【作者】 刘博瑜；

【导师】 韩树海；

【作者基本信息】 吉林大学 ， 临床医学， 2012， 硕士

【摘要】 背景：腰麻以其起效快、用药量小、阻滞效果完善正在越来越多的应用于剖宫产手术麻醉中，联合硬膜外置管术后，更提高了麻醉的成功率。但相对于单纯硬膜外麻醉，腰麻的阻滞平面较广，对患者，尤其是孕妇的循环系统影响较大，对于中期以上的妊娠，曾被列为腰麻的相对禁忌症[11]，为了母婴的安全，临床上尽量采用较一般腰麻剂量要小的腰麻剂量，目的是将阻滞平面控制在一个安全的范围，使循环、呼吸系统更加稳定，减少麻醉的风险及不良反应。除了剂量方面的因素，腰麻药物的另一性质——比重也是影响麻醉阻滞平面进而影响循环系统等的重要因素，以往，临床多倾向于选择重比重药液，认为其麻醉效果确切，麻醉范围易于调整，而用等比重药液，麻醉平面不确定。但近年来的多项研究发现，用等比重药液麻醉效果也可靠，对患者血流动力学影响更小，基于以上观点，本实验将小剂量布比卡因和等比重布比卡因两种与传统布比卡因用药方案不同的用药方案结合对照组进行比较研究，从而为临床腰麻方案的选择提供参考。方法：选择ASA分级1-2级，自愿在腰麻下行剖宫产手术的足月（>37周）单胎孕妇60例，随机分为对照组（A组）、小剂量组（B组）和等比重组（C组），每组各20例，分别用0.5%重比重布比卡因1.8ml（9mg）、0.5%重比重布比卡因1.2ml（6mg）和0.5%等比重布比卡因1.8ml（9mg）进行蛛网膜下腔麻醉，观察并记录注药后产妇的血压、心率、脉搏血氧饱和度、感觉、运动阻滞平面及达到感觉阻滞平面所用的时间、硬膜外追加利多卡因及静脉应用麻黄碱的剂量、术中不良反应、腰麻后并发症及新生儿出生1min、5min时Apgar评分。结果：三组产妇的一般状况及术前血压心率值没有显著差异，注药后10min收缩压舒张压和平均动脉压三组间差别有统计学意义，显示A组<B组<C组，小剂量组和等比重组低血压的发生率显著低于对照组，麻黄碱用量亦少。小剂量组和等比重组腰麻最初的感觉阻滞平面和运动阻滞评分没有显著差异，与对照组比较差异有统计学意义，显示对照组的阻滞程度高于小剂量组和等比重组。三组达到胸8平面所用的时间A组短于B组和C组。达到最高阻滞平面所用时间及平面消退2个节段的时间，等比重组显著长于对照组和小剂量组，小剂量组术中发生牵拉反应的概率显著高于另外两组，术后并发症发生率及新生儿Apgar评分三组间无显著差异。结论：在剖宫产手术腰麻中，应用等比重或小剂量布比卡因，对产妇血流动力学稳定性都有益处，能降低低血压的发生率，但单独应用小剂量布比卡因术中牵拉反应发生率高，总体效果不如等比重布比卡因。更多还原

【Abstract】 Background:SA(spinal anesthesia) is increasingly widely used in the cesarean delivery for its bestefficiency and guaranteed effect.Combined with epidural catheter insertion,the success rateof anesthesia can be improved more.However,compared with epidural anesthesia,the patientsundergoing SA are more likely to develope hypotension,especially for the parturients.Thetext book even takes SA as a contradiction for the parturients of middle-late stage.Socurrently the a relatively low dose anesthetic solution is commonly used to confine the blockheight,in order to protect the maternal and neonatal circulatory and respiratory systems toavoid too much side effects of anesthesia.Apart from the dose of bupivacaine,the baricityalso matters.Hyperbaric bupivacaine is conventionally used as it makes a reliable andregulatable block height,but many research suggested that the isobaric bupivacaine can alsobe reliable,and interferes circulatory and respiratory systems less.So this study is aimed tocompare two untraditional solutions of bupivacaine used in SA for cesarean section and thusget reference for the clinical practice.Method:60term parturients of ASA1-2with singleton pregnancy scheduled to receive cesareansection under SA were randemly equally divided into control group(group A),low-dosegroup(group B) and isobaric group(group C),receiving0.50%hyperbaric bupivacaine1.8ml(9mg),0.5%hyperbaric bupivacaine1.2ml(6mg) or0.5%isobaric bupivacaine1.8ml(9mg) respectively.After lumber puncture,the following parameters were evaluated:BP,HR,SpO2,upper limit of the sensorial blockade,degree of motor blockade,time forregression of the sensorial blockade by two dermatomes,requirement of epidural lidocavineor intravenous anesthetics,fluid and ephedrine received,maternal side effects,and neonatalApgar score at1and5min after delivery.Results:There was no difference between three groups in demographic and clinicalfeatures,BP,HR and SpO2.The SBP,DBP and MAP had significant difference between threegroups at10min after intrathecal injection.It showed that BP in group A are lower than thatin B which are lower than in C.Incidence of hypotension was greater in the contralgroup,resulting in a higher dose of ephedrine.There was no difference on LMAXand modified Bromage scores early,while it showed a decreased potency of block compared to the contralgroup.The time reaching T8was also shorer in the contral group.While the time of TPEAKandTDOWNwere longer in the isobaric group.There were more intense viscus traction response ingroup B compared with group A and C.The postoperative complications of parturients andApgar scores of neoborns at1min and5min showed no difference.Conclusions：It showed helpful effect of sustaining hemodynamic stability by using lower dose orisobaric bupivacaine in spinal anesthesia for cesarean section,resulting in a significant lowerincidence of hypotetion.But it can be more likely to see viscus traction response using areduced dose of bupivacaine only.So on the whole,it showed better effect of using isobaricsolution.更多还原