雷米芬太尼诱导行全身麻醉剖宫产术不同麻醉操作方法的对比研究

目的 通过观察降低全身麻醉诱导时雷米芬太尼的剂量,待新生儿断脐后加深麻醉再行气管插管的操作方法对产妇、新生儿及麻醉医生的影响,探讨此方法用于全身麻醉剖宫产时的可行性及效果.方法 将30例ASA分级Ⅰ～Ⅱ级足月择期行全身麻醉剖宫产术产妇按随机数字表法分为Ⅰ、Ⅱ、Ⅲ组,雷米芬太尼诱导剂量分别为1.0、1.5、1.0μg/kg,Ⅰ、Ⅱ组产妇麻醉诱导后气管插管与手术切皮同时开始,新生儿断脐后加深麻醉；Ⅲ组产妇待新生儿断脐后加深麻醉再行气管插管.观察三组产妇诱导前、切皮时、插管后即刻的收缩压、舒张压、心率,记录胎儿娩出时间、插管完成时间及新生儿Apgar评分.结果 所有麻醉方案均能满足全身麻醉剖宫产术的要求.Ⅰ组和Ⅲ组切皮时收缩压、舒张压、心率较诱导前明显升高Ⅰ组：（136.5±9.7） mm Hg（1 mm Hg=0.133 kPa）比（113.5 ±7.8） mm Hg、（96.5±9.1） mmHg比（74.2±6.0） mm Hg、（98.5±8.7）次/min比（81.2±8.4）次/min;Ⅲ组：（138.1±11.4） mm Hg比（118.7±9.9） mm Hg、（90.1±9.9） mm Hg比（77.3±7.9）mmHg、（100.3±9.0）次/min比（81.7±9.2）次/min],差异有统计学意义（P＜0.05）；插管后即刻Ⅲ组收缩压、舒张压、心率均明显低于Ⅰ组和Ⅱ组（97.6±10.1）mm Hg比（138.9±11.2）、（130.1±4.5）mm Hg,（80.1±5.5） mm Hg比（97.7±8.9）、（82.0±8.6） mm Hg,（80.4±7.8）次/min比（99.3±12.2）、（95.9±9.6）次/min],差异有统计学意义（P＜0.05）.三组胎儿娩出时间比较差异无统计学意义（P＞0.05）.Ⅱ组新生儿1 min Apgar评分显著低于Ⅰ组及Ⅲ组（7.4±0.9）分比（8.8±0.6）、（8.9±0.6）分],差异有统计学意义（P＜0.05）.Ⅲ组插管完成时间长于Ⅰ组和Ⅱ组（8.5±1.8） min比（3.0±0.5）、（2.8±0.6） min],差异有统计学意义（P＜0.05）,但均可在10 min内完成.结论 采用雷米芬太尼1.0 μ g/kg行全身麻醉诱导,待新生儿断脐后,给予咪达唑仑2 mg、芬太尼0.2 mg加深麻醉再行气管插管的方法,可有效避免雷米芬太尼对新生儿1 min Apgar评分的影响以及气管插管操作对产妇的强刺激反应,同时也不会过多影响麻醉医生.该方法简便、有效,可推荐作为择期全身麻醉剖宫产的常用方法

Comparison of remifentanil induction of general anesthesia in cesarean section of different anesthesia methods

Objective To explore the feasibility of reducing induction dose of remifentanil,deepening anesthesia and intubation after umbilical removal and its effect on maternal,neonatal and anesthesiologists during cesarean section.Methods Thirty cases of ASA Ⅰ-Ⅱ scheduled for elective cesarean section were divided into three groups according random digits table method with 10 cases each.The induction dose of remifentanil was 1.0,1.5,1.0 μ g/kg in group Ⅰ,group Ⅱ,group Ⅲ.Group Ⅰ and group 11 received routine procedure after induction of anesthesia,intubation,while group Ⅲ received anesthesia umbilical removal.Systolic pressure （SBP）,diastolic pressure （DBP） and heart rate （HR） were recorded before induction of anesthesia,skin incision and immediately intubation.And the fetal childbirth time,intubation time and neonatal Apgar score at 1,5,10 min were recorded.Results Three anesthesia procedures could meet the requirements of cesarean section.The SBP,DBP and HR at skin incision in group Ⅰ and group Ⅲ were significantly higher than those at before induction of anesthesia group Ⅰ：（136.5 ±9.7） mm Hg （1 mm Hg=0.133 kPa） vs.（113.5 ±7.8） mm Hg,（96.5 ±9.1） mm Hg vs.（74.2 ±6.0）mm Hg,（98.5 ± 8.7） times/min vs.（81.2 ± 8.4） times/min; group Ⅲ：（138.1 ± 11.4） mm Hg vs.（118.7 ±9.9） mm Hg,（90.1 ±9.9） mm Hg vs.（77.3 ±7.9） mm Hg,（100.3 ±9.0） times/min vs.（81.7 ±9.2）times/min],there were statistical differences （P 〈 0.05）.The SBP,DBP and HR at immediately intubation in group Ⅲ were significantly lower than those in group Ⅰ andgroup Ⅱ （97.6±10.1）mmHgvs.（138.9±11.2） and （130.1 ± 4.5） mm Hg,（80.1 ± 5.5） mm Hg vs.（97.7 ± 8.9） and （82.0 ± 8.6） mm Hg,（80.4 ±7.8） times/min vs.（99.3 ± 12.2） and （95.9 ± 9.6） times/min],there were statstical differences （P 〈 0.05）.There was no statistical difference in fetal childbirth time among the 3 groups （P〉 0.05）.The neonatal Apgar score at 1 min in group Ⅱ was significantly lower than that in group Ⅰ and group Ⅲ （7.4 ± 0.9） scores vs.（8.8 ± 0.6）,（8.9 ± 0.6） scores],there was statistical difference （P 〈 0.05）.The intubation time in group Ⅲ was significantly longer than that in group Ⅰ andgroup Ⅱ （8.5±l.8） min vs.（3.0±0.5）,（2.8±0.6）min],there was statistical difference （P〈 0.05）,but the intubation time in group Ⅲ was completed within 10 min.Conclusions Using the protocol of remifentanil 1.0 p g/kg induction,midazolam 2 mg,fentanyl 0.2 mg deepening after the umbilical removal can effectively avoid the effect of remifentanil on neonatal 1 min Apgar score,decrease the intubation stress with no effect on anesthesiologists.This method is simple,method of anesthesia for elective cesarean section.