控制麻醉平面后,测血压、脉搏、呼吸。结果麻醉起效时间为1~3min,注药后(6.3±2.2)min阻滞完善。腰骶部阻滞完善,对产妇血压的影响不超过其基础值的20%,脉搏、呼吸基本无明显影响,术后并发症少,新生儿Apgar评分(18.8±0.7)分。结论腰硬联合麻醉起效快、效果确切、肌松良好、对胎儿循环干扰小、并发症少。     

抗菌药物不同使用时间对预防剖宫产术后感染的影响

目的观察抗菌药物不同使用时间对预防剖宫产术后感染的影响。 方法选择2012年2月至2014年10月243例剖宫产产妇为研究对象,根据入院顺序随机分为A组、B组和C组,每组各81例。Ａ组产妇在术前30 min静脉滴注抗菌药物,术后不再使用抗菌药物;Ｂ组产妇术前30 min和术后3 d连续静脉滴注抗菌药物;C组产妇仅在术后连续静脉滴注3 d抗菌药物。 结果手术情况：A、B组产妇术后住院时间和住院费用均显著低于C组（t = 13.603、27.024、13.367、7.939,P = 0.000、0.000、0.000、0.008）,A组患者住院费用显著低于B组（t = 18.019、P = 0.000）;生理指标与切口愈合：A、B组产妇术后3 d最高体温、WBC计数和CRP水平均显著低于C组（t = 27.322、1 333.269、21.327、16.484、119.541、17.689,P = 0.000、0.000、0.000、0.000、0.000、0.000、0.000）,A组产妇WBC、CRP水平显著低于B组（t = 16.037、4.557,P = 0.000、0.038）;术后感染：A、B两组患者术后感染率均显著低于C组（4.94% vs 6.17% vs 17.28%）（χ² = 4.830、6.250,P = 0.032、0.026）。 结论剖宫产术前30 min预防性使用抗菌药物能降低术后炎性反应及并发症发生率,促进切口愈合,缩短住院时间,节约住院费用,是一种较为理想的预防术后感染方式。     

新型可充气抗休克裤预防蛛网膜下腔阻滞下剖宫产术中低血压的效果

目的 观察新型可充气抗休克裤预防蛛网膜下腔阻滞(腰麻)下剖宫产术中低血压的效果.方法 选择择期在腰麻下行剖宫产术的单胎足月妊娠产妇97例,年龄18～35岁,ASAⅡ或Ⅲ级,孕期>37周.采用随机数字表将产妇分为两组:对照组(n=48)和观察组(n=49).观察组腰麻后立即穿戴新型可充气抗休克裤,对照组不使用.腰麻后2～...     

剖宫产术患者罗哌卡因混合芬太尼腰麻的量效关系

目的 观察剖宫产术患者罗哌卡因复合芬太尼腰麻的临床效果及罗哌卡因的量效关系。方法 60例单胎、足月产妇,ASAⅠ-Ⅱ级,随机分为三组:1％罗哌卡因10mg 芬太尼20μg组(A组)、1％罗哌卡因13mg 芬太尼20μg(B组)、1％罗哌卡因15mg 芬太尼20μg(C组),每组20例。三组均L2-3穿刺行腰麻-硬膜外联合麻醉,蛛网膜下腔注药。记录三组的下肢运动阻滞情况、术中麻醉效果、硬膜外用药量、麻醉后不良反应、新生儿出生后1、5 min时Apgar评分及术后不良反应,用概率单位回归方法建立罗哌卡因的量效关系直线方程,计算ED50及ED95。结果 A组麻醉效果分级低于B组、C组(P<0.05)。三组的最高麻醉平面、达到最高平面的时间及达Bromage3级时间差异无显著性(P>0.05),而A组麻醉平面消退至T12的时间及Bromage分级恢复至0级时间均短于B组、C组(P<0.01)。A组有14例(70％)Bromage分级达到3级,低于B组、C组(P<0.05)。罗哌卡因的量效关系直线方程为:Y=-3.116 8.053logX,决定系数(r2)为0.9980 ED50(95％可信区间)和ED95(95％可信区间)分别为10.3(8.5-12.1)、[15.5(14.3-18.7)]mg。三组在麻醉后发生低血压、呼吸困难、恶心呕吐、寒战及钳产率等方面均无显著性差异。三组新生儿娩出后1、5 min的Apgar评分亦无显著性差异。术后随访未发现有任何     

A risk score for postoperative nausea and/or vomiting in women undergoing cesarean delivery with intrathecal morphine

BackgroundPostoperative nausea and/or vomiting affects up to 80% of parturients undergoing cesarean delivery, but there is a lack of obstetric-specific risk-prediction models. We performed this study to identify postoperative nausea/vomiting risk factors in parturients undergoing cesarean delivery, formulate an obstetric-specific prediction model (Duke score), and compare its performance against the Apfel score.MethodsA post-hoc analysis of data from two randomized controlled trials studying nausea/vomiting in women undergoing cesarean delivery with intrathecal morphine. Potential risk factors for postoperative nausea/vomiting within 24 h of surgery with univariate associations with P ≤0.20 were considered for inclusion in the multivariable analysis. After identifying the final multivariable model, we derived our Duke score by assigning points to the selected factors. We then tested the association of the Duke and Apfel scores with postoperative nausea and vomiting, and compared the area-under-the-receiver operating characteristic curve.ResultsAnalysis included 260 parturients, of whom 146 (56.2%) experienced postoperative nausea/vomiting. Non-smoking during pregnancy (OR 2.29 [95% CI 1.12 to 4.67], P=0.023), and history of postoperative nausea/vomiting after cesarean delivery and/or morning sickness (2.09 [1.12 to 3.91], P=0.021) were independent predictors of postoperative nausea/vomiting and included in the Duke score. Both Duke and Apfel scores trended linearly with postoperative nausea/vomiting risk (Duke P=0.001; Apfel P=0.049) and had comparable areas-under-the-receiver operating characteristic curve (Duke 0.63 [0.57 to 0.70]; Apfel 0.59 [0.52 to 0.65], P=0.155).ConclusionsBoth Duke and Apfel scores exhibited similar but poor predictive performance. Until better tools are developed, routine prophylactic anti-emetics appears to be a reasonable approach in this patient population.     

剖宫产术后腹壁切口子宫内膜异位症20例临床分析

目的探讨剖宫产术后腹壁切口子宫内膜异位症的临床特点、诊治方法及预防措施。方法回顾性分析我院近5年收治的20例腹壁切口子宫内膜异位症患者的临床资料。结果本组20例全部接受手术治疗并治愈,术后随访6个月至1年无复发。结论剖宫产术后腹壁切口子宫内膜异位症根据病史、症状、体征并结合B超可初步诊断,术后病理确诊,预防该病的发生极为重要,手术是首选的治疗方法,切除的彻底性是治疗本病的关键。