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The Influence of Epidural Local Anesthetics Consumption Volume during Labor Analgesia on the Effect of Epidural Anesthesia When Undergoing Intrapartum Cesarean Delivery
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摘要:
目的 探讨椎管内阻滞分娩镇痛硬膜外间隙镇痛药液用量对中转剖宫产时硬膜外麻醉效果的影响。 方法 前瞻性收集并分析2019年5月至2020年2月在首都医科大学附属北京妇产医院接受椎管内阻滞分娩镇痛且中转剖宫产产妇的临床资料。以纳入本研究的所有产妇分娩镇痛期间硬膜外间隙镇痛药液用量的算术均值(60 mL)为分界值，将其分为高容量组(硬膜外间隙镇痛药液用量≥60 mL)和低容量组(硬膜外间隙镇痛药液用量＜60 mL)。中转剖宫产时，通过原分娩镇痛置入的硬膜外导管给予试验剂量的1.5%利多卡因3 mL及1%利多卡因+0.5%罗哌卡因混合液10~20 mL进行硬膜外麻醉，比较两组产妇硬膜外麻醉失败率及麻醉效果。 结果 共36例符合纳入和排除标准的产妇入选本研究。其中高容量组17例、低容量组19例。高容量组硬膜外麻醉失败率明显高于低容量组(23.5% 比0, P=0.040)。两组产妇剖宫产术中局部麻醉药用量(P=0.057)、给予首次麻醉诱导剂量至切皮时间(P=0.290)、给予首次麻醉诱导剂量至术毕时间(P=0.748)均无显著性差异。36例产妇均顺利完成剖宫产术(4例硬膜外麻醉失败者改行腰硬联合麻醉)，均无产妇和新生儿不良事件发生。Pearson相关法分析显示，给予首次麻醉诱导剂量后10 min体表感觉阻滞平面与硬膜外间隙镇痛药液用量明显相关(r=0.509, P=0.003)，与单位时间镇痛药液用量无线性相关(r=0.272, P=0.125)。高容量组给予首次麻醉诱导剂量后10 min右侧体表感觉阻滞平面[T9(T6, T9)比T6(T4, T7), P=0.048]及术毕右侧运动阻滞分级[1(0, 1)比2(1, 3), P=0.034]均低于低容量组。高容量组在切皮后分离肌肉时主诉不适(23.1%比0, P=0.058)和回纳子宫并腹腔探查时主诉不适(30.8%比15.8%, P=0.401)的产妇比率与低容量组均无显著性差异。 结论 接受椎管内阻滞分娩镇痛且中转剖宫产的产妇，若硬膜外间隙镇痛药液用量增多，不仅增加后续硬膜外麻醉失败风险，且影响硬膜外麻醉效果。 Abstract:Objective To investigate the influence of epidural local anesthetics consumption volume (ELACV) during neuraxial labor analgesia on the effect of epidural anesthesia when undergoing intrapartum cesarean delivery. Methods Parturients undergoing intrapartum cesarean delivery after neuraxial labor analgesia were prospectively recruited in Beijing Obstetrics and Gynecology Hospital, Capital Medical University from May 2019 to February 2020. Using the average amount (60 mL) of ELACV of all the parturients as the cut-off in our study, we divided the parturients into the high volume group (ELACV≥60 mL) and the low volume group (ELACV < 60 mL). Epidural anesthesia was performed by a top-up of the epidural catheter, which was introduced during the labor, with the experimental dose of 1.5% lidocaine 3 mL and a mixture of 10~20 mL of 1% lidocaine and 0.5% ropivacaine. The failure rate and effect of epidural anesthesia were compared between the two groups. Results A total of 36 parturients who met the selection and exclusion criteria were enrolled. There were 17 cases in the high volume group and 19 cases in the low volume group. The failure rate of the high volume group was significantly higher than that of the low volume group (23.5% vs. 0, P=0.040). There was no significant difference in the local anesthetics consumption during cesarean delivery (P=0.057), the length of time from the first epidural top-up dose to skin incision (P=0.290), and the length of time from the first epidural top-up dose to the end of surgery (P=0.748) between the two groups. All surgeries were successfully completed (4 cases, who suffered failure of epidural anesthesia, were converted to combined spinal epidural anesthesia) with neither maternal nor neonatal adverse events. Pearson correlation analysis showed that the level of sensory block at the 10 minutes after the first epidural top-up dose was significantly correlated with the ELACV (r=0.509, P=0.003), but not linearly correlated with the ELACV per hour (r=0.272, P=0.125). In the high volume group, the level of sensory block at the 10 minutes after the first epidural top-up dose[T9 (T6, T9) vs. T6 (T4, T7), P=0.048] and the grade of motor block at the end of surgery[1(0, 1) vs. 2(1, 3), P=0.034] on the right side of the body were lower than those in the low volume group. The difference of the proportion of parturients who complained of discomfort during muscle separation after skin incision (23.1% vs. 0, P=0.058) and discomfort during abdominal exploration (30.8% vs. 15.8%, P=0.401) was not statistically significant between the high volume group and the low volume group. Conclusion In the parturients, who need intrapartum cesarean delivery after neuraxial analgesia, the larger the volume of local anesthetics consumed during labor analgesia, the greater the chance of failure and poor effect during conversion of epidural analgesia to epidural anesthesia. 作者贡献: 赵娜负责研究设计、病例招募、数据采集整理、论文撰写；李晓光、徐铭军参与研究设计、论文撰写；汪愫洁、白云波负责病例招募、数据采集整理；徐涛负责数据整理、统计分析。利益冲突: 无 -
表 1 两组产妇术前资料比较
指标 高容量组(n=17) 低容量组(n=19) P值 年龄(x±s, 岁) 31.59±3.16 31.26±3.48 0.772 身高(x±s, cm) 162.47±4.96 160.47±5.53 0.265 体质量(x±s, kg) 72.35±6.72 69.74±10.05 0.371 体质量指数(x±s, kg/m2) 27.43±2.49 27.04±3.40 0.695 孕周(x±s, 周) 39.24±0.90 39.74±0.93 0.112 术前宫口开指程度[M(P25, P75), cm] 3(2, 5.5) 2(2, 3) 0.327 镇痛时间(x±s, h) 11.44±3.19 6.32±2.74 0.000 镇痛药液用量(x±s, mL) 88.47±23.75 36.11±14.64 0.000 单位时间镇痛药液用量(x±s, mL/h) 8.02±2.25 5.89±1.57 0.002 镇痛初始启动方式[n(%)] 1.000 硬膜外镇痛 12(70.6) 14 (73.7) 腰硬联合镇痛 5(29.4) 5(26.3) 中转剖宫产指征[n(%)] 0.001 相对头盆不称 15(88.2) 6(31.6) 胎儿窘迫 0(0) 7(36.8) 宫内感染 1(5.9) 4(21.1) 其他 1(5.9) 2(10.5) 
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表 2 两组产妇术中资料比较(x±s)
指标 高容量组(n=13) 低容量组(n=19) P值 术中局麻药用量(mL) 15.03±1.19 14.18±1.37 0.057 给予首次麻醉诱导剂量至切皮时间(min) 22.00±4.56 20.53±3.19 0.290 给予首次麻醉诱导剂量至术毕时间(min) 67.31±19.77 65.47±12.26 0.748 输液总量(mL) 823.08±101.27 878.95±154.84 0.350 出血量(mL) 503.85±172.56 466.32±100.29 0.677
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表 3 两组产妇硬膜外麻醉效果比较
指标 高容量组(n=13) 低容量组(n=19) P值 给予首次麻醉诱导剂量后10 min[M(P25, P75)] 左侧体表感觉阻滞平面 T9(T4, T10) T6(T4, T7) 0.175 右侧体表感觉阻滞平面 T9(T6, T9) T6(T4, T7) 0.048 左侧运动阻滞分级 0(0, 0) 0(0, 1) 0.233 右侧运动阻滞分级 0(0, 1) 0(0, 1) 0.672 术毕[M(P25, P75)] 左侧体表感觉阻滞平面 T4(T3, T4) T4(T2, T4) 0.361 右侧体表感觉阻滞平面 T4(T3, T4) T4(T2, T4) 0.467 左侧运动阻滞分级 1(0, 1) 2(1, 3) 0.095 右侧运动阻滞分级 1(0, 1) 2(1, 3) 0.034 切皮后分离肌肉主诉不适[n(%)] 0.058 有 3(23.1) 0(0) 无 10(76.9) 19(100) 回纳子宫并腹腔探查时主诉不适[n(%)] 0.401 有 4(30.8) 3(15.8) 无 9(69.2) 16(84.2)
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